HospitalInspections.org

Based on record review, interview, and policy review the facility failed to retain and secure the medical record of 1 (pt.#2) of 13 patients resulting in the potential to breech confidential medical information. Findings include:

On 7/10/2018 at 1100 a review of the document of discharged patients from 5/1/2018 to 7/10/2018 the facility failed to have pt.#2 (patient of the complaint investigation) listed as being at the facility for care.

On 7/10/2018 at 1120, staff A the Director of Risk and Quality was queried if he was familiar with pt.#2. Staff A responded "yes...the patient was at our facility for less than four hours and discharged himself." Staff A further responded "when a patient is not at our facility at midnight they are not listed on the discharge log if they checked in on the same day." Staff A was then asked if the patient belongings log would contain the patient and the items the facility secured upon his entry. Staff A then reviewed the patient belongings log and verified the patient was listed on the log with the items the facility secured.

On 7/11/2018 at 0900, staff A stated that although a thorough search had been conducted patient #2 medical record could not be located. Staff A was then queried if at a minimum should the facility have kept the patient consents for admission. Staff A replied "yes...unfortunately we have yet to find anything of the patient's chart."

On 7/11/2018 at 1000 a review occurred of the policy titled "Admission procedures", policy number 2.00.00, dated 2/2018. According to the policy it states "unless admitted by the involuntary process, the patient must sign the (facility name) admission form with specific treatment procedures and the general unit philosophy, the admission consent form and an Adult Formal Voluntary Admission application before entering the unit."