Observations
Based on the review of patient records, the facility failed to obtain an informed and voluntary consent for the disclosure of patient information in three of seven patient records.
The findings included:
Seven records requiring documentation of informed and voluntary consent for disclosure information were reviewed on May 12, 2017.
Patient record #1 contained a release of information form to a human services agency that was not signed by a witness.
Patient record #2 contained release of information forms to a family member and to an insurance company that were not signed by a witness.
Patient record #3 contained release of information forms to a family member and to an insurance company that were electronically signed by the witness prior to the client signing the forms.
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Plan of Correction
The consents identified on patients #1, 2 and 3, which were closed charts, were completed by the Crisis Department at the time of the individual's presentation to MCES. MCES identified this problem was due to the lack of availability of technology in the crisis lobby which resulted in staff preparing the consents in the crisis office prior to presenting them to the patient for signature. In order to correct this problem and assure proper witnessing of signatures, MCES provided crisis staff with a portable cart, laptop and digital signature pad to take to patients to sign the consent forms. This allows for the crisis staff to witness the patient's signature and sign, date and time appropriately.
Monitoring of proper completion will be done by the Safety and Quality Systems Director, Medical Records Director and Medical Records staff. Supervisors of staff who are not following the policies will be notified, and reeducation will be provided to the staff.
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