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Based upon review of 1 of 5 medical records (#5), grievances filed from 09/10 to 01/11, and staff interviews, the hospital failed to ensure confidentiality of patient information as evidenced by providing a copy of patient #5's medical record to family members that contained another patient's information. Findings:

Review of the grievances filed from 09/10 to 01/11 revealed on 12/13/10, the family of patient #5 filed a complaint regarding an Intensive Care Unit Nursing Progress Note that identified the patient had undergone dialysis of which the family was unaware and did not give permission for the dialysis treatment. Investigation of the complaint by Risk Manager S4 revealed the Nursing Progress Note in question belonged to another patient that was in the Intensive Care Unit at the same time as patient #5. S4 further documented that due to the HIPAA violation, this was brought to the attention of the Director of Medical Records, S6.

Interview with Risk Manager S4 on 03/15/11 at 9:50 AM, revealed during her investigation of the complaint related to patient #5, she identified another patient's information was located in patient #5's medical record that was copied and sent to the family. The incident was then forwarded on to the Medical Records Director S6 regarding a possible HIPAA violation.

Interview with Medical Records Director S6 on 03/16/11 at 12:20 PM revealed the hospital uses a contracted company for medical record storage and when a copy of a closed record is requested, the contracted company copies the medical record. S6 further stated if the patient was in the Intensive Care Unit, the 6 page flow sheet would be separated into 6 individual sheets in order to make the copying process easier. When asked how another patient's medical information could be mixed into patient #5's copied medical record, S6 stated he was not aware this had occurred and would check on it. Further interview with S6 on 03/16/11 at 2:35 PM revealed he had no record that a possible HIPAA violation had occurred and when it was discovered in 12/10, S6 stated he was on vacation during that time and if the information had been slipped under his door, housekeeping could have "possibly moved or shredded it".

The hospital failed to safeguard confidential patient information from unauthorized disclosure by allowing another patient's clinical information to be copied and sent to the family of patient #5.

Based upon review of 1 of 5 medical records (#5), Quality Assurance/Performance Improvement Activities, and staff interviews, the hospital failed to ensure quality indicators were developed for monitoring closed medical records as related to the Intensive Care Unit (ICU) 24 hour treatment records used prior to the implementation of the computerized system for nursing notes. During the medical record copying process, the ICU record would be separated into 6 individual pages and when copied, each page failed to identify the patient's name and the date of service. Findings:

Review of patient #5's closed medical record revealed the patient was hospitalized from 08/12/10 to 08/30/10. From 08/18/10 to 08/30/10, the patient was in the Intensive Care Unit and the nursing staff utilized a 6 page 24 hour treatment record for documentation. It was further found during the review this 6 page ICU treatment record was separated into 6 individual pages with each page failing to identify the treatment date and the patient's name.

On 03/16/11 at 12:20 PM, interview with the Medical Records Director S6 revealed when the department received the patient's closed medical record, if the patient had been in the ICU during the hospitalization, the 6 page tri-fold treatment record was attached. If a copy of the medical record was requested, the ICU treatment record would be separated into 6 individual pages to make copying process easier. A copy of patient #5's medical record was requested and reviewed with Medical Records Director S6 and the Chief Nursing Executive S1 on 03/16/11. During this review it was found when the 6 page ICU treatment record was separated, the pages were not in chronological order and the patient's name and date of service failed to be documented on each page. When asked if the medical record department reviewed the closed medical record for completeness related to nursing entries, S6 stated this review would be done by the Registered Nurse during the 24 hour shift audit while the patient was still in the hospital.

Interview with the Risk Manager S4 on 03/15/11 at 9:35 AM, revealed she had investigated a patient complaint related to a copied medical record that was requested by the family of patient #5. According to S4, the family was questioning why it was documented on an ICU Nursing Progress Note that patient #5 had a dialysis treatment. Through her investigation she found the ICU Nursing Progress Note in question, which failed to identify a patient name or date of service, belonged to another patient.

Further interview with Medical Records Director S6 and the Quality Resource Manager S8 on 03/16/11 at 2:35 PM, revealed when asked if there were any quality assurance indicators for monitoring the medical record for completeness, S6 replied the only indicators reviewed by the Medical Record Department were related to the Medical Staff's completion of the History and Physical within a 30 day time frame and that the transcription was in the medical record.

Interview with the Chief Nurse Executive S1, and the Director of Staff Development S2, on 03/16/11 at 3:00 PM, revealed after August 2010, the hospital used computerized nursing notes and the 6 page ICU 24 hour treatment record would not be used unless the computer system was down. It was confirmed with S1 and S2 that if a medical record copy was requested and the ICU treatment records were present, there was not a system in place to monitor the copied record to ensure all entries were dated and the patient's name present on each copied page.

Based upon review of 1 of 5 medical records (#5), and staff interview, the hospital failed to ensure patient #5's medical record was complete with each entry dated along and the patient's name identified. This was evidenced by the hospital separating the 6 page tri-fold Intensive Care Unit 24 hour treatment record into 6 individual pages resulting in missing entries for the date of service and the lack of the patient's name being present on each page. Findings:

Review of patient #5's medical record revealed the patient was admitted to the hospital on 08/12/10 and expired on 08/30/10 from respiratory failure. During review of the medical record it was found during August 2010, the Intensive Care Unit used a tri-fold six page treatment record for recording 24 hour nursing care; however, each 24 hour ICU record had been separated into 6 individual pages. Page 1 was titled Patient Progress Notes, Pages 2, 3 and 4 were 24 hour graphic pages documenting the patient's Intake and Output, Vital Signs, Ventilator Settings, Cardiac Monitoring and sensorium level. Pages 5 and 6 were again titled Nursing Progress Notes. On page 2 of the ICU record, there was an area to place the patient's name stamp and on page 3 there was a designated area for documenting the date and patient name. At the bottom of page 4 was an area to document the date; however, on pages 1, 4, 5, and 6 there was not an area identified for the patient's name. Review of the 24 hour ICU treatment records from 08/18/10 to 08/30/10 revealed each page of the 24 hour ICU treatment record failed to identify the date of treatment and patient name.

Interview with the Medical Records Director S6 on 03/16/11 at 12:20 PM, revealed when the department received the closed medical record, assemblers and analyzers review the medical record for completeness. If missing components were identified, a checklist would be placed on the front of the medical record and once completed, the medical record would be assembled in accordance with an outline. When asked if this included reviewing the nursing documentation for dates, times and signatures, S6 replied "no" and that this review would be conducted by the Registered Nurse during the 24 hour chart audit.

Further interview with S6 revealed when a medical record was copied, the ICU record would be separated into 6 individual pages for easier copying. It was confirmed by Medical Records Director S6 and the Chief Nurse Executive S1 when the ICU tri-fold record was separated, the patient's name and date of service was not documented on each page of the patient's record.

On 03/15/10, a copy of patient #5's medical record was requested. During this review it was found when the 6 page ICU treatment record was separated and copied, the pages were not in chronological order and the patient's name and date of service failed to be documented on each page. This made it difficult to identify the treatment provided to the patient in the 24 hour period.

The hospital failed to ensure the ICU 24 hour nursing treatment record contained the patient's name and date of service on each page to ensure when the medical record was copied, it was for the correct patient and the nursing progress notes documenting the patient's care was in chronological order.