HospitalInspections.org

Based on observation and interview the facility failed to ensure that unauthorized individuals cannot gain access to or alter patient records. Findings include:

During the tour of the Short Stay Unit (SSU) on 7-12-11 at approximately 1240 it was observed that patient medical records were being kept on a centralized nursing station with the names of the patients observable and the charts easily accessible.

During an interview with staff D, E, and F on 7-12-11 at approximately 1245 they all confirmed these findings.

During the tour of the General/Surgical Unit, 5E on 7-12-11 at approximately 1300 it was observed that patient medical records were outside the rooms placed sideways into a wall file with the patients names visible and easily accessible.

During an interview with staff D and G on 7-12-11 at approximately 1315 these findings were confirmed.

During the course of the complaint investigation on 7-12-11 and 7-13-11 at multiple times throughout the survey and with the frequent interaction with the medical records department, it was found that the back door of the medical records department was unlocked on multiple occasions. On one occasion this surveyor was able to access medical records and walk thru the area for several minutes before being asked if help was needed.

During an interview with staff C on 7-13-11 at approximately 1000, she confirmed these findings. When asked why the door remained unlocked, she said it was because, "staff complained about having it locked". She immediately locked the door and said it would no longer be left unlocked.

Based on interview and CMS regulations, the facility failed to ensure that all medical records had a final diagnosis and completed within 30 days following discharge. Findings include:

During an interview on 7-13-11 at approximately 1030 with Director of Health Information Management, it was identified that there were 710 incomplete patient medical records beyond the 30 days following discharge.