HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 10 (Pt #2), clinical records reviewed for patient rights, the hospital failed to ensure that a patient's revocation of the designation of a representative, who was authorized to receive health information about the patient's care, was documented in accordance with policy.

Findings include:

1. The Hospital's policy titled, "Release of Information" (dated November 2014), was reviewed, and required, " ...The consent form shall be signed by the person entitled to give consent and the signature shall be witnessed by a person who can attest to the identity of the person so entitled ...Any revocation of consent shall be verbally or in writing, signed by the person who gave the consent and the signature shall be witnessed by a person who can attest to the identity of the person so entitled. No written revocation of consent shall be effective to prevent disclosure or records and communications until it received by the person otherwise authorized to disclose records and communications ...".

2. The clinical record for Pt #2 was reviewed on 8/2/2023. Pt #2 was admitted to the hospital's 2 South Inpatient Adult Transitional Unit (adult male behavioral health) on 6/22/2023. Pt #2's record included:
-Pt #2's "Authorization to Disclose/Obtain Information"/Release of Information (ROI), dated 6/22/2023, indicated that Pt #2's mother was authorized for information to be disclosed and obtained.
-A Social Worker note, dated 6/29/2023 at 9:48 AM, documented by the Social Worker Supervisor (E #7), included, "Therapist followed up with pt to discuss pt's discharge plan... While meeting with pt, pt stated [Pt #2] no longer wanted [Pt #2's] mom to be involved in treatment and rescinded consent for her to be involved ..."
-A Social Worker note, dated -6/30/2023 at 7:48 AM, by the Social Worker (E#6), included, "Therapist spoke with pts mother ...[Mother] reported that she is concerned with the pts discharge because pt does not have a safe place to discharge to. Therapist reported that she was off work the previous day, however, was informed that the pt had revoked consent for mom. Mom reported that, 'yeah', I understand that. I don't get how you guys have a mentally ill person revoke consent..."
-Pt #2's "Authorization to Disclose/Obtain Information"/Release of Information (ROI), dated 6/22/2023, indicated that Pt #2's mother was authorized for information to be disclosed and obtained. However, this form had a line drawn through it and was signed by the Social Worker Supervisor (E #7) indicating that the consent was rescinded on 6/29/2023. The form included that, " ...I understand that I may revoke this authorization, however the revocation must be in writing and must be sent/given to the facility's record department. I understand that no revocation of this authorization shall be effective to prevent disclosure of records and communication until it is received by the person otherwise authorized to disclose records and communication ..." Although Pt #2's mother was not given further information on Pt #2 after 6/29/2023, the clinical record lacked the documentation of revocation in writing, as required.

3. On 8/2/2023 at 12:00 PM, an interview was conducted with the Social Worker Supervisor (E #7). E #7 stated that Pt #2 told her that (Pt #2), did not want information to be given to the mother anymore. E #7 stated that Pt #2 initially signed the Release of Information form on admission. E #7 stated that once Pt #2 informed her that the mother was no longer to be involved, she drew a line through the Release of Information form, as this is how she was taught to do it if the patient wants it rescinded. E #7 stated that now looking at the form, she realizes that the revocation, was not done according to the required procedure.