HospitalInspections.org

Based on observation and staff interview it was determined the Critical Access Hospital failed to ensure current outpatient information/records in the therapy department were safeguarded against loss and unauthorized use. This failure impacted all current physical therapy patients, including Patient #12, Patient #13, Patient #14, Patient #15, Patient #16 and Patient #17 and creates the potential for loss or unauthorized access and use of record information for all patients who receive outpatient treatment.

Findings include:

1. Tour and observation of the Therapy Department was conducted on 7/6/15 from 1:46 p.m. to 1:50 p.m. The surveyors were accompanied by the Emergency Department's (ED) Nurse Manager. The department was unlocked and unoccupied by staff at the time of observation.

2. The door of the Therapy Office, contained in the Therapy Department, was observed to be open. The patient appointment book was laying on the desk and multiple files with patient names on the outside were observed to be setting behind the desk in a file holder. A sample of these files revealed the names of Patient #12, Patient #13, Patient #14, Patient #15, Patient #16 and Patient #17. The ED's Nurse Manager agreed with these findings.

3. On 7/7/15 at 8:34 a.m. Physical Therapist #1 confirmed current outpatient records are maintained in hardcopy in the therapy office until patients are discharged.

4. At 7/7/15 at 11:30 a.m. the Rehabilitation Director acknowledged all charts of current inpatients are located on the counter behind the desk in the therapy office and agreed the area should be locked when staff are not present.