HospitalInspections.org

Based on findings from observation, document review and interview, the facility did not ensure confidentiality of a patient's medical record (MR). Specifically, a computer screen containing patient protected health information (PHI) was not secured and was unattended. This lack of securing PHI does not ensure protecting confidential patient information.

Findings include:

-- Per observation on 11/14/17 at 10:20 am, a computer monitor screen, in the triage room on the maternity unit, was open and contained PHI of a patient, (e.g., name, date of birth, fetal monitoring tracings, etc) that others could view.

-- Per review of the hospital's policy and procedure (P&P) titled "Workstation Security," last reviewed 11/2017, it indicated staff must be responsible not to leave computers unattended or open access to the network.

-- During interview of Staff L (Nurse Manager) on 11/14/17 at 10:20 am, he/she acknowledged the above finding.

Based on findings from medical record (MR) review and interview, nursing staff did not provide appropriate care to a patient (Patient #1). Specifically, in 1 of 10 MRs (Patient #1), nursing staff failed to obtain a full set of vital signs (V/S) until 5 1/2 hours after a Rapid Response Team was initiated and nursing documentation failed to adequately describe Patient #1's condition and address changes in Patient #1's condition.

Findings include:

-- Per MR review, on 8/15/17 at 5:58 am, Patient #1 presented to the Emergency Department (ED) with a chief complaint of right hip pain after a fall. He was alert and oriented and denied any head injury or loss of consciousness. Past medical history included chronic obstructive pulmonary disease (COPD), (current smoker), and dementia. Patient #1 had surgery to repair his hip on 8/16/17.

On 8/17/17 at 3:12 am, Staff A documented that at 2:05 am Patient #1 displayed seizure activity. A Rapid Response Team and MD (physician) called. (The Rapid Response Team responds to emergency calls for adults within the hospital. It places critical care trained clinicians at the the bedside of patients who need expert assessment and early intervention to attempt to stabilize patients condition and prevent adverse outcomes.)

Patient was stabilized.

At 7:48 am, a complete set of V/S was documented.

This was the first set of V/S done after a Rapid Response Team was initiated for Patient #1 (5 1/2 hours later.)

At 8:16 am respiratory therapy documented, patient unable to do incentive spirometer. (Patient #1 was previously able to do incentive spirometry.) However, further nursing assessments completed at 9:30 am, 11:30 am, and 1:30 pm, all indicated Patient #1's condition remained unchanged.

At 2:48 pm documentation by a physical therapist (PT) indicated, Patient #1 was very confused, agitated and cried out in pain when the right lower leg was moved the slightest (1-day post-operative). Attempted to transfer him to the chair, with the nurse's assistance, but unsuccessful due to confusion and pain. Registered nurse made aware of pain and confusion. However, the next nursing documentation at 3:04 pm did not reveal any information related to PT assessment or any intervention to address patients condition.

-- During interview with Staff F (Vice President of Clinical Services) on 11/29/17 at 10:30 am, he/she acknowledged these findings.

Based on findings from medical record (MR) review and interview, in 1 of 10 medical records MRs (Patient #1) the physician did not document an assessment of the patient after the rapid response team (RRT) had been called to evaluate a change in the patient's condition. This could lead to untoward patient outcomes.

Findings include:

-- Per review of Patient #1's MR on 8/17/17, Staff A (RN) documented "at 2:05 am Patient #1 displayed seizure activity." Diagnostic testing was subsequently performed.

There was no documentation in the MR indicating Staff K (physician) had responded to the RRT call or documentation by Staff K indicating an evaluation of this patient had been performed.

-- During interview of Staff K on 11/16/17 at 5:00 pm, he/she indicated Patient #1 was evaluated and the chest x-ray indicated a pneumonia, therefore he was started on antibiotics. He/she felt the patient was stable and did not need to be transferred to the Intensive Care Unit. Staff K indicated he/she gave report to the oncoming hospitalist at the change of shift and he/she does not always document in the MR. He/she indicated if a procedure was performed on a patient then it would be documented.