HospitalInspections.org

Based on review of facility policies, documents and interview with staff (EMP), it was determined that the facility failed to follow adopted policies related to the release of patient information for one of two medical records reviewed (MR2).

Findings include:

A review of facility policy "Patient Rights and Responsibilities" last revised March 2016 revealed, "You have the right to: Personal privacy, privacy of your health information and to receive a notice of the facility's privacy practices. ... ."

A reviewed of the facility's "Compliance with HIPAA Privacy Regulations, Definitions Policy" last revised October 18, 2016, revealed, "To achieve and maintain compliance with the Standards for the Privacy of Individually Identifiable Health Information promulgated by the U.S. Department of Health and Human Services. ... . Any unauthorized use or disclosure of PHI, or failure to follow the facility's privacy or confidentiality policies and procedures, including all HIPAA policies, may result in corrective action of employees, up to and including termination. ... ."

A review of the facility's "Confidentiality Policy" last revised November 4, 2016, revealed, "The use and disclosure of a patient's individually identifiable health information must be in compliance with existing federal and state regulations. The purpose of this confidentiality policy is to protect the patient, the clinical team and the facilty from the inappropriate use and disclosure of individually identifiable health information. ... . Protected Health Information refers to individually identifiable health information that is transmitted or maintained in any form (including written, verbal or electronic)which is protected under federal regulations. Examples include the patient's name and other demographic information, medical records, x-ray films, slides, tracings, strips, etc. ... . To ensure compliance with federal and state privacy laws and regulations, PHI collected and/or generated within the facility will be maintained in manner which restricts access to those with a need-to-know. ... ."

An interview conducted on April 18, 2017, at 1:20 PM with EMP3 confirmed that patient MR1 was accidentally sent home with a copy of patient MR2's medication list, which included the patient's name, address, phone number, medical record number, date of birth, sex, physician's name and also MR2's lab results from March 7, 2017, through March 24, 2017. The interview also revealed that the facility obtained this information from MR1's family and confirmed it had occurred through verification with MR2's nursing home residence administrator. Further interview confirmed that the facility failed to follow their established policies and had violated patient MR2's right to privacy of their personal health information.

A review of what the complainant had forwarded to patient MR2's nursing home residence revealed a copy of patient MR2's medication list, which included the patient's name, address, phone number, medical record number, date of birth, sex, physician's name and also MR2's lab results from March 7, 2017, through March 24, 2017.

Based on review of facility policy, medical record review (MR) and interview with staff (EMP) it was determined that the facility failed to follow their policy for preparation and administer of medications for one of two medical records reviewed (MR1).

Findings include:

A review of facility policy "Administration of Drugs: Patient's Own Medications" effective date 10/8/14 revealed, "All medications must be properly labeled and identified before use. An order will be entered which indicates that the patient may take his/her own medication. ... . A patient's personal medication may be used for active orders if clinically necessary if one of the following conditions is met: ... The medication is not on formulary. ... . Orders for patient-owned medication will be entered into Cerner with a note to Nursing and Pharmacy staff indicating those that are the "patient's own meds" and a "no charge" (NC) should be placed. Drugs to be used in house are placed in a bag by Nursing Service personnel, the patient's name is placed on the bag and the bag is not sealed. The bag of medications is sent or delivered to the Pharmacy to be identified. No patient's own medication will be used in house until identified by pharmacy. Covering Pharmacist is to ensure that no formulary alternatives exist for the patient's medication. Pharmacist then will identify medication with patient's own medication stickers that are initialed and dated by the pharmacist confirming the identification. ... ."
A review of MR1 revealed a medication order written by EMP 16 on March 24, 2017, at 6:22 AM for "Evoxac 30 mg, Oral, QID PRN for secretions". Also "no" was checked next to "patient's own med".

A review of MR1's medication administration record revealed that Evoxac did not show on the list of ordered medications.

A phone interview conducted on April 18, 2017, at 2:10 PM with EMP11 revealed that, when the patient requested the Evoxac medication on March 24, 2017, about 1:30 PM, EMP11 checked and informed the patient that the hospital pharmacy did not carry Evoxac but saw the medication order. The patient explained that their own Evoxac had been taken to the pharmacy on admission so EMP11 retrieved the patient's pill box from pharmacy. EMP11 confirmed that the pills were not in separately labeled pill bottles and that the patient had to point to the correct pill (Evoxac) and then EMP11 administered it to the patient. EMP11 revealed that they thought this was an active order and okay to administer as they did. EMP11 further stated that she thought she had documented the medication administration.

An interview conducted on April 18, 2017, at 2:30 PM with EMP14 revealed that Evoxac was not stocked by the hospital pharmacy and the patient's order for Evoxac was pending "verification" as of March 24, 2017, at 1:30 PM and was not an active medication order. EMP14 explained that, had the ordering physician clicked "yes" next to "patient's own med", the pharmacy would have pulled the patient's own medications stored in the pharmacy, identified and separated the pills. The Evoxac would have been placed in a pill box, labeled and then sent to the nursing unit and placed in the Pyxis to be administered to the patient as ordered. EMP14 explained that, until a medication order is verified, it was not an active order and should not be administered. EMP14 confirmed that, as per EMP11's recitation of what occurred on March 24, 2017, EMP11 had given the patient the Evoxac without an active medication order and had not followed the facility's medication administration policies.

A phone interview conducted on April 21, 2017, at 10:00 AM with EMP16 confirmed that they had inputted the order for Evoxac, but did not remember checking "no" next to "patient's own med". EMP16 further stated that they were not aware that Evoxac was not in the hospital's formulary.

A phone interview conducted on April 24, 2017, at 10:45 AM with EMP15 revealed that when the patient asked for Evoxac, EMP15 found a "grayed out" order for Evoxac, which EMP15 said usually meant the medication was not in the Pyxis. EMP15 stated they did not check if the physician had written "patient allowed to take own medications" before allowing the patient to take the pill out of their home pill box that they identified as Evoxac and take it . EMP15 stated that they probably should not have allowed the patient to take her own Evoxac from her home pill box without an order allowing this. EMP15 further stated that they had not followed the facility policy for administration of patient's own medications.

A phone interview conducted on April 24, 2017, at 11:45 AM with EMP17 and EMP18 confirmed that EMP15 had not followed the facility policy for administration of patient's own medications.