HospitalInspections.org

Based on interview with hospital personnel, review of the health information department's policies and procedures, and observation, the hospital failed to ensure that records of discharged patients are readily accessible and that records in storage are protected from destruction and/or unauthorized use.

Findings include:

· Because of the lack of space in the Health Information department, only about one (1) year of discharge records are kept on-site.

· Interview with hospital personnel revealed the hospital utilizes a record storage company located in Memphis, TN for the storage of discharge records. The records are boxed with 12 to 15 records in each and each box is indexed according to the medical record numbers of the charts contained in each box.

· When a record that is not on-site is needed, personnel have to request the chart from the record storage facility. The storage facility locates the box that contains the requested record, pulls the box and delivers the entire box containing the requested record to the hospital. Interview with hospital staff revealed that because of the cost of delivering boxes, several boxes are requested from the storage company before a delivery is made. Usually 20 or more boxes are delivered to the hospital each week. A medical record could be delivered by the next morning after being requested.

· The policies and procedures reviewed for the storage of medical records did not include the policy related to Record Storage Facility and how the the records are boxed, requested, returned, etc.

· Even though there have been no incidents as of the date of the survey related to the transport of medical records back and forth to the hospital, the probability of an incident exist with the number of records that are being shipped back and forth each week.

Based on observation, and testing, the hospital failed to be constructed, arranged, and maintained to ensure the safety of patients.

Findings Include:

Refer to A709 for the hospital's failure to comply with the Life Safety Code, and A710 for the hospital's failure to comply with the applicable provisions of the Life Safety Code of the National Fire Protection Association.

Based on observation and testing, the hospital failed to be constructed, arranged, and maintain to ensure the safety of the patients.

Findings Include:

The standard of Life Safety Code is considered not met due to the hospital's failure to comply with the applicable provisions of the Life Safety Code of the National Fire Protection Association. Refer to A710.

Based on observation and testing, the hospital failed to be constructed, arranged, and maintained to ensure the safety of the patients.

Findings Include:

1. Refer to K-025--The hospital failed to maintain smoke barrier walls capable of resisting the passage of smoke.
2. Refer to K-029-- The hospital failed to properly protect hazardous areas.
3. Refer to K-052-- The hospital failed to provide a properly tested and maintained fire alarm system.
4. Refer to K-145-- The hospital failed to properly protect all of the components of the emergency generator.