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Based on document review and interview, it was determined that the Hospital failed to ensure an effective and well-organized medical record service to maintain medical records and ensure efficient continuity of patient care. Therefore the, the Condition of Participation CFR 482.24, Medical Records, was not in compliance.This has the potential to affexct all inpatients and outpatients who receive care by the Hospital.

Findings include:

1. The Hospital failed to ensure patients' medical records were retained, accessible and secured. See deficiency at A-0438.

Based on interview, observation, and document review, it was determined the Hospital failed to ensure medical records were retained, accessible and secured. This has the potential to affect all in-patients, out-patients and the surrounding communities.

Findings include:

1. During the entrance conference on 3/30/2021 at approximately 9:30 AM, E#1 (Vice President of Quality and Community Services) stated the hospital had a cyber attack on February 21, 2021. E#1 stated all computers, servers, networks, Internet and PACs (Radiology Software) were infected and all patient records were unable to be retrieved as of 3/30/2021.

2. During the tour of the Medical Records Department on 3/30/2021 at approximately 12:30 PM, E#6 (Medical Records Legal Clerk) stated "When medical records are requested, I immediately call the requesting party and notify them there will be a delay. I also follow-up with a fax ..." Approximately 178 medical record requests had been made since 02/21/2021 and each request was observed to have a receipt date, date of phone call and a copy of the fax that was sent. As of 04/01/2021, the records remained inaccessible to the requesting party.

3. The policy titled "Storage, Retrieval and Retention of Patient Records" (issued by the Hospital March 2019) was reviewed on 3/30/2021. The policy noted "Records are maintained for all patients who receive treatment ... are maintained to ensure confidentiality of patient health information.... A storage and retrieval system has been established to meet the following guidelines, A. The current record system will retain records according to an approved retention schedule... B. To preserve the records and protect them against unauthorized access, loss, or inadvertent destruction during all phases of required retention and to protect confidentiality.... E. Prompt retrieval..."

4. Between 05/2020 and 01/2021, the following sexual assault survivors presented to the Emergency Department for a medical screening exam. As of 04/01/2021, their records. remained inaccessible for review
a) Pt #11, Date of Service (DOS): 1/18/2021;
b) Pt #12, DOS: 11/06/2020;
c) Pt #13, DOS: 08/15/2020;
d) Pt #14, DOS: 06/09/2020;
e) Pt #15, DOS: 05/03/2020.