HospitalInspections.org

Based on observation during a tour of the Critical Care Unit and staff interview, it was determined the facility failed to safeguard the contents of patient medical records for fourteen (14) of fourteen (14) patients. This has the potential to violate all patients rights to the confidentiality of their medical records.

Findings include:

1. Observation during a tour of the Critical Care Unit (CCU) conducted on 09/12/16 revealed patient charts are kept unsecured at desks located outside patient rooms. Unsecured charts were noted for fourteen (14) of fourteen (14) patients in rooms 2101, 2102, 2103, 2104, 2106, 2108, 2109, 2111, 2112, 2114, 2117, 2118, 2119 and 2120. A computer was observed to be on with patient information on the screen outside room 2111. The Registered Nurse was inside the patient's room. The Critical Care Director was observed closing the screen on the computer.

2. When the Critical Care Director was questioned regarding the unsecured patient charts, he reported the nurses are usually at the desk. When asked where the charts were when the nurse was in the patient's room he replied: "At the desk".

3. On 09/12/16 the Critical Care Director and the Vice President of Nursing concurred with these findings.

4. Review of facility document titled "Security and Protection of the Medical Record", with a last revised and/or reviewed date of 7/14 states: "Records not yet in electronic format shall be protected by all clinical staff in respective hospital areas until such time as scanned into HPF as the legal medical record".

5. An interview was conducted on 09/14/16 at 2:25 p.m. with the Director of Health Information/Privacy Officer. When questioned regarding unsecured patient charts on the Critical Care Unit she stated in part: "It is a locked unit...There is no policy on charts and the specifics of where they need to be located for CCU."

6. On 09/14/16 the Director of Health Information/Privacy Officer concurred with these findings.

Based on record review and interview it was revealed the facility failed to ensure adequate documentation of a patient's discharge planning evaluation for use in establishing an appropriate discharge plan in nine (9) of ten (10) records reviewed (#1, 3, 4, 5, 6, 7, 8, 9, & 10). This failure has the potential for all patients at the facility to be negatively impacted by inadequate discharge planning.

Findings include:

1. The facility policy entitled 'Discharge Planning System, last revised 7/16, was reviewed on 9/15/16'. It stated under the heading of 'Procedure: During Admission: The Case Management staff will identify needs. The Case Management staff will document the discharge plan in the permanent patient medical record'. The next heading is 'After Admission: The Case Management staff will reassess the discharge plan...evaluating whether the plan meets the individual needs of the patient and make any changes to the plan to meet those needs'. The last heading is 'Prior to day of discharge: Case Management staff ensures post discharge care arrangements are complete'.

1. Records were reviewed for patients #1, 3, 4, 5, 6, & 7. No documentation of Case Management identifing the patient's needs during admission were found in the record. No documentation of Case Management staff reassessing the discharge plan were found in the record. Lastly, no documentation of Case Management staff ensuring post discharge care arrangements were complete were found in the record.

In an interview with the Manager of Case Management/Social Services and the Nurse Manager of Behavior Health on 9/14/16 at about 1:56 p.m. the above findings were discussed. They agreed this documentation was not on the patient record.