HospitalInspections.org

Based on observation and staff interview it was determined the hospital failed to ensure the confidentiality of clinical records/patient information is maintained. This practice was noted during two (2) of two (2) observations and has the potential to adversely impact the confidentiality of records for all patients.

Findings include:

1. Tour and observation of the nursing unit was conducted at 1330 on 4/28/14. The surveyors were accompanied by the Chief Nursing Officer (CNO). During this tour unlocked boxes were noted in the hallways. The surveyor opened the box located between patient rooms 219 and 220. Multiple pages of patient information, each labeled Confidential Document, were found. The CNO removed this patient information.

The CNO stated the information in the box was patient kardexes and acknowledged this should not be left in the unlocked wall boxes.

During this same tour medical records were noted to be hanging from the bottom of the patient beds. The CNO stated these were 'travel charts' which include patient demographics such as patient name, date of birth, admission date and medical record number. The chart also included patient flowsheets, treatment information and progress notes.

The CNO acknowledged these 'travel' charts were kept in the patient rooms and were not under constant visual observation.

2. Tour and observation was conducted on the nursing unit at 0845 on 4/30/14. The surveyor again observed medical records hanging on the foot of patient beds. The surveyor opened the box located between rooms 219 and 220. Multiple pages of patient information, each labeled 'Confidential Document', were found. Some pages were dated 4/29/14 and some were labeled 4/30/14.

This patient information was reviewed and discussed with the Nurse Supervisor at 0905 on 4/30/14. She stated these were 'patient kardexes from yesterday and today'. She confirmed the patient information is to be kept with the staff or behind the nursing desk.