HospitalInspections.org

Based on observation and staff interview the facility failed to ensure access to medical records was limited to individuals with a need to know patient information for 1 of 1 storage areas. The findings were:

1. Observation on 2/10/22 at 8:45 AM of the medical record storage area showed a single room which stored paper medical records on metal shelves. Access to the room was provided by the director of the maintenance department. The room was dry and with sufficient space for access to all records. The shelving consisted of approximately 6 shelves, 8 foot tall and 15 foot long. The area was protected by the building's fire suppression system. The following concerns were identified:
a. Interview with the director of medical records on 2/10/22 at 8:45 AM revealed her office was at an offsite location which did not house any medical records. The facility had a limited number of records in storage due to the facility recording all current records in digital format and those records in storage being systematically transferred to digital format or destroyed at the end of the required storage time. Further interview revealed the medical record department had a key to the storage area as did the maintenance department. The director stated that she did not know that maintenance having a key was a problem.
b. Interview with the director of the maintenance department on 2/10/22 at 9 AM revealed he did have a key to the storage area, as did all of the maintenance staff. Further interview revealed access to the area was required for maintenance and inspection functions.