HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the patient right to the confidentiality of his or her clinical record for one of one patient (Patient #1) whose personal and detailed medical care information was made accessible to Patient #2.




Findings included:

Patient #2's electronic medical record contained a scanned 18-page discharge summary report dated 08/09/16 at 1126 reflecting Patient #2's name, medical record number, and hospital encounter number in the document's header.

Patient #2's discharge summary report reflected Patient #1's discharge summary data. It included instructions regarding Patient #1's self-care and wellness needs, medications, allergies, vital signs noted during Patient #1's 19-day hospitalization, results of urine and blood lab tests, and more than 70 results of point of care blood glucose testing dated 07/21/16 at 2016 through 08/07/16 at 1957. In addition, the document contained Patient #1's full name, date of birth, room/bed assignment, hospital encounter number, and the name of Patient #1's personal care physician. The last page of the document was dated 08/09/16 at 1126 and carried Patient #2's signature.

Employee #17 stated during a face-to-face interview on 10/26/16 at 1130 that nursing staff reviewed discharge information with the patient.


During a telephone interview on 11/03/16 at 1612, Employee #3 acknowledged the above findings and denied awareness that Patient #1's personal and medical information had been accessible to Patient #2.


Hospital Patients' Rights Policy RI.01.01.1 dated 09/2016 reflected that hospital patient's rights included the privacy regarding medical care.