HospitalInspections.org

Based on a review of hospital policies, staff interviews, and a tour of the hospital, the facility failed to ensure that patients had the right to privacy of protected health information.

Findings included:

During a tour of the hospital the afternoon of 3/2/2015, while the surveyor was alone in the 5 North patient hallway, a computer on a cart was observed unattended with a patient medical record displayed; protected health information was visible on the computer screen to anyone in the hallway. There was also a paper patient medical record which was opened with protected health information visible on the unattended cart. Anyone in the hallway could see the patient information. There was no one present on the hallway for approximately 4 minutes while the surveyor remained with the computer cart. This was brought to the attention of Staff #5, Chief Operating Officer when he returned to the hallway, who observed and acknowledged the unattended visible protected health information. Staff #5 secured the patient information when it was brought to his attention.

Review of hospital policy, "NWTHS Security Policies and Procedures Policy", policy number 007, last revised/reviewed 5/30/2014, included an attachment entitled, "NWTHS Information Security Policies Summary" which stated, in part, "Users should log off of applications, or otherwise secure access, before leaving a computer workstation unattended ....Computer monitors should be aligned as much as possible so that displays of protected health information (PHI) or other confidential information are shielded from unauthorized or public exposure."

The above findings were confirmed in the hospital boardroom with Staff #5 and Staff #3 the afternoon of 3/2/2015.