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Based on observations, review of policies/procedures, and staff interviews, the Critical Access Hospital (CAH) laboratory staff failed to secure and maintain the confidentiality of medical records for 1 of 1 laboratory. The CAH administrative staff reported a census of 14 patients.

Failure to secure and maintain the confidentiality of the medical records could potentially result in unauthorized use of patient's information.

Findings include:

1. Observation during a tour of the laboratory on 3/28/2011 at 3:30 PM with the Laboratory Director, revealed in the clean area of the laboratory 2 of 2 drawers that contained approximately 3,000 patient lab results per drawer for the calendar years of 2008 and 2009. The drawers lacked any mechanism to secure the patient records.

2. Review of the CAH policy/procedure on 3/28/11 titled, "Confidentiality", dated 10/1/04, stated in part. ". . . Background: All information, regardless of where it is handled or stored (e.g. in computers, file cabinets, desks, fax machines, voice-mail, etc.) must be protected from unauthorized access, modification, disclosure, and/or destruction ....Non-Information User or Users. Individuals who have not been granted authorization and who typically do not require access to protected health information as it pertains to their specific job duties ....Secure area. An area not accessible to unauthorized persons or an area where the information is attended by an authorized person. Examples include: nursing stations, private offices, work areas, monitored by a staff member or receptionist, most employee-only areas, secure buildings."

3. During an interview on 3/28/11 at 3:30 PM, the Laboratory Director verified the unsecured patient medical records in the drawers in the clean area of the laboratory. Housekeeping cleans the laboratory after staff leave for the day. Housekeeping has a key to the laboratory.

During an interview on 3/28/11 at 3:33 PM, Staff A, Clinical Laboratory Technician, stated housekeeping staff come into the laboratory to clean at 5:00 PM and sometimes Staff A leaves the laboratory to go to the Emergency Room. Housekeeping staff would continue cleaning the Laboratory unattended.

Based on review of policies/procedures, documentation, and staff interview, the Critical Access Hospital (CAH) administrative staff failed to include external peer review results during the credentialing process for all practitioners that provided care and services to the CAH patients for 14 of 17 practitioners reviewed. (Practitioners A, C, D, E, F, G, H, K, L, M, N, O, P, Q) The CAH administrative staff reported a census of 14 patients.

Failure to ensure an external entity evaluated the quality and appropriateness of the diagnosis and treatment furnished by doctors at the CAH could potentially result in medical staff members misdiagnosing patients and/or providing inappropriate or substandard patient care.

Findings include:

1. Review of the CAH policy/procedure on 3/28/11 titled, "External Peer Review", dated 11/2010, stated in part, "A minimum of one chart per credentialing period will be sent for external peer review on Greater Regional Medical Center active Medical Staff, Specialty Physicians who perform procedures in our surgical department, Tele-Radiologist, and Emergency Department Physicians."

2. Review of peer review documentation for the past credentialing period of 2 years revealed the CAH quality staff failed to include external peer review results during the credentialing process for all practitioners that provided care and services to the CAH patients (Practitioners A, C, D, E, F, G, H, K, L, M, N, O, P, Q).

3. During an interview on 3/28/11 at 3:50 PM, the Director of Quality Services stated the CAH quality staff acknowledged records for Practitioners A, C, D, E, F, G, H, K, L, M, N, O, P, Q were sent out 12/20/2010 for external peer review. THe Director of Quality Services also acknowledged the results of the external peer review for Practitioners A, C, D, E, F, G, H, K, L, M, N, O, P, Q had not been returned and available for review during the last credentialing period.