HospitalInspections.org

Based on observation, policy review, and staff interviews, it was determined the facility failed to maintain the confidentiality of medical records for patients in the Emergency Room. Observations on 03/20/19, revealed health information about all patients being treated, and waiting in the Emergency Department (ED) to be treated, was displayed on computer screens and visible to other patients and visitors in the triage room.

The findings include:

Review of the facility's policy, Privacy Safeguards for Storage, Transmission and Disposal of Protected Health Information (PHI), dated April 2016, revealed the facility must utilize appropriate Administrative, Technical, and Physical Safeguards to protect the privacy, security, and integrity of PHI. The policy stated safeguards would include but were not limited to restricting the view of computer monitors/screens with positioning or screensavers.

Review of the facility's policy, Patient Rights and Patient Responsibilities, dated December 2016, revealed the patient had the right to personal privacy and to expect documents and communications concerning care to be treated as confidential, as well as having confidentiality of their clinical records.

Observation during tour in the ED triage room on 03/20/19 at 1:32 PM revealed two large computer monitors were present and each screen had patient names, their dates of birth, and the reason for their visit to the facility listed, allowing the patient's medical information to be accessible to non-hospital staff including other patients and visitors. During the tour, observations revealed two (2) patients in the ED triage room with the monitors present and patient information displayed for each patient that was present in the ED and in the ED waiting room.

Interviews on 03/20/19 with Registered Nurse (RN) #1 at 2:40 PM and RN #2 at 3:12 PM, revealed the computer screens usually had a privacy screen that obscured patient information from patients in the triage room. However, the nurses stated the privacy screens often fell off the computer monitors. In addition, neither nurse could recall the last time the privacy screens had been on the computer monitors.

Interview with the ED Clinical Supervisor on 03/20/19 at 3:28 PM revealed the computer monitors were supposed to have a privacy screen over them to prevent patients in the triage room from viewing patient information. However, she stated she had not paid attention to the monitors and had not noticed that the privacy screens were not in place.

Interview with the Intensive Care Unit (ICU) Director on 03/20/19 at 4:25 PM revealed she was covering as Director of the ED while the ED Director was off on medical leave. She stated she conducted daily rounds in the ED when she was working, but had not identified that the triage room monitors did not have privacy screens in place.

Interview with the Compliance Officer on 03/20/19 at 4:30 PM revealed she conducted rounds in the facility daily, spoke with staff, and observed for privacy concerns, but she had not identified any concerns with the computer monitors in the triage room being visible for patients to see information about other patients. She stated that the patient information screen should be minimized and the privacy screen should be in place when there is a patient in the triage room to prevent the patient from seeing other patients' information.

Interview with the Chief Nursing Officer (CNO) on 03/20/19 at 5:00 PM revealed she was not aware that the computer monitors in the triage room were visible with patient information for patients in the triage room. She stated the privacy screen should have been in place, but if they were not available, staff should have used another method to protect patients' health information.

Interview with the Quality Director on 03/20/19 at 5:00 PM revealed she was not aware the computer monitors in the ED triage room were visible with patient information to patients and visitors in the triage room.