HospitalInspections.org

Based on review of policies and procedures, specimen log, and staff interview, the governing body failed to ensure policies and procedures were followed for specimen collection, handling and processing for 1 of 5 patient specimens received by the laboratory after hours.

Findings include:
1. On 3/11/3013 at 1300 the policy, " Bedford Regional Medical Center Laboratory Procedure, Department: Spec. (sic Specimen) Collection/Handling " " effective date 09/08 " , read, " Purpose: Provide a tracking system to ensure specimens are actually received. Home Care/Nursing Home: 1. Specimens will be brought into the Lab Secretary ' s office accompanied by the order. 2. Information will be documented on the specimen log sheet (Date, Pt. test to be done). 3. Lab secretary will document coll(sic collection)/received time, initials, color and number of tubes on order and take to registration. Specimen will be taken to lab for storage/processing until test(s) ordered in HMS. 3. Registration will return order and face sheet to secretary who will then order the test(s). "

2. On 3/11/13 at 1315 the policy, "Laboratory Testing Information", no date listed, read:
"Urinalysis 8 hours
The testing information list is to be used as a guideline only. Turnaround times may vary at the discretion of the laboratory. Every attempt will be made to notify the physician of any delay in testing due to unforeseen circumstances."

3. On 3/11/13 at 1400, the Indiana University Health Bedford Hospital Administrative Manual policy " Incident Reporting " reviewed 8/12 read, " D. Incident: any happening out of the ordinary which results in a potential for injury or actual injury or damage to the following: patient, volunteer, physician, employee, hospital property or other property for which the hospital could have liability ... V. Procedure: ... Incident reports and any other material which may be required to document event should be completed and forwarded to Quality and Risk department ...3. Any staff member who discovers, witnesses or is involved in an event shall complete an incident report as soon as possible. "

4. On 3/11/13 at 1515, review of the laboratory's specimen receipt log indicated five patient's had been entered into this log between 9/17/12 to 10/12/13. Patient #3's urinalysis specimen was received by the laboratory on 9/18/12 at 1545, a verbal order was eventually received for this specimen on 9/18/13 at 1857. The patient's test report for this date could not be located.

5. In interview on 3/11/13 between 1315 to 1600, staff member #3 indicated:
a. This specimen was delivered at the laboratory after hours and the "Lab secretary" is not available during this time.
b. Although patient #3 had been entered into the laboratory's specimen receipt log; there was no documentation available that the specimen had been stored and processed.
c. The missing patient report indicated the testing requested on the log had not been completed.
d. There was no documentation the physician had been notified of this delayed testing,
e. The above incident had never been documented or forwarded to Quality and Risk department.

Based on review of policies and procedures, observation, review of laboratory ' s specimen receipt log, and staff interview, the hospital failed to follow an approved policy and procedure to ensure the confidentiality of patient information for five of five patient specimens received by the laboratory.

Finding(s) include:

1. On 3/11/13 at 1100 the policy, "Confidentiality of Patient Health Information",
Policy #102, read: "The Bedford Regional Medical Center has a statutory obligation to maintain the confidentiality and the integrity of medical information regarding treatment rendered to the patients ... B Confidential Information Confidential Information includes patient demographic information, information regarding the nature and extent of the patient ' s injury, illness or condition, symptoms, diagnosis and treatment ... BRMC (SIC) has the obligation to safeguard these records against unauthorized disclosure."

2. On 3/11/3013 at 1300 the policy, " Bedford Regional Medical Center Laboratory Procedure, Department: Spec. (sic Specimen) Collection/Handling " " effective date 09/08 " , read, " Purpose: Provide a tracking system to ensure specimens are actually received. Home Care/Nursing Home: 1. Specimens will be brought into the Lab Secretary ' s office accompanied by the order. 2. Information will be documented on the specimen log sheet (Date, Pt. test to be done). 3. Lab secretary will document coll(sic collection)/received time, initials, color and number of tubes on order and take to registration. Specimen will be taken to lab for storage/processing until test(s) ordered in HMS. 3. Registration will return order and face sheet to secretary who will then order the test(s). "


3. During the laboratory tour on 3/11/13 at 1400 the laboratory's specimen receipt counter area and corresponding specimen receipt log were located on a laboratory counter within ten feet of a laboratory door which failed to have an outside lock. The specimen receipt log contained confidential information including the patient's name and the name of the agency collecting the specimen.


4. On 3/11/13 at 1515, review of the laboratory's specimen receipt log indicated five patient's had been entered into this log between 9/17/12 to 10/12/12. The specimen receipt log contained confidential information including the patient's name and the name of the agency collecting the specimen.

5. In interview on 3/11/13 between 1315 to 1600, staff member #3 indicated:
a. Two of three laboratory door entrances had security locks; however, the above-mentioned unlocked door was used by nursing home personnel delivering specimens directly into the laboratory.
b. After hours the laboratory secretary as listed in policy was not available and the home health staff would enter their own information on the receipt log. There would be times when no employee would be available and home health staff would leave the specimen on the counter with the order if no one was there.
c. During delivery, patients names whose specimen was previously delivered to the laboratory were in full view on this log which was positioned on the counter next to additional testing specimens from other patients.
c. No specific approved policy and procedure was available to assure outside received specimens were delivered into the laboratory after hours in a manner to prevent unnecessary access to confidential information.