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Based on interview and policy review, the facility failed to protect the confidentiality of patients diagnosed with infectious disease, when submitting written follow up notification of the possible exposure to transferring facility or emergency transport service personnel.

Findings include:

1) On 1/16/13 at 10:00 am, an interview was conducted with the infection control nurse. She was asked: When it is determined that a patient who has been transferred to the hospital from home or other facility has a confirmed diagnosis of an infectious disease, who makes the initial notification of the potential exposure? She stated "I do that". She was asked how the notification was made. She stated, "the first notification is by email with a follow up fax within 48 hours". She was then asked if the confidentiality of the infected patient is protected during notification process and she stated, "yes, the information that is emailed to the facility or the person involved, does not include the name of the patient that has been diagnosed, just their initials. But the follow up fax does have the name of the patient".

2) Review of the policy and procedure of the facility for notification was reviewed. It clearly indicated that no patient name will be included in the notification.

Based on patient record review, policy review and staff interview, the facility failed to follow their policy by not maintaining a complete record following discharge for 1 of 10 discharge records (#26).

The findings are:

Review of patient record #26 on 1/16/13, indicated the patient was discharged on 12/13/12. The record had an unsigned consult report from 12/4/12 and unsigned operation report from 12/6/12.

The facility's policy titled "Deficiency Management" indicted Medical records were considered delinquent when not completed within 30 days of discharge.

Interview with the Medical Records Director on 1/16/13 at approximately 2:40 pm indicated: "the physicians have 30 days to complete the charts".