HospitalInspections.org

Based on review of records and interview, the hospital did not provide physician availability for emergency services for January 1, 2010 through February 5, 2010 for 7:00 am through 7:00 pm.

Findings:

In the Medical Staff Rules & Regulations dated 12/17/09, "Use of Emergency Services: b. Nursing Services shall be responsible for notifying the appropriate practitioners ..."

Hospitalist Coverage On Call Calendar dated January 2010 and February 2010, did not designate physician available for 7:00 am through 7:00 pm for January 1, 2010 through February 5, 2010.

In an interview on the morning of 02/05/10, the Nursing Supervisor (Personnel #7) was asked which physician is available if a patient should present with an emergency. She stated, "I don ' t know."

In an interview on the afternoon of 02/05/10, the CEO (Personnel #1) was asked if there is a schedule for physicians who are available for patients presenting with emergencies from 7:00 am until 7:00 pm. She stated, "No."

Based on review of records and interview, the hospital did not protect confidential patient healthcare information for 3 of 4 patients' (Patient #2, 3, and 4) who were discharged between July 10 and August 14 of 2008.

Findings:

In a Complaint Intake to the Texas Department of State Health Services dated 12/17/09, copies of patient's (Patient #2, 3, and 4) medical records were attached to the complaint.
? Patient #2 Medication Administration Record (pages 3 of 3) dated 07/03/08
? Patient #3 Rehabilitation Nursing Notes dated 06/16/08 and Auxiliary Notes dated 06/25/08.
? Patient #4 Consultation dated 07/25/08

In Administrative Policy "Patient Rights Pursuant To HIPPA" , revised date 07/09, "To ensure that the rights afforded to patient, pursuant to the HIPPA Privacy Laws are properly observed and maintained ..."

In Administrative Policy "Texas - Access, Authorization and Release of Protected Health Information" , revised date 12/14/09, "To ensure that a patient's right to access, authorize access to and release protected health information (PHI) ...is protected and maintained as defined under the HIPPA Privacy Laws."

In Patient Rights and Responsibilities, document number HD_003-DL, not dated, "The patient has the right to: Expect confidentiality of his or her clinical records."

In Hospital Notice of Privacy Practices, document number HD_010, dated 02/25/08, "We are required by law to: Make sure that medical information that identifies you is kept confidential ...."

In an interview the afternoon of 02/03/10, the Health Information Management Coordinator (Personnel #4), was asked if a policy is followed regarding the right to patient confidentiality of health care information. Personnel #4 stated, "Yes, we follow the federal HIPPA (Health Insurance Portability and Accountability Act) Privacy Laws for patient confidentiality."

Based on review of records and interviews, four of four closed patients' medical records (Patient #1, 2, 3, and 4) contained copies of other patient's records and/or copies of records with no patient identifiers.

Findings:

Patient #1 medical record contained:

? Consultation notes dated 07/25/08 of Patient #4
? Rehabilitation Nursing Notes dated 06/16/08 and Auxiliary Notes dated 06/25/08 of Patient #3
? Medication Administration Record (MAR) (3 of 3 pages) dated 07/03/08 of Patient #2
? Physician's Progress Note dated 06/16/08 timed 12:00 with no patient identifier
? Interdisciplinary Progress Note dated 06/05/08 timed 2:00 with no patient identifier
? MAR dated 07/01/08 with no patient identifier.

Patient #2 medical record contained:

? Braden Scale for Predicting Pressure Score Risk undated with no patient identifier
? Physician Progress Notes dated 06/30/08, timed 18:30 with no patient identifier
? Physician Progress Notes dated 06/28/08 timed 15:10 with no patient identifier
? Treatment Administration Record dated 07/28/08 timed 08:00 with no patient identifier
? Rehabilitation Nursing Notes undated, timed 07:00 -19:00 and 19:00 - 07:00 with no patient identifier
? Notes dated 06/28/09 timed 14:50 with no patient identifier.

Patient #3 medical record contained:

? Consultation notes dated 06/13/08 (3 of 3 pages) of Patient #7
? Comprehensive Metabolic Panel Final Report dated 07/04/08 timed 06:30 of Patient #8
? Auxiliary Notes dated 06/23/08 timed 18:00 of Patient #9
? IV Therapy Notes dated 07/10/08 timed 7 am - 7 pm of Patient #10
? Braden Scale for Predicting Pressure Score Risk dated 02/01/08 timed 7 am with no patient identifier
? Auxiliary Notes undated and timed 20:00 with no patient identifier
? IV Therapy Notes undated timed 7 am - 7 pm and 7 pm - 7 am with no patient identifier
? Treatment Administration Record dated 06/14/08 timed 7 am with no patient identifier
? Respiratory Therapy Flow Sheet dated 07/07/08 timed 09:00 with no patient identifier.

Patient #4 medical record contained:

? Medication Reconciliation List (2 of 2 pages) dated 07/25/08 with no patient identifier
? Arterial Blood Gas Results dated 08/03/08 timed 4:32 am with no patient identifier
? Interdisciplinary Assessment (10 of 10 pages) dated 07/28/08 timed 09:12 with no patient identifier.

In an interview the afternoon of 02/03/10, the Health Information Management Coordinator (Personnel #4), was asked what the procedure is for assuring individual patient medical records are filed accurately. Personnel #4 stated that the medical records personnel should visually look at each page of the medical record and verify for accuracy prior to filing the records in a patient's chart.

In Health Information Management (HIM) Policy "Filing", dated 08/07, required, "The HIM Department ...The responsibility for accurate patient identification ...shall routinely check the patient identification and medical record number and account numbers on patient records ...shall be carried out as part of concurrent chart review, discharge processing, assembly, and chart completion."

Based on review of records and interviews, the hospital did not have a procedure in place to protect confidential patient healthcare information, in that portions of three patient's medical records (Patient #2, 3, and 4) were released to an unauthorized individual.

Findings:

In a Complaint Intake to the Texas Department of State Health Services dated 12/17/09, copies of patient's (Patient #2, 3, and 4) medical records were attached to the complaint.
Patient #4 Consultation dated 07/25/08, Patient #3 Rehabilitation Nursing Notes dated 06/16/08 and Auxiliary Notes dated 06/25/08, Patient #2 Medication Administration Record (3 of 3 pages) dated 07/03/08.

In an interview the afternoon of 02/03/10, the Health Information Management Coordinator (Personnel #4), was asked what the procedure is for assuring that no other patients' medical records are included in a patient's chart prior to release. Personnel #4 stated that the medical records personnel should visually look at each page of the medical record and verify for accuracy prior to sending a copy to other entities.

Administrative Policy "Security Requirements Under The Privacy Rule", revision date 07/21/09, required, "RehabCare facilities have appropriate administrative, technical and physical safeguards in place in accordance with the security requirements set out in the HIPPA Privacy Rule...must reasonably protect PHI (protected health information) to limit...disclosures."

Based on review of records and interview, the hospital performance improvement program did not monitor and evaluate performance improvement activities:
1) Healthcare information was not protected for 3 of 4 patients discharged in 2008.
2) 4 of 4 medical records contained copies of other patients medical records and/or no patient identifiers.

Findings:
1) The Quality Council Committee Notes, dated 10/27/09, did not demonstrate monitoring or evaluating quality assurance or performance improvement activities regarding patient rights.

Performance Improvement Plan, revised 11/08 included, "monitoring and evaluation of patient rights..."

In an interview the afternoon of 02/04/10, the Director of Quality and Risk Management (Personnel #3) was asked if the Performance Improvement Program monitored activities for assuring patient rights of protected health care information. She stated, " No. "

In an interview the afternoon of 02/04/10, the Health Information Management (HIM) Coordinator (Personnel #4) was asked if the HIM department monitored HIPPA Compliance. She stated, " No. "

Cross Refer to Tag X0814

2) The Organizational Performance Policy, "Performance Improvement Plan" , revised date 11/08 included, " Monitoring and Evaluation: The monitoring and evaluation process will include the following activities: medical record completion..."

The Quality Council Committee Notes, "Information Management ...3. Open/Closed chart review results and focus area" , dated 10/27/09, did not identify inaccuracies in the patients' medical record.

The Health Information Management (HIM) Policy "Filing", dated 08/07, required, "The HIM Department ...The responsibility for accurate patient identification ...shall routinely check the patient identification and medical record number and account numbers on patient records ...shall be carried out as part of concurrent chart review, discharge processing, assembly, and chart completion."

Cross refer to Tag X0285