HospitalInspections.org

Based on observation, document review and staff interview it was determined the Director of Nursing failed to ensure the confidentiality of twenty-seven (27) out of twenty-seven (27) medical records. This failure has the potential for all patients admitted to the hospital to have their medical records breached or stolen.

Findings include:

1. A tour of the hospital was conducted on 01/28/19 at 9:45 a.m. with the Director of Quality. It was noted that every patient on the unit had an unsecured medical record outside of their room in unlocked wall boxes. At the time of the tour the hospital had a census of twenty-seven (27) patients.

2. Review of the policy titled "Medical Records Security Policies" with a revision date of 2/2019 revealed it states in part: "Paper records and medical charts must be stored or filed in such a way to avoid access by unauthorized persons."

3. A review of the patient rights, with no published date noted, revealed it states in part: "The patient has the right to every consideration of privacy."

4. An interview was conducted during the tour with the Director of Quality and she concurred the medical record boxes outside of the patients' rooms should have been locked to maintain their privacy.

Based on observation, document and staff interview it was determined the Director of Nursing failed to ensure the confidentiality of twenty-seven (27) out of twenty-seven (27) medical records. This failure has the potential for all patients admitted to the hospital to have their medical records breached or stolen.

Findings include:

1. A tour of the hospital was conducted on 01/28/19 at 9:45 a.m. with the Director of Quality. It was noted that every patient on the unit had an unsecured medical record outside of their room in unlocked wall boxes. At the time of the tour the hospital had a census of twenty-seven (27) patients.

2. Review of the policy titled "Medical Records Security Policies" with a revision date of 2/2019 revealed it states in part: "Paper records and medical charts must be stored or filed in such a way to avoid access by unauthorized persons."

3. A review of the patient rights, with no published date noted, revealed it states in part: "The patient has the right to every consideration of privacy."

4. An interview was conducted during the tour with the Director of Quality and she concurred the medical record boxes outside of the patients' rooms should have been locked to maintain their privacy.

Based on observation, document review and staff interview it was determined the Director of Nursing failed to ensure the confidentiality of twenty-seven (27) out of twenty-seven (27) medical records. This failure has the potential for all patients admitted to the hospital to have their medical records breached or stolen.

Findings include:

1. A tour of the hospital was conducted on 01/28/19 at 9:45 a.m. with the Director of Quality. It was noted that every patient on the unit had an unsecured medical record outside of their room in unlocked wall boxes. At the time of the tour the hospital had a census of twenty-seven (27) patients.

2. Review of the policy titled "Medical Records Security Policies" with a revision date of 2/2019 revealed it states in part: "Paper records and medical charts must be stored or filed in such a way to avoid access by unauthorized persons."

3. A review of the patient rights, with no published date noted, revealed it states in part: "The patient has the right to every consideration of privacy."

4. An interview was conducted during the tour with the Director of Quality and she concurred the medical record boxes outside of the patients' rooms should have been locked to maintain their privacy.