|Survey Date: 5/25/2010|
Regulation Title: MR-PROTECT PT RECORDS FM LOSS/CONFIDENTIAL
Regulation Description: The dialysis facility must-
(1)Safeguard patient records against loss, destruction, or unauthorized use; and
(2) Keep confidential all information contained in the patient's record, except when release is authorized pursuant to one of the following:
(i) The transfer of the patient to another facility.
(ii) Certain exceptions provided for in the law.
(iii) Provisions allowed under third party payment contracts.
(iv) Approval by the patient.
(v) Inspection by authorized agents of the Secretary, as required for the administration of the dialysis program.
Based on staff interviews, facility tours, review of medical records, and review of facility documents, it was determined that the facility failed to ensure that the patients' medical records were protected from loss, destruction or unauthorized use. The facility also failed to ensure that patient information was kept confidential.
The findings were:
A facility tour was conducted on 5/18/2010 at approximately 1:00 p.m. It was noted that on the spine of each chart the patient's first and last name were written in marker and were visible from the patient care area to any individual walking past the nurses' station desk. In addition, the medical records were visible from the facility's front door when the facility was closed. There were no measures in place to secure medical records after business hours.
The medical records of six patients were reviewed throughout the survey. In four (#1, #2, #3, #5) of six records, original physician progress notes and written physician orders were absent from the chart for the months of March and April 2010. In two (#2 and #6) of six records, original physician progress notes and written physician orders were absent from the chart for the month of October 2009. In one (#2) of six records, original physician progress notes and written physician orders were absent from the chart for the month of February 2010. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for April 2010 on four (#1, #2, #3 & # 5) of the five patients. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for March 2010 on two (#1 and #2) of the four patients. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for February 2010 on the one (#2) patient. The facility was unable to provide the absent physician progress notes and written physician orders from October 2009.
An interview with the medical director was conducted on 5/19/10 at approximately 3:30 p.m. S/he stated that the physician rounding sheets that contained physician progress notes and written orders were part of the patients' medical records and were being removed by providers (physicians and allied health personnel) against the facility's policies.
On 5/19/10 the surveyors received a letter from the Medical Director, dated 5/19/10, that was addressed to one of the physicians treating patients in the facility. The letter states, in pertinent parts,
"It has recently come to my attention that you, and/or other physicians or midlevel providers have removed patient charts/labs/or other protected material from DaVita facilities...this is a violation of policy and will not continue...Please immediately return all information you may have and cease removing any more from our facilities..."
An interview with the Facility Administrator for the Acute Care Hospital Dialysis Program was conducted on 5/19/2010 at approximately 8:30 a.m. When asked where the physician rounding reports were for sample patient #3, s/he stated that they may be in the patient's treating physician's office.
On 5/19/10 at approximately 5:00 p.m., when the documents listed above were provided, the Facility Administrator stated that the documents were obtained from one of the treating physician's office.
In summary, the facility failed to ensure that original documents that were part of the patient's medical records remained on premises. It is unknown how long this practice had been going on before the Medical Director had addressed the practice of providers removing original documents from the facility. It is also unknown why the facility had permitted this practice to continue prior to the survey. The facility failed to ensure that the patients' medical records were protected from possible theft or misuse of unauthorized individuals. In addition, the facility failed to ensure that patient information was kept confidential as patients' first and last names were visible from the patient care floor and could be viewed by any and all individuals in the facility.
Facility Plan of Correction:
The Governing Body will ensure the
facility maintains an effective, data driven,
quality assessment and performance
improvement program (QIFMM) that
includes a monthly medical record review.
Policy #3-02-01Medical Record
Maintenance has been reviewed with the
facility team with emphasis on ensuring the
confidentiality of the medical record and
the need for a monthly review of 10% of
the medical records and that medical
records are to remain in the facility at all
times, until such time they are archived in
an approved medical records storage
company. Pt. charts have been secured by
placing a locked bar across the medical
records shelf, so they cannot be removed
from their slots. The patient chart labels
were changed from full names to initials to
protect patient identity. A fabric covering
will be placed over the charts so they will
not be visible by 07/01/2010.
AA's are to complete all filing and audit
100% of the patient charts by 6/21/10,
followed by monthly audits of 10% of the
charts. These medical records audits will be
documented on the QIFMM form and
reviewed in QIFMM meeting with action
plans developed and implemented as
needed. A letter was written to XXX
Nephrology Associates on May 20, 2010
by the Medical Director, stating that no
documents are to be removed from the
facility from that date forward. FA and
Medical Director are responsible for
ongoing compliance with POC.