HospitalInspections.org

The hospital governing body entrusted with the services provided at the hospital failed to ensure the rights of 11 of 11 patients (Patients # 27, #30, #29, #28, #11, #38, #2, #41, #34, #13, #32) to confidentiality of their medical records when a non-hospital-credentialed person had weekly access to all patient records to prepare physician discharge summaries.

Findings included:

Record review of the hospital's credentialing list, employee roster, and list of contracted services provided by the hospital on 04/12/23, did not reflect the name of Non-hospital Personnel V.

Record review of Patients #27, #30, #29, #28, #11, #38, #2, #41, #34, #13, and #32 on 04/14/23 reflected their discharge summaries were signed by Non-hospital Personnel V.

During a meeting on 04/14/23 at or around 1445, administrative Hospital Personnel A and Hospital Personnel W denied awareness of non-hospital Personnel V. Hospital Personnel A denied awareness of the physician discharge summary dictation process. The administrative personnel confirmed that Non-hospital Personnel V did not have a credentialing or employee file.

Hospital Personnel C stated on 04/14/23 at 1445 that Non-hospital Personnel V "is here once a week in [the] medical records [department]."

During an interview on 04/14/23 at 1455, Hospital Personnel X stated that Non-hospital Personnel V came into the hospital's medical record department "once a week to do discharge summaries for the doctors."

Hospital Personnel Y stated during an interview on 04/14/23 at 1505 in the hospital's medical records department that Non-hospital Personnel V "dictates and writes the discharge summaries himself for the doctors. He is not transcribing recorded dictations from the doctors. He is the one writing the discharge summaries."