HospitalInspections.org

Based on observation, document review and staff interview, it was determined for 15 of 15 (Pt #2-Pt #16) adult behavior health patients, the hospital failed to ensure personal privacy was maintained, due to staff having cell phones in the work area which have to potential to violate patients rights to privacy. This has the potential to affect all adult, behavior health patients who receive care at a hospital that has current census of 15 behavioral health patients.

Findings include:

1. A tour of the Adult, Behavioral Health Unit (BHU) was conducted on 10/26/2021 at 10:15 AM, while being escorted by the Quality Coordinator (E #9). The following was observed: Behavioral Health Technician (E #7) and BHU Charge Nurse (E #8) had cell phones in their possession, in the patient care area.

2. The "Human Resources Policy, Code of Conduct", revised, June 2021 was reviewed on 10/27/2021 at 10:11 AM. It defines what acceptable behavior is allowed and under "Acceptable Behavior" it's defined as, but not limited to: observing the confidentiality and rights of patients, employees, and the Hospital. Avoid creating conflicts of interest, both real and perceived, and report any potential conflicts to your supervisor".

3. The policy "Mobile Device Usage" revised 08/06/2020, was reviewed on 10/26/2021 at 12:45 PM. Under "General Cell Phone Usage:" it reads "Cell phone use should not occur in patient care areas."

4. The policy "Cell Phone Usage Policy" revised June 2021, was reviewed on 10/26/2021 at 12:55 PM. Under "POLICY" it reads "Cell phones are prohibited in work areas during working hours.......may be used during authorized break times in non-work areas. Employees are prohibited from taking unauthorized pictures of patients or using these devices in the patient care areas where a HIPAA privacy violation could occur."

5. An interview with Behavioral Health Technician (BHT) (E #3) was conducted on 10/26/2021 at 12:27 PM. When asked if E #3 carried a cell phone on the Behavioral Health Unit, E #3 replied "I do but I don't use it unless I'm on break. It shouldn't be out unless you're on break".

6. An interview with Behavioral Health Unit, Registered Nurse (E #4) was conducted on 10/26/2021 at 12:47 PM. When asked if E #4 carried a cell phone on the Behavioral Health Unit, E #4 replied "I do carry a cell phone on the Behavioral Health Unit but can't have the phone in the presence of the patients".

7. An interview with the Executive Director/Behavioral Health Unit (E #6) was conducted on 10/26/2021 at 4:00 PM. E #6 revealed that E #6 was aware that cell phones were being used on the treatment floor of the Adult Behavioral Health Unit.

8. An interview with BHT (E #7) was conducted on 10/26/2021 at approximately 10:20 AM. E #7 indicated that E #7 was an orientee and didn't know cell phones were not allowed on the treatment floor.

9. An interview with BHT Registered Nurse (E #8) was conducted on 10/26/2021 at approximately 10:40 AM. E #8 explained that E #8 was aware of the hospital policy of not having cell phones on the treatment area but had one in her possession anyways.

10. An interview with the Quality Coordinator (E #9) was conducted on 10/26/2021 at approximately 12:50 PM. E #9 confirmed E #7 and E #8 did have cell phones in their possession in the patient care area. E #9 stated "They should not have had their cell phones in the patient care area." E #9 explained that "paper charts are kept on the BHU and have face sheets which contains the patient's personal information. The Behavioral Health Technicians should not be accessing that information. Their documentation is done in the electronic medical record."