HospitalInspections.org

Based on records reviewed and interviews, the Hospital failed, for one (Patient #1) patient out of ten sampled patients, to ensure Quality Assessment and Performance Improvement (QAPI) activities identified opportunities for improvement.

Findings include:

It was alleged that the Hospital failed to maintain Patient #1's Protected Health Information from his/her non-custodial parent, who brought him/her to the Hospital for emergency medical treatment, by identifying Patient #1's address to the non-custodial parent.

Patient #1 was brought to the Emergency Department in 3/2019 for treatment of an ear laceration. Patient #1 was a five year old who was brought in to the Emergency Department by his/her father after falling off a bed and hitting his/her ear on the window sill.

The Pediatric Patient Social History Assessment, dated 3/1/19 at 8:57 P.M., indicated that Patient #1 lives with his/her parents and there are no custody issues that the Hospital should know about.

The Vital Signs/Progress Note, dated 3/1/19 at 9:46 P.M., indicated that Patient #1's mother contacted the Emergency Department and informed the nurse that she was suspicious about the accident, that she had a restraining order against Patient #1's father and wanted to visit the Hospital.

The Vital Signs/Progress Note, dated 3/1/19 at 9:53 P.M., indicated the mother's current telephone number in the narrative of the note.

The Vital Signs/Progress Note, dated 3/1/19 at 10:02 P.M., indicated that Patient #1's mother called back and said that she would get her lawyer involved. The nurse told the mother that she should call the police about the restraining order and that Patient #1's fall off of the bed was not suspicious.

During an interview with the Patient Advocate on 2/18/20 at 12:15 P.M., the Patient Advocate said that Patient #1's mother came to the Hospital to meet with her about the fact that the Hospital shared her private home address with Patient #1's father. Patient #1's mother had a restraining order on Patient #1's father and he was unaware of her address due to this restraining order. The Patient Advocate said that the Hospital may have given Patient #1's father the address when they confirmed the address during the registration process. Patient #1's mother wanted to be sure that Patient #1's father would not get her personal information in the future should Patient #1's father bring Patient #1 back to the Hospital for care. The grievance was turned over to the Risk Department for review.

During an interview with the Emergency Department Patient Care Director on 2/19/20 at 8:10 A.M., the Emergency Department Patient Care Director said that when the doctor discharges a patient their address is on the discharge paperwork. The Emergency Department Patient Care Director said that Risk Management got involved and was looking to the whole system. The Emergency Department Patient Care Director said that they questioned if the Hospital did violate someone's safety. The Emergency Department Patient Care Director said that the Emergency Department staff talked about this case for weeks and the fact that they may have given personal information to the father bothered people. The Emergency Department Patient Care Director said that no changes have been made as a result of this incident.

During an interview with the Director of Risk and Quality Improvement on 2/19/20 at 8:36 A.M., the Director of Risk and Quality Improvement said that the incident took place during a change in Risk Management personnel and they could not find a file on the investigation.

During an interview with the Director of Risk and Quality Improvement on 2/19/20 at 10:00 A.M., the Director of Risk and Quality Improvement said this case was missed and no changes have been made to prevent a like occurrence from happening again as a result of this incident.