HospitalInspections.org

Based on observation, interview and policy and procedure review the facility failed to ensure the confidentiality of patients medical records. Findings include:
During the observational tour of the facility on 5/23/12 at approximately 1300 there were three pages of Respiratory Therapy assignments for March 31st, 2012 for eight different patients found in the airway box unsecured. These assignment sheets have patients names, room #'s, history, diagnosis, orders, assigned doctors, etc. This finding was confirmed by Staff A.
During policy and procedure review on 5/24/12 at approximately 1300 it was found in the policy titled, "Confidentiality of Records", states under #3, "All departments and sections responsible for retaining information shall exercise suitable precautions to insure that unauthorized individuals cannot gain access to these records".

Based on medical record review, policy and procedure review and interview the facility failed to ensure that hospital policy and procedure for non-violent restraint use was followed for 5 out of 7 (#8, #10, #15, #16, and #17) restrained patients medical records reviewed. Findings include:

During policy and procedure review on 5/24/12 at approximately 1400 in the policy titled, "Restraints and Seclusion" states, "Restraint must be ordered by a physician", "An initial assessment performed by the RN shall be reviewed by the physician and a physician's order is issued as indicated. The physician's order indicates agreement with assessment and the plan of care to use restraints", "A written order, based on an examination of the patient by the MD/DO or LIP is entered into the patient's medical record on a daily bases when restraint use is clinically appropriate", "Orders for restraints must be renewed on a daily basis. The order for a restraint may never be written as a standing order or on an as needed bases (PRN)".

During medical record review through out the survey the following was found in regards to restraint orders:
1. Patient #8 medical record indicated that from 4/29/12 thru 5/8/12 there were 5 out of 10 restraint orders not dated or timed by the ordering physician.
2. Patient #10 medical record indicated that for the twenty-one days reviewed of the patient being in restraints, 4 of them were not dated and timed by the physician. The 4/27/12 order sheet was not signed until 4/30/12 and multiple order sheets had the date and time written in by the Registered Nurse filling out the form, not the physician when it was actually signed.
3. Patient #15 medical record indicated that from 4/11/12 thru 5/3/12 there were 9 out of 23 restraint orders not dated or timed by the ordering physician.
4. Patient #16 medical record indicated that from 1/12/12 thru 2/13/12 there were 20 out of 32 restraint order sheets not dated or timed by the ordering physician.
5. Patient #17 medical record indicated that the restraint order sheet for 3/1/12, 3/2/12 and 3/3/12 were not signed dated or timed by the physician until 3/3/12 at 1830. The 3/6/12 restraint order sheet had not been dated or timed by the ordering physician. The 3/7/12 restraint order sheet was not signed until 3/8/12 by the physician.

These findings were confirmed by Staff A.