HospitalInspections.org

Based on record review and interview, the hospital failed to provide a patient access to their complete medical record as evidenced by failing to provide a copy of a patient's lab results upon request after an accidental exposure to blood and body fluids for 1 out 1 patient's (Patient #1) medical records reviewed for access to their medical records. Findings:

Review of the hospital's policy for Processing Release of Information Requests in part revealed, "Upon request, medical records are release in a timely manner to the requestor, the patient or the patient's representative, unless such a release is likely to cause sufficient harm to the patient or another individual."

Review of the Hospital's Medication Error report revealed Patient #1 was administered Novolog (insulin) with another patient's insulin pen on 4/17/19.

Review of Patient #1's Electronic Medical Record, navigated by S4RN and S5RN, revealed Hepatitis B Surface Antigen, Hepatitis C Antibody and HIV lab work was ordered and obtained on 4/17/19 on Patient #1.

An interview was conducted with S3IP on 8/20/19 at 10:00 a.m. She reported that Hepatitis B Surface Antigen and Hepatitic C Antiboy and HIV lab work was drawn on Patient #1 on 5/29/19 also. She further reported that she called the patient with the results on 6/03/19. When questioned if the patient requested a copy of her lab work, she stated the patient had, but the lab work was confidental and she could not give the patient a copy of her lab work. She further explained the lab work was coded under employee health and not under the patient's name.