HospitalInspections.org

Based on review of medical records and interview with staff, the hospital failed to ensure that all discharged medical records from the geriatric psychiatric unit were protected from unauthorized use.

Findings include:

1. At 11:15 a.m. on 05-17-11, geriatric psychiatric medical records were found to be filed on open shelves in the outer office of the medical record department. One employee works in the room. On both days of the survey the door was observed to be open to the hallway, even when the employee was not at her desk.

2. The Director of the Medical Record Department stated that these geriatric psychiatric medical records were filed in the department because the geriatric psychiatric unit's file room did not have available filing space to accommodate any more records.

3. On 05-17-11 at 1:00 p.m., the file room in the geriatric psychiatric unit was found to be locked. The room contained open shelf files, and all shelves were full of records.

Based on review of Medical Staff Rules and Regulations, and review of medical records, the hospital failed to ensure that all medical record entries were timed.

Findings include:

1. Twenty (20) medical records were selected at random from a list of discharges for February, March and April, 2011, and reviewed along with five (5) inpatient medical records for a total of 25 records reviewed.

2. Physician progress notes had not been timed when written in the medical record on 16 of 25 medical records reviewed.