HospitalInspections.org

Based on direct observation, review of patient records and staff interviews, it was determined the hospital failed to keep patient medical records in a secure location for patient #3, 4, 5, and 6. This deficient practice poses the potential risk to patient health and safety when hospital staff fail to implement methods to prevent unauthorized persons from gaining physical access to information in patient records.

Findings include:

Direct observations were conducted on 11/20/2019, of the medical / surgical / telemetry unit with employee #1 and #2. When this surveyor asked to review the nursing documentation and medication administration record for patient #8, employee #2 walked over to the wall directly across from patient #8's room, and opened the unlocked bin, labeled with the room number for patient #8. The storage bin contained a variety of medical records for patient #3, 4, 5, and 6. The bin labeled with patient #8's room number did not have any medical records for patient #8.

The following documents were located in the unlocked storage bin for patient #8:

PATIENT #3
- One (1) telemetry strip (11/20/2019)
- One (1) Nursing assessment flow sheet (11/20/2019)
- Two (2) medication administration records (11/20/2019)
- One (1) telemetry strip (11/20/2019)

PATIENT #4
- One (1) "Nursing Assessment" flow sheet (11/20/2019)
- One (1) "Medication Administration Record" (11/20/2019)
- One (1) "Report Sheet" (11/20/2019)

PATIENT #5
- One (1) "Nursing Assessment" flow sheet (11/20/2019)
- One (1) "Medication Administration Record" (11/20/2019)

PATIENT #6
- Two (2) "Medication Administration Records" for patient #6 (11/20/2019)
- One (1) telemetry strip (11/20/2019)
- One (1) "Nursing Assessment" flow sheet (11/20/2019)

Employee #6 confirmed in an interview conducted on 11/20/2019, that s/he was assigned to care for pateint #3, 4, 5, and 6 and placed the documents in the bin labeled with patient #8's room number stating, "I didn't even pay attention to the number on the bin".

Employee #1 confirmed in an interview conducted on 11/20/2019, the documents found in the bin for patient #8, did not belong in this location and identified that anyone walking down the hall has access to these documents.