HospitalInspections.org

Based on a review of facility documents and interview with staff (EMP), it was determined that the facility failed to follow adopted policies related to the release of patient information for one of 13 medical record reviewed (MR1).

Findings include:

A review of the facility's policy titled Patient Rights & Responsibilities revealed, "Privacy and confidentiality ... Expect full recognition of individuality, including privacy in treatment and in all communications and records related to care. ... "

A review of MR1 revealed the patient was admitted on April 9, 2016, with "bilateral CVA (cerebral vascular accident, stroke) with resultant ADL (activities of daily living), ambulatory, language/cognition dysfunction."

An interview conducted on July 18, 2016, at 2:00 pm with EMP4 revealed that patient MR1 was sent home with MR2's fall bracelet on their wrist and MR1's family was accidently given a copy of MR2's "My Health Journal," a copy of MR2's the signed, dated and timed Important Medicare Message (IMM), a copy of MR2's "Acknowledgement of Receipt of Notice of Privacy Practices" and a copy of MR2's "Consent to Treat and Conditions of Admission." The interview also revealed that the facility obtained all this information from MR1's family. The interview further confirmed that HealthSouth Reading Rehabilitation Hospital failed to follow their established policy.