HospitalInspections.org

Based on observation, interviews and policy review the facility staff failed to prevent possible unauthorized access and protect confidential patient medical records when:
-medical records were left unattended and unsupervised
-doors were not locked at the close of business
-a door to the medical record room was unlocked and was accessible to a private business
- a key to the medical records was kept in an unlocked drawer and was accessible to housekeeping staff. The facility census was 38.

Findings included:

1. Observation on 1/10/11 at 1:40 PM, showed an open door to the medical records room of the Pain Clinic which is part of the hospital. The room was open and unattended.

During an interview on 1/10/11 at 1:45 PM, Registered Nurse (RN), Staff L stated the door is not usually locked.

During an interview on 1/10/11 at 2:30 PM, RN, Staff K of the Western Missouri Women's Health Center stated the two doors to the medical records room, where all patient medical records are kept were not always locked when the office closed. He/she stated the housekeeping staff often cleaned the room at night and were unsupervised.

Observation on 1/10/11 at 3:00 PM, at Surgical Services of Warrensburg showed an unlocked door to the medical records room which contained pateint medical records. This door opened into a private business that was not affiliated with Surgical Services.

During an interview on 1/10/11 at 3:30 PM, RN, Staff K at Western Missouri Bone and Joint stated the medical records are kept locked. He/she stated the key to the medical records room is kept in his/her desk drawer which is unlocked. He/she stated housekeeping comes in to clean after business hours and they are unsupervised by facility staff. His/her office is cleaned by housekeeping staff and the key to the medical records would be accessible in an unlocked desk drawer.

Record review of the facility policy titled "Health Information Mgmt., Access to the Medical Record on or behalf of the patient Number: 7180.6050" effective 1/15/10, showed (in part) the following information:
- ...the general rule governing access by the patient may be stated as follows: The medical record is a confidential document, access to which should be restricted to the patient, the patient's authorized representative, and to the attending physician and hospital staff members with a legitimate need for such access.