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Based on a review of facility documents and employee interviews (EMP), it was determined that the facility was unable to provide documentation that the patient's designee was provided access to information contained in his or her clinical records within a reasonable time frame for three of four medical record (MR) requests.

Findings include:

Review of Policy No. 100.001, Patient's Rights and Responsibilities, revised October 2016, revealed, "... 18. ... The hospital shall provide you, or your designated or legal representative, upon request, access to all information contained in your medical records within a reasonable time frame, unless restricted for medical or legal reasons. ... 25. You have the right to formulate an "advance directive", or to appoint a surrogate to make health care decisions on your behalf. These decisions will be honored by this hospital and its health care professionals within the limits of the law and this organization's policies. ... ."

Review, at approximately 11:53 AM on January 18, 2017, of Policy #115.008, Release of Health Information Management, revised June 8, 2016, revealed, "... C. Request in Writing, Signed and Filed: ... All records and releases shall be properly signed out and a copy of the request for and/or receipt of the information shall be kept with the patient's medical record. ... Photocopy of Medical Records: A. No copies of medical records shall be made except as authorized above and only upon signed authorization. The request shall be logged as part of the correspondence record for accounting and disclosure. ... ."

1. Review of photocopies of requests, by the complainant, for copies of medical records, revealed a request dated July 6, 2016, (no recipient listed). Additional review of the request dated July 6, 2016, revealed a handwritten note on the form, stating, "7-13-16 11:00 AM- Spoke with [complainant] concerning this request advise [him/her] they will need to go through [his/her] lawyer." Review of the handwritten note revealed no signature or identification of the author. Review of the Medical Records Accounting of Disclosure List for the time period January 1, 2016, through January 2017, did not reveal the request or that the request had been satisfied.

2. Further review of the photocopies of additional requests, by the complainant, for copies of medical records revealed a request dated September 16, 2016, to a designated healthcare facility; and September 20, 2016, for records to be released to [himself/herself]. Further review of the Medical Records Accounting of Disclosure List for the time period January 1, 2016, through January 2017, revealed no documentation of the aforementioned requests, or that they had been satisfied.

3. At approximately 9:34 AM on January 18, 2017, EMP2 stated, "As long as we have the consent, we give them the medical record." When asked whether a patient's power of attorney would be granted a request for medical records, EMP2 stated, "As long as its proper paperwork, they give them the record."

4. When asked via conference call, at approximately 12:10 PM on January 18, 2017, if EMP5 was aware of a request for medical records for PT1, EMP5 stated, "... I am very familiar with PT1 and [his/her] [son/daughter]. ... I'm unaware of anything that OTH1 wanted that [he/she] didn't receive with the proper release of information." When asked if the Medical Records Department maintains a log for those individuals calling the facility to request medical information, EMP5 stated, "[A log] of phone calls, yes." When asked if EMP5 was aware of any type of letter being sent to the facility from OTH1 or PT1 regarding the release of the patient's medical information, EMP5 stated, "I would have to look through each account. ... ."

5. At approximately 2:03 PM on January 18, 2017, EMP5 presented to the survey team with documentation from Medical Records regarding PT1. When EMP5 was asked if OTH1 received any of the medical records requested, EMP5 stated, "I would have to ask the staff, I don't want to speak out of turn. ... Our documentation is that [form provided], that we sent the record." EMP5 confirmed that if a denial for medical record request occurs, there should be documentation of why. ..." EMP5 stated that the older request did not go out, and the second request had been sent, but there was no way to confirm that the second request had been sent. EMP5 confirmed that the facility did not follow their policy regarding logging photocopies of medical records in the case of this particular patient's medical record.

6. At approximately 10:44 AM on January 19, 2017, EMP1 confirmed that the facility did have Power of Attorney document on file for PT1; however, no information had been disclosed to OTH1 with regard to the patient's medical record.