HospitalInspections.org

Based on record review and interviews, the hospital failed to specify the rights to disseminate patient information on the Authorization and Request for Release of Information for 11 (P#1, P#3, P#4, P#6, P#11, P #12, P# 14, P#15, P #16, P#17 and P#20) of 20 patients (P#1- P#20).This failed practice exposed patients to potential breaches in private patient information. The findings are:

A. Record review of the Authorization and Request for Release of Information for 11 (P#1, P#3, P#4, P#6, P# 11, P #12, P#14, P#15, P #16, P #17, and P#20) of 20 patients indicated the forms were signed but no designation of the kind of information was selected. This "blank check" (no selected information sources) consent does not qualify as informed consent.
1. The forms contained only the name of the patient, the patient, or legal representative signature, and date, and witness signature and date. On form:
2. Section A Scope of Authorization stating:
A."...The facility (sic) to release the following information contained in the medical/financial record of:" did not contain any names or addresses.
B. "The information will be used/disclosed for the following purposes: Personal, Continuity of Care, Billing/Insurance Claims, Litigation, Other (please explain)" (sic) did not contain any checkmarks or any other identifying mark indicating which records may and/or may not be used and/or disclosed.
3. Section C Patient/Resident Authorization
A. "This authorization shall expire on/or (event)" (sic) did not specify a date or event.

B. On 04/25/18 at 3:30 pm during interview, the Director of Nursing (Staff #S2) stated they do this in the event information is needed at a later date, they have a signed release on file.

C. On 04/25/18 at 3:45 pm during interview, the Director of Quality (Staff #S1) stated the facility is aware of the blank forms with only patient and witness signatures. She stated, "We are working on correcting this issue through a Performance Improvement Project [as part of Quality Assurance Process Improvement]."

D. Record review of the Hospital's policy dated 11/2012 titled "Disclosure of Protect Health Information/Medical Records" revealed: Section II - 4, "3A. Preparing the Medical Record for Release- A. The information released is restricted to the information requested."