HospitalInspections.org

Based on observation and interview the hospital failed to provide security for patient's archived medical records in a shared medical record room and in 4 of 4 medical record rooms.
Findings include:
On 10/31/12, at 10:10 a.m., during the hospital tour it was noted that the hospital medical record office shared an open space with the unafilliated clinic medical records office. Unauthorized clinic staff had access to 30 days of current medical records waiting to be scanned, as well as cardex files indicating patient hospital admission dates and medical record numbers.
The hospital shared four rooms of stored patient medical records with the clinic's medical records. The key for these rooms hung on the wall in the clinic medical record office. There were no safe guards to determine if unauthorized staff had been in the hospital patients records.
Interview with the supervisor of health information management on 10/31/12, at approximately 10:15 a.m. stated the clinic staff arrived at 6:00 a.m. 2 hours before the hospital medical records staff arrived and left one half hour after the hospital medical records staff went home for the day. The keys to the 4 rooms were available to both the clinic staff and hospital staff.
Interview with manager of health information management on 10/31/12, at 10:30 a.m. said they will lock, the records to be scanned, up right away and would take a couple of weeks to secure the rest of the hospital's records.
The hospital's policy Protection of Patient Privacy last revised 7/2010 was unclear to who had access to the paper record. The hospital's policy Protection of Patient Privacy last revised 12/2009 indicated the records must be stored securely. The means for securing such information must be appropriate to the location and the risk of unauthorized access.

The hospital was found out of compliance with 42 CFR 482.41, the Condition of Participation for Physical Environment with deficiencies issued as a result of a Life Safety Code inspection.

Findings include:

Please refer to Life Safety Code inspection tags: K0018, K0029, K0072, K0076 and K141 for additional information.

Based on interview and documentation review the hospital did not ensure 4 of 10 patient care staff (PT-A, PT-B, SLP-A, OT-A ) reviewed for organ procurement (OPO) training received the OPO training.

Findings include:

Review of the hospital training records indicated Physical therapist (PT-A, PT-B), speech therapist (A-SLP) and occupational therapist (OT-A) did not receive training on OPO issues.

Interview with the human resource person on 10/31/12, at 2:40 p.m. indicated the decision in their hospital was to train only the registered nurses. She confirmed the speech, OT, and PT do care for inpatients.