HospitalInspections.org

Based on observation, staff interview and policy review the facility failed to ensure access to medical records was limited to individuals with a need to know patient information for 1 of 1 storage areas. The findings were:

Observation on 6/1/22 at 10:15 AM of the medical records storage area in the basement of the hospital showed a large room with wall shelves on all four walls and several floor to ceiling island shelves. All shelves were filled with folders containing medical records. The door of the room had a lock system activated by pass-cards issued by the facility information technology department. The following concerns were identified:
a. Interview with the director of the medical records department on 6/1/22 at 10:30 AM revealed all medical record department staff and all maintenance department staff had access to the storage room. Further interview revealed the director was unaware of the requirement for access restriction.
b. Interview with the facility assistant CEO on 6/1/22 at 10:35 AM revealed administration concurred with medical records statement and further stated maintenance had access for building maintenance and emergency purposes.
c. Review of the policy titled "Health Record Processing CoP 485.60 CAH Clinical Records" dated 6/2021 showed "Hardcopy records must be organized and stored in such a manner that they may be efficiently retrieved by authorized personnel for patient care, business matters, or legal requirements, but are still secured from unauthorized access."

Based on staff interview, staff vaccine documentation review, employee email review, and policy and procedure review, the facility failed to ensure a procedure was in place to monitor for compliance regarding additional precautionary measures intended to mitigate the transmission and spread of COVID-19 for those staff who were not fully vaccinated. There were 33 (of 186) employees who were granted exemptions. The findings were:

Review of the 4/2022 revised policy and procedure titled, "COVID-19 VACCINATION" showed the facility had a policy and procedure to address COVID-19 vaccination status for staff. The following concerns were identified:
a. Review of the 4/2022 policy and procedure regarding staff vaccination and exemptions for COVID-19 showed the facility had a process in place for staff to apply for medical and religious exemptions. However, the policy failed to address any required additional precautionary measures for exempt staff to take to mitigate the transmission and spread of COVID-19.
b. Review of the 3/11/22 email from HR #1 to staff exempt from the COVID-19 vaccination showed exempt staff could choose from 2 additional precautionary measures: weekly testing, or use of an N95 or equivalent mask while at the facility. The email failed to detail how that choice would be known by the facility, and failed to document any monitoring of the staff choice regarding compliance. Review of the staff vaccine documentation showed 33 staff exemptions. Review of the contracted staff showed 13 exemptions.
c. Interview with the infection preventionist (IP) on 6/2/22 at 2:05 PM confirmed the facility policy and procedure for staff COVID-19 vaccinations did not include additional measures for exempt staff. She further confirmed the 3/11/22 email to exempt staff failed to establish a process for the facility to determine which of the 2 additional measures each employee chose, the facility had not tracked which measure each exempt employee chose, and the facility had not monitored exempt staff regarding compliance. The IP stated she reviewed staff testing, but had not specified monitoring of exempt staff, as the facility had not determined which exempt staff chose testing, and which chose N95 masks.