HospitalInspections.org

Based on observation and facility policy review, the facility failed to ensure patient confidentiality was maintained by displaying possible patient identifiers within public view. This had the potential to effect all patients. The facility census was 215.

Findings include:

1. Observation on 7/26/10 of the 2 Henson Unit at nursing station one revealed a white board approximately 2 feet x 2 feet on the wall behind the nursing station. This board revealed the first three letters of the patient's last name and the first two letters of the first name of the patients. The white boards were clearly visible to anyone who came into the unit.

2. Observation on 7/26/10 of the 2 Henson Unit at nursing station two revealed a white board approximately 3 feet x 2 feet on the wall behind the nursing station. This board revealed the first three letters of the patient's last name and the first two letters of the first name of the patients. The white boards were clearly visible to anyone who came into the unit.

3. Observation on 7/26/10 of the 2 Henson Unit revealed name plates outside of each patient's room with the first three letters of the last name and the first two letters of the first name of the patients.

4. Observation on 7/26/10 of 2 Henson Burn Unit revealed a white board approximately 2 feet on the wall behind the nursing station with the first three letters of the last name and the first two letters of the first name of the patients. The white boards were clearly visible to anyone who came into the unit.

5. Observation on 7/26/10 of 2 Henson Burn Unit revealed name plates outside of each patient's room with the first three letters of the last name and the first two letters of the first name of the patient.

6. Observation on 7/26/10 of 6 Henson at the first nursing station revealed a white board approximately 2 x 3 feet on the wall behind the nursing station with the first 3 letters of the last name and the first two letters of the first name of the patients. The white boards were clearly visible to anyone who came into the unit.

7. Observation on 7/26/10 of 6 Henson at the second nursing station revealed a white board approximately 2 x 4 feet on the wall behind the nursing station with the first there letters of the last name and the first two letters of the first name of the patients.

8. Observation on 7/26/10 of 6 Henson at the third nursing station revealed a white board approximately 2 x 4 feet on the wall behind the nursing station with the first there letters of the last name and the first two letters of the first name of the patients.

9. Observation on 7/26/10 of the 6 Henson Unit revealed name plates outside of each patient's room with the first three letters of the last name and the first two letters of the first name of the patients.

10. Observation on 7/27/10 of 4 Henson Unit revealed a white board approximately 2 x 4 feet on the wall behind the nursing station with the first three letters of the last name and the first two letters of the first name of the patients.

11. Observation on 7/26/10 of the 4 Henson Unit revealed name plates outside of each patient's room with the first three letters of the last name and the first two letters of the first name of the patients.

-Record review of the facility policy titled Incidental Uses and Disclosures of Protected Health Information (PHI) revised 07/1010 in part revealed the following information:

POLICY: It is the policy of The Children's Mercy Hospital to provide health care services in a confidential setting, respecting the privacy rights of our patients in accordance with the regulations set forth in the Health Insurance Portability and Accountability Act (HIPAA), as well as any applicable state laws and accreditation standards.

B. Incidental Uses and Disclosures
4. Patient Identification Boards, Lists, Chart Spines & Beds - Patient Identification Boards/Lists are used facilitate efficient patient flow and assist staff in locating patients. Patient Identification Boards/Lists are used in both the inpatient and ambulatory areas.

Ambulatory Areas:
- Whenever possible, patient identification boards and lists will be located in a secure location without access for public viewing.
- If they are located in public viewing, then the information on the patient identification board information will be limited to:
-the first three (3) letters of the patient's last name and the first two (2) letter of the patient's first name. Example: patient name is John Smith, the patient identification board would identify the patient as SMI, JO
-the patient's age, (not DOB), gender, diet, and safety/fall precautions may be noted;

Med/Surg Inpatient Areas:
-the first three (3) letters of the patient's last name and the first two (2) letter of the patient's first name. Example: patient name is John Smith, the patient identification board would identify the patient as SMI, JO

Same Day Surgery Areas:
- If they are located in public viewing, then the information on the patient identification board information will be limited to:
-the first three (3) letters of the patient's last name and the first two (2) letter of the patient's first name. Example: patient name is John Smith, the patient identification board would identify the patient as SMI, JO
-the patient's age, (not DOB), gender, diet, and safety/fall precautions may be noted.

ED/Urgent Care Clinic Areas:
- The bed tracking board in the EDUCC will display the first three (3) letters of the patient's last name and the first two (2) letters of the patient's first name. Example: patient name is John Smith, the patient identification board would identity the patient as SMI, JO;