HospitalInspections.org

Based on observation and staff interview, the Critical Access Hospital (CAH) failed to provide safeguards against loss, destruction, or unauthorized use of medical records for 1 of 3 off-site medical record storage areas (basement of clinic building north of the CAH). Failure to store records in a secure manner limited the CAH's ability to prevent loss or destruction of records and to ensure the maintenance of patient confidentiality.

Findings include:

Observation, at approximately 10:00 a.m. on 05/08/13, of the CAH's medical record storage area in the basement of the clinic building north of the CAH identified boxes of inactive medical records from the CAH. The basement door did not have a lock and was in an area of the building accessible to the public.

During interview, at approximately 10:10 a.m. on 05/08/13, two administrative staff members (#1 and #2) confirmed the CAH did not securely store the records in the basement of the clinic building. The staff members confirmed the CAH rents the main level of the building to another business. This business is open at times when CAH staff is not present in the building. The business owner and clients have access to the basement of the clinic.

During interview, at approximately 10:30 a.m. on 05/08/13, an administrative medical records staff member (#3) confirmed the CAH did not securely store the records in the basement of the clinic building north of the CAH.

Upon request on 05/08/13, the CAH did not provide a policy requiring storage of medical records in a confidential and secure manner.