HospitalInspections.org

Based on staff and patient interviews, medical record review, and facility policy review, it was determined that the facility failed to protect the confidentiality of a patient's medical record for one patient (P) (P#3) three patients reviewed for medical record confidentiality. Specifically, facility staff gave P#2 their discharge instructions but included P#3's "Pre-admission Screening Form" as part of the packet which included protected health information (PHI).


Findings included:


The facility's "HIPPA [Health Insurance Portability and Accountability Act] Policies and Procedures Manual," "2021 Edition," included a policy, titled, "101.2: SAFEGUARDING AND STORING PROTECTED HEALTH INFORMATION," that indicated, "[The facility's corporation's name] will put in place reasonably safeguards to ensure that Protected Health Information (PHI) is not intentionally or unintentionally Used or Disclosed in a manner that would violate the Privacy Rule or any other federal or state regulation governing the confidentiality and privacy of PHI." The policy revealed, "D. Safeguards for Written PHI. All documents containing PHI should be stored appropriately to reduce the potential for incidental Access, Use, or Disclosure. Documents should not be easily accessible to any unauthorized staff or visitors. Physical safeguards should be used such as locking drawers and offices, and minimizing the amount of paper left in public areas ."


P#2's "Facesheet" indicated the facility admitted the patient on 03/25/2025 and discharged the patient on 04/03/2025.


P#3's "Facesheet" indicated the facility admitted the patient on 04/03/2025 and discharged the patient on 04/15/2025.


During a telephone interview on 05/27/2025 at 11:20 a.m., P#2 stated the nurse who reviewed their discharge instructions had left a couple pieces of paper that did not belong to them, and they were attached to the discharge instructions. P#2 stated the nurse told them that they did not need those papers, and thought the nurse took them, but they were still attached to the discharge instructions. P#2 stated the pieces of paper had another patient's health information on them.


An email from P#2 dated 05/27/2025 included attached images of P#3's "Pre-admission Screening Form" from the facility. Information on the form included P#3's demographic information, which included their name, address, phone numbers, date of birth, and gender; referring information, including the facility referring the patient to this facility, their admission date to the referring facility, the referral date, the patient's primary care physician, and the referring physician; and insurance information, including their Medicare identification number.


During an interview on 05/27/2025 at 1:43 p.m., Registered Nurse (RN) #1 stated his expectations were for no other patient's medical record information to be left in another patient's room or given to another patient. He stated that the only reason the "Pre-Screening Form" might have been left in another patient's room was because a nurse printed it for an admission and the nurse who discharged P#2 printed out discharge instructions for P#2 using the same printer, and the nurse who discharged P#2 grabbed all the paperwork on the printer without noticing.


During an interview on 05/29/2025 at 9:47 a.m., the Chief Nursing Officer (CNO) stated P#2 mentioned that they had a document that was left in their room when they were discharged but the patient did not give any specifics, such as name or who it was from, to take corrective action.