HospitalInspections.org

Based on interviews and record reviews, the facility failed to meet the Condition of Participation (CoP) for Patient Rights by failing to ensure protection of patients from misuse of protected health information (PHI, any information about health status, provision of health care, or payment for health care that is created or collected by a facility, and can be linked to a specific patient) and acts of emotional abuse as evidenced by:

1. The facility failed to maintain the privacy of protected health information for 3 (P (patient) 1, P2, and P3) out of 10 patients. The registration clerk loudly announced on the radio the patients medical condition that individuals in the waiting area heard the information and moved away from the specific patient. The patients medical information were also displayed openly. See tag 143.

Based on observations, interviews, and record reviews, the facility failed to maintain the personal privacy of protected health information for 3 (P (Patient) 1, P2, and P3) out of 10 patients. This failed practice lead to direct inappropriate disclosure of PHI and is likely to lead to an increased risk of misuse and breach of PHI.

The findings are:

Findings related to P1:

A. On 08/17/2021 at 1:00 pm, during interview with P1, it was reported that on 07/10/2021, P1 sought care at the facility's Emergency Department. P1 continued with his concern by stating that "on 07/10/2021 I went to the Emergency Department and was registered by the Registration clerk (S (staff) 14)." P1 stated "After I sat down, she [S14] got on a radio and loudly said 'the guy who was last here for an STD (sexually transmitted disease) is back.' I was the only male in the waiting room and felt very embarrassed. Everyone heard them [S14] and moved away from me." After this situation occurred, P1 reported he approached S14 to request a supervisor to make a complaint. "The house supervisor came down and they got the director of the Emergency Department. S10 (Emergency Department Director) moved me into a room and told me that S14 would be told about breaking HIPAA rules because she shouldn't have talked about my protected health information or my past visits. She [S10] did apologized to me and I was given the number to the patient advocate, and I called multiple times, but no one answered."


B. Record Review of P1's medical record from 07/10/2021 revealed:

1. P1 arrived to the Emergency Department at 1:23 pm.

2. P1 was moved into a room in the Emergency Department at 2:36 pm.

3. P1's triage was completed at 2:38 pm.


C. Record Review of P1's "Notice of Patient Rights and Responsibilities" signed 07/10/2021, revealed:

1. "You [patients at the facility] have the right to be treated in a dignified and respectful manner."

2. "You have the right to personal privacy, privacy of your health information."

3. "You have the right to an environment that is safe, preserves dignity and contributes to a positive self-image."


D. On 08/18/2021 at 10:30 am, interview with S10 confirmed that the above incident alleged by P1 had transpired and that they (S10) stepped in to help facilitate a favorable resolution for P1. "I came to the waiting room and was told that the Registration Clerk spoke about a patient's previous visit loud enough for everyone to hear. I moved them [P1] into a private room so they could wait to be seen and apologized for what happened. I then educated S14 on speaking with a softer voice and the risk of disclosing health information inappropriately. I notified S14's supervisor about the incident."


E. On 08/18/2021 at 11:00 am, interview with S12 (Director of Patient Access) indicated that they were never notified by S10 or any other staff member about the situation that occurred with P1 on 07/10/2021.


F. On 08/18/2021 at 12:30 pm, interview with S15 (Patient Access Manager), confirmed to be the immediate supervisor for S14. S15 reported that they were not notified of any potential inappropriate disclosure of protected health information by S14 or by S10. S15 confirmed that registration does not disclose pervious medical visits for any reason "We [registration] gather demographics and generate a visit for the patient, that's all." In regards to the situation on 07/10/2021, S15 stated "They [those handling the situation that day] should've called me immediately and I would've escalated it to the director [S12]. The Emergency Department Director [S10] has my phone number so I don't know why I wasn't called."


G.On 08/18/2021 at 11:30 am, interview with S14 denied working at the facility on 07/10/2021 or that the event in question happened. S14 denies being spoken to by S10 regarding protected health information or HIPAA compliance.


H. Record Review of S14's Kronos Time Card (employee time card used to track hours worked) from 07/10/2021 revealed:

1. S14 punched in at 7:15 am and punched out at 5:06 pm.


I. On 08/18/2021 at 10:45 am, interview with S11 (Registration Clerk) confirmed that there is no circumstance to their knowledge to address a patient by their previous medical visits. "I would call them by their last name, that's all." S11 denied that after 07/10/2021 they were given trainings or education on HIPAA compliance and expectations by the facility. "I didn't even know there was a problem going on."


J. Record review of S14's "Health Stream (educational training software) Student and Group Transcript Record" as of 08/06/2021 revealed:

1. "Compliance, Privacy, and Security" training completed 02/02/2021.

2. No evidence of new HIPAA related training given after 07/10/2021


K. On 08/18/2021 at 10:0 am, interview with S9 (Facility Privacy Officer/Interim Health Director of Privacy (HIPPA)) confirmed that no report was made to them regarding a breach on 07/10/2021 by stating "I'm surprised the Director of the ED [S10] and the clerk's bosses [S12 & S15] did not say anything about this to me." S9 confirmed that the facility has multiple methods that empower a staff member to report a concern such as, an anonymous hotline number, calling the facility privacy officer, or going to their supervisor to refer the concern. When asked if the situation from 07/10/2021 would constitute a circumstance that should've been reported, S9 replied "absolutely, registration clerks are trained and educated to speak in a low voice, especially when in a crowded area and to only utilize the patient's last name when addressing them, nothing else."


Findings related to P2 and P3:

L. On 08/17/2021 at 9:45 am, during observation flash tour of the facility's Emergency Department revealed:

1. P2's patient registration form (demographic form including personal and protected health information) and stickers (containing personal and protected health information) were left facing up in the internal results waiting room.

2. P3's medication order sheet (part of the medical record, indicates what medication was ordered) was on the counter by a water dispenser visible at the nurse's station with no staff member around it.


M. Record Review of P3's medical record from 08/16/2021 revealed:

1. P3 was discharged from the Emergency Department at 4:09 pm.


N. On 08/18/2021 at 11:15 am, during interview with S13 (Registered Nurse, Emergency Department) confirmed that the process for patient specific documents is to keep them in a secure area, face down, so no one can see them unless they have a purpose in which they need them and it should not be in an open area, such as P2's were found. In regards to P3's patient information found after discharge, S13 confirmed that when a patient is discharged, technicians will collect the patient's chart and place it in a specific area on the nurse's station face down so it can be retrieved by medical records.


O. Record Review of facility's "Patient Rights and Responsibilities Policy" published 05/06/2021, revealed:

1. "Patients' rights include, but are not limits to, the right to privacy regarding medical care."


P. Record Review of facility's "Abuse, Neglect, & Exploitation" policy effective as of 02/01/2010, revealed:

1. Emotional abuse is defined as "causing or permitting the person to be in a situation in which the person sustains a mental or emotional injury that results in an observable and material impairment in growth, development, or psychological functioning."


Q. Record Review of facility's "Compliance with HIPAA Privacy Regulations, Definitions Policy" published 01/08/2021, revealed:

1. "Each facility will have a Facility Privacy Officer appointed and is responsible for the facility's compliance with HIPAA policies including receiving privacy complaints, conducting investigations of alleged violations, and ensuring that facility department directors monitor their staffs' activities for compliance with the privacy policies."

2. "Each facility should ensure that members of the workforce are familiar with the role of the facility privacy officer in receiving HIPAA privacy complaints."

3. Breach is defined as: "the acquisition, access, use, or disclosure of protected health information in a manner not permitted under the HIPAA Privacy Rule, which compromises the security or privacy of the protected health information."


R. On 08/18/2021 at 10:0 am, interview with S9 (Facility Privacy Officer/Interim Health Director of Privacy (HIPPA)) confirmed regarding P2's registration information and stickers, S9 confirmed that the expected practice is to have them face down and at the nurse's station.In regards with P3, S9 confirmed that it is the expecation for the physical medical record to be sent to the Medical Records Department after a patient is discharged.

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Based on observation, record reviews, and interview, the facility failed to ensure secure storage of single use medication vials (medications that are only used for one patient). This failed practice is likely to lead to an increased risk of reusing single use medication vials and cross contamination ( transfer bacteria or viruses or fungi unintentionally from one patient or staff member, to another).

The findings are:

A. On 08/17/2021 at 9:45 am, during observation of facility's Emergency Department revealed:

1. Three used vials of Lidocaine (medication, local anesthetic), with medication still in vials, found on top of a laceration cart (procedural cart for cuts requiring stitches) in the direct patient care area.


B. On 08/18/2021 at 11:15 am, interview with S13 (Registered Nurse, Emergency Department) confirmed that the Lidocaine vials used in the Emergency Department are single use and should be stored inside the medication storage machine in the medication room, if unused, or, if used, disposed of in the blue pharmaceutical waste bin (trash bin specified for the disposal of medications).


C. Record Review of facility's "Pharmaceutical Waste Disposal" policy, undated, revealed:

1. "If a drug is not considered hazardous and no waste code (specfic medication designated as being dangerous to people, animals, and the environment) has been assigned, then the product with partial drug remaining in the container may be discarded in a blue container."

D. Record Review of facility's "Infection Control: Single Use Sterile Drugs and Devices" policy, undated, revealed:

1. "Single use drugs shall not be reused."

2. "Unused portion of single-use sterile drugs shall not be saved for later."

Based on observation and interview, the facility failed to maintain a sanitary (clean and conducive to infection prevention) environment. An (IV) intravenous (vein) tubing with medication in the trash can inappropriately disposed of that should have been in a biohazard bag (red plastic bag used to separate infectious waste from regular garbage), boxes of medical supplies on the floor. The self-temperature checking station was not working to detect COVID (respiratory virus) related issues. This deficient practice will likely lead to contamination and potential infection control issues, placing patients and staff at risk.

The findings are:

A. On 08/17/2021 at 9:30 am, during a tour of the Emergency Department, the following was observed:

1. A wall-mounted "no-touch" forehead thermometer reader was not working to determine if a person has an elevated temperature potentially caused by a COVID-19 infection.

2. In the trash can located by the patient waiting area, a used (IV) intravenous (vein) tubing with medication (vancomycin) (a medicine (such as penicillin) that inhibits the growth of or destroys microorganisms (bacteria, virus, or fungus.)

3. When the surveyor asked Staff (S)#3 Chief Nursing Officer, about the IV tubing with medication, S#3 reached into the trash can without gloves and did not disinfect hands afterward.

4. Patient bathroom: Used bedpan full of excrement (waste matter discharged from the bowels; feces) in a standard trash bag and not a biohazard bag.


B. On 08/17/2021 at 9:45 am, during a tour of the Emergency Department Medical Supply Room, the following was observed:

1. Several cardboard boxes with medical supplies stored on the floor (should store cardboard boxes off the ground due to their potential to grow and perpetuate bacteria, mold, or insects.)

2. A box of Central Venous Catheters- Antimicrobial with Oligon Technology (a tube placed in a large vein to give fluids, blood, or medications, containing a material proven to be effective against bacteria, fungi, and strain-resistant microorganisms) on the floor.

3. A blue plastic hand bucket filled with sterile gloves, intravenous catheters (introduced into the vein by a needle (similar to blood drawing) on the hand or arm), intravenous start kits (supplies needed to prepare and dress an IV site), was on the floor.

4. An open box of face shields on the floor.


C. On 08/17/2021 at 10:00 am, during tour of the Emergency Department Soiled Utility Room (storage for biohazard (a risk to human or the environment arising from biological work, especially with microorganism)) materials for pick up the following was observed:

1. In the trash can, a used bedpan, and urinal (items used for waste matter discharged from the bowels and feces should be in a biohazard bag.)


D. On 08/17/2021 at 10:05 am, during an interview, S#3 (Chief Nursing Officer) confirmed the IV tubing with medication and the bedpan and urinal in the trash can.

E. On 08/17/2021 at 10:10 am, during an interview, S#4 (Director Risk Management) confirmed the temperature screening station was not working and that boxes and medical supplies were on the floor and understood that there shouldn't be any boxes or medical supplies on the floor.