HospitalInspections.org

The Condition of Participation for Pateint Rights was not met.

Findings include:

Based on records reviewed and interview, the Hospital failed to protect and limit the release of patient
information resulting in an unauthorized nursing department practice that resulted in protected patient information being posted on social media.


Refer to TAG: A-143

Based on records reviewed and interview, the Hospital failed to protect and limit the release of patient information resulting in an unauthorized nursing department practice that resulted in protected patient information being posted on social media.

Findings include:

Federal regulations indicate that the right to personal privacy includes limiting the release or disclosure of patient information. Patient information includes: the patient 's presence or location in the hospital, demographic information,, such as name, age, address, income; or information on the patient ' s medical condition. Such patient information may not be disclosed without informing the patient in advance of the disclosure and providing the patient an opportunity to agree, prohibit, or restrict the disclosure.

During an interview on 7/5/21, at 11:00 A.M., the Director of Clinical Quality Improvement said that on 6/23/21, the Labor and Delivery Department's resource Registered Nurse (RN) took a cell phone picture of the white board (dry erase board), containing patient information including patients' initials, patients' medical conditions, and patients' status of delivery in the labor and delivery area. The Director of Clinical Quality said that the resource RN took that photo so she could erase the board and update it during change of shift with the most current information and status of the patient's in the labor and delivery area. The resource RN intended on deleting the picture once the new board was completed. The Director of Clinical Quality said that the picture was used as a copy for the resource RN to re-write the board and not forget any important/critical patient information.

The Director of Clinical Quality said that the picture taken by the resource RN on 6/23/21, which contained the protected patient information was inadvertently posted to the resource RN's public social media account. The social media post was viewed by coworkers on the labor and delivery unit. The resource RN that took the picture does not know how the picture got onto her social media account. The Director of Clinical Quality said that when the resource RN was informed the picture was on her social media account, she immediately took it down/removed it. The resource RN stated the picture was on the publicly viewed social media account for 8 minutes.

The Director of Clinical Quality said that when the Hospital investigated this incident it was discovered that the practice of taking a photo of the white board was a practice used by the nurses on the labor and delivery department.

The Director of Clinical Quality said that the Labor and Delivery nurse manager had implemented corrective actions including informing/reeducating staff that taking pictures of clinical information was not allowed. However, not all staff were educated as of 7/5/21. The Director of Clinical Quality said that two other nursing units ( Intensive Care Unit & Behavioral Health Unit) also used white boards and the Hospital did not know if the nurses on those units were photographing patient information for their change of shift. No education/retraining was conducted on the Intensive Care Unit or Behavioral Health Unit.

The Condition of Participation for QAPI was not met.

Findings include:

Based on records reviewed and interview, the Hospital failed to implement an adequate preventative action for an unauthorized nursing department practice that resulted in protected patient information being posted on social media.


Refer to TAG: A-286

Based on records reviewed and interview, the Hospital failed to implement an adequate preventative actions for an unauthorized nursing department practice that resulted in protected patient information being posted on social media.

Findings include:

Federal regulations require that performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital.

During an interview on 7/5/21, at 11:00 A.M., the Director of Clinical Quality Improvement said that on 6/23/21, the Labor and Delivery Department's resource Registered Nurse (RN) took a cell phone picture of the white board (dry erase board), containing patient information including patients' initials, patients' medical conditions, and patients' status of delivery in the labor and delivery area. The resource RN intended on deleting the picture once the new board was completed.

The Director of Clinical Quality said that the picture taken by the resource RN on 6/23/21, which contained the protected patient information was inadvertently posted to the resource RN's public social media account. The social media post was viewed by coworkers on the labor and delivery unit. The resource RN stated the picture was on the publicly viewed social media account for 8 minutes.

The Director of Clinical Quality said that when the Hospital investigated this incident it was discovered that the practice of taking a photo of the white board was a practice used by the nurses on the labor and delivery department.

The Director of Clinical Quality said that the Labor and Delivery nurse manager had implemented corrective actions including informing/reeducating staff that taking pictures of clinical information was not allowed. However, not all labor and delivery staff were educated as of 7/5/21. The Director of Clinical Quality said that two other nursing units ( Intensive Care Unit & Behavioral Health Unit) also used white boards and the Hospital did not know if the nurses on those units were photographing patient information for their change of shift. No education/retraining was implemented on the Intensive Care Unit or Behavioral Health Unit.