HospitalInspections.org

Based on observation and interview, the hospital failed to protect patients' health information by leaving medical record information readily available for anyone entering the hospital to see for three observations on 10/30/24.


Findings Include:


Review of a hospital policy titled, "Patient Rights and Responsibilities" Revised 10/21/24 showed, " ...1. Every patient admitted to a [The Hospital] hospital is given a written copy of the Patient's Bill of Rights prior to admission, and, within 24 hours of admission, each patient is given an explanation of his/her rights and responsibilities as a patient. 2. The hospital will provide an explanation of the patient's rights and responsibilities in the patient's primary language, if requested. 3. The hospital shall obtain a signed copy of the Patient's Bill of Rights from each patient or patient's family, if appropriate. The signed copy shall include a statement that the patient and or patient's family has read the document and understands the rights specified in the document. 4. The hospital shall retain a signed copy of the Patient's Bill of Rights in the patients' medical file. 5. The [The Hospital] Patient Rights and Responsibilities Poster must be placed in prominent locations within the hospital. 6. Patients' Rights: Patients have the rights to: a) Considerate and respectful care given by competent personnel and to be made comfortable. b) Respect for cultural, psychosocial, spiritual, and personal values, beliefs, and preferences ... Have personal privacy respected. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly. The patient has the right to be told the reason for the presence of any individual. The patient has the right to have visitors leave prior to an examination and when treatment issues are being discussed. Privacy curtains will be used in semi-private rooms ... Receive care in a safe setting ... The patient has the right to access protective services and advocacy services including notifying government agencies of neglect or abuse..."


Review of the hospital's QAPI meeting minutes from April 2024 through September 2024 the hospital had identified areas of non-compliance with medication carts not being locked and Patient's Health Information (PHI) being left open and unattended on computers on wheels.


During an observation of second floor north nurses' station on 10/30/24 at 10:27 AM showed three unattended computers on wheels with patient information displayed on the screen.


Further observation of the computers on wheels showed them unlocked and unattended with patient medications present in the drawers.


During an observation of the second-floor south nurses' station on 10/30/24 at 10:34 AM showed one unattended computer on wheels with patient information displayed on the screen.


Further observation of the computer on wheels showed it unlocked and unattended with patient medications present in the drawers.


During an observation of the first-floor nurses' station on 10/30/24 at 10:45 AM, one unlocked and unattended computer on wheels with patient medications present in the drawers. Surveyors observed medication cart for approximately 5 minutes and the cart did not lock automatically nor did staff attempt to lock the cart.


During an interview on 10/31/24 at 12:20 PM Staff J, RN stated that the computer on wheels have automatic locks and should lock after a few seconds. Staff J went on to state there is a computer on wheels that was broken.


During an interview on 10/31/24 at 1:27 PM Staff B, Quality Manager stated, ...I go out and do physical audits and note unlocked medication carts, broken med carts, and unattended computers with PHI...Several staff were notified and retrained regarding unattended computers with PHI open. Broken computers on wheels should be put into locked med room until the computer on wheels is replaced ...