HospitalInspections.org

Based on document review, interview and observation, the facility failed to limit the release or disclosure of patient information in 1 of 10 medical records (MRs) reviewed (P1).

Findings include:

1. Review of policy/procedure titled, "Reasonable Safeguards for Privacy and Confidentiality of Protected Health Information," Publication date 09/28/2023, indicates the following:
Under VI. Procedures:
A. Confidentiality Requirements:
1. All individuals engaged in collection, handling, uses or dissemination of Patient Health Information (PHI) shall exercise reasonable safeguards to protect the confidentiality of PHI.
2. Discussions involving PHI shall be conducted in settings which protect confidentiality, to the extent practical and possible.
Activities at Nursing Stations and in Clinical Units:
2. In these circumstances, reasonable precautions may include the following in addition to a general awareness of the use and disclosure of individual health information at nursing stations and other similar locations:
b. Proper telephone etiquette and confidentiality awareness when using telephone, cell phones, pagers, or voice message systems.

2. Review of Complaint and Grievance log from (07/01/24 - 01/31/25) contained a complaint related to P1. On 01/23/25 P1's child filed a complaint with the facility regarding P1 being upset with the provider talking about their diagnosis history with their child. The privacy office emailed the ED (Emergency Deparment) medical director to remind their staff to double check with patients before discussing treatment or diagnosis while visitors are around or on the phone. HIPAA/Privacy Office mailed P1 a letter informing them they were filing a grievance on their behalf. Resolution to this was listed as unresolved.

3. On 04/28/25 at 3:34 p.m., this surveyor, accompanied by A2 ( Medicine Service Line Director) and A3 (Emergency Room Manager), was given a tour of the ED (Emergency Department). During this observation, there were 2 patients in hallway beds. As we were walking by, the discussion between the provider and the patient was able to be heard. There were no curtains or dividers up around the patients in the hallway beds.

4. In interview with A9 (Physician Assistant), on 04/30/25 at approximately 5:36 p.m., indicated P1 handed them their phone and asked A9 to update their child on their medications. A9 indicated they summarized P1's visit with the child. A9 confirmed they did not ask P1 if it was ok to discuss information regarding P1 with their child, they indicated they thought it was implied as P1 handed them their phone.

5. In interview with P1 (complainant) on 05/01/25 at approximately 1:47 p.m., indicated when the provider was going over discharge instructions, they handed the provider their phone and asked them to inform their child of the new medications they were prescribed. At this point in the conversation, P1 started crying and indicated the provider discussed their diagnosis history with their child. P1 indicated the provider did not ask if it was ok to do that and they did not give the provider permission to discuss this information.

Based on document review nursing services failed to complete an initial pain assessment and failed to implement interventions after reassessment of pain in 2 of 10 medical records (MRs) reviewed (P1 and P10).

Findings include:

1. Review of policy/procedure titled, "Pain Assessment and Management," Publication date 10/12/2023, indicates the following:
Under I. Purpose:
A. All patients have the right to appropriate assessment and management of pain.
V. Policy Statements:
A. Patients will receive interventions (pharmacologic and/or non-pharmacologic) to reduce or eliminate pain associated with their diagnosis, procedure, or treatment and will be re-assessed for the effectiveness of the intervention.
VI. Procedures:
B. Pain Reassessment
1. The frequency of reassessment should be done individually based on pain level and the patient's comfort-function goal.
2. For both pharmacological and non-pharmacological pain interventions, effectiveness of the intervention is evaluated through reassessment.
3. If upon reassessment the patient's pain is not reduced, relieved, or at the comfort-function goal; implement additional interventions or consider contacting the patient's practitioner.
C. Documentation
1. Pain assessment, comfort-function goal, pain interventions and patient/family education are documented in the patient's medical record as it occurs.
2. Unless otherwise documented, all pain reassessments following an intervention are completed and within acceptable limits.

2. Review of policy/procedure titled, "Triage," Publication date 09/16/2024; indicates the following:
Under V. Policy Statements:
C. All patients will be reassessed depending on the patient's presenting condition and pertinent clinical findings.
VI. Procedures:
A. All patients should have an initial assessment by a nurse as soon as possible, ideally within 10 minutes of arrival.
2. The initial assessment should include quick registration in the electronic health record, vital signs, medications, allergies, and a brief history of the presenting problem including pain assessment.


3. MR review for P1 indicated patient had a pain assessment completed on 01/24/25 at 1:19 a.m., approximately 1 hour prior to their discharge, and rated their pain at 7/10. MR lacked documentation of a pain intervention.


4. MR review for P10 indicated they did not have pain assessments completed by nursing personnel from admission on 01/24/25 at 2:16 p.m. to discharge on 01/24/25 at 6:16 p.m.
At 2:41 p.m., P10 had an order to receive Ibuprofen 600 mg orally, ONCE NOW and received it at 2:55 p.m. MR lacked assessment and reassessment of pain for this medication given.
At 5:09 p.m., P10 had an order to receive hydrocodone-acetaminophen orally, ONCE NOW and received it at 5:18 p.m. MR lacked assessment and reassessment of pain for this medication given.