Failure to Maintain Confidentiality and Proper Organization of Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality and proper organization of resident medical records, resulting in portions of two residents' medical records being found in another resident's file. Specifically, intake and output forms for one resident and a physician's order regarding the time of death and release of body for another resident were discovered in a third resident's medical record. This was confirmed during a concurrent interview and record review with the Medical Records staff, who acknowledged that the documents were mixed up and that facility policy was not followed. The affected residents had significant medical histories, including conditions such as cerebral infarction, hemiplegia, hemiparesis, respiratory failure, and diabetes mellitus. The facility's policy required that all medical records be complete, accurately documented, and stored to protect against unauthorized use, with each patient assigned a unique medical record number. The improper filing and mixing of documents created the potential for exposure of private and confidential information to unauthorized individuals and could have led to inappropriate care actions if orders were followed for the wrong resident.