HospitalInspections.org

Based on review of facility documents, medical records (MR), observation, and staff interview, it was determined the facility failed to ensure privacy was provided in the Emergency Department (ED) for patient case discussion and consultation for one of one medical record reviewed (MR1).

Findings include:

Review on December 18, 2014, of the facility's "Patient's Right and Responsibilities," start date August 3, 1981, revealed "Article I Introduction It is the policy of Pocono Health System to promote the interests and well being of all patients. It is declared to be the policy of Pocono Health System that the interests of Pocono Health System's patients be protected by a Patient's Bills of Rights. ... Article II Patient Bill of Rights The Board of Directors of Pocono Health System hereby establishes that each patient at Pocono Health System shall enjoy each of the following: ... 6. The right to privacy and to receive care in a safe environment. ... 9. The right to every consideration of his/her privacy concerning his/her own medical care program. Case discussion, consultation, examination, and treatment are considered confidential and should be conducted discreetly. ..."

Review on December 17, 2014, of the facility's policy "Confidentiality of Protected Health Information," dated reviewed March 2014, revealed "Purpose: To ensure that protected health information is protected so that all individuals are not afraid to seek health care or to disclose sensitive information to health professionals, and also to ensure that protected health information is protected during it's collection, use, disclosure, and destruction by or on behalf of Pocono Medical Center and all health care facilities within Pocono Health System (collectively "PHS") in accordance with the provisions of applicable state and federal regulations. Scope: 1. Procedure/Responsibility/Action 2. Definitions: ... d. All PHS employees and persons associated with PHS are responsible for protecting the privacy and security of all protected health information (oral or recorded in any form) that is obtained, handled, learned, heard, or viewed in the course of his/hers work or association within PHS. e. Protected health information shall be protected during it's collection, use, disclosure, storage and destruction by or on behalf of PHS. f. Use or disclosure of protected health information is accepted and proper only as necessary in the discharge of one's work responsibilities and duties (i.e., for legitimate work-related purposes) and based on the need to know. Discussion regarding protected health information shall not take place in the presence of persons not entitled to such information or in public places (elevators, lobbies, cafeterias, off premises, etc). ..."

Review on December 17, 2014, of MR1 revealed the patient was admitted to the ED on November 12, 2014, with the complaint of abdominal pain and left lower extremity cellulitis. The patient was assigned to hallway bed 10 in the ED. Laboratory tests, electrocardiogram, and radiology studies were performed. Documentation revealed the ED physician discussed the test results with the patient in hallway bed 10.

Documentation noted EMP7 was present and spoke with the patient, and apologized to the patient for being in the hallway.

Interview with EMP7 on December 17, 2014 at 9:30 AM confirmed MR1's care and case discussion were provided in the hallway in the ED.

Tour of the Emergency Department on December 18, 2014, at approximately 11:00 AM revealed a ED bed capacity of 41. Hallway bed 10 was located directly outside the ED room 10. There were no hallway beds being utilized at the time of the ED tour.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to document discussion and approval of a quality improvement project for high risk/low use medications.

Findings include:

Review on December 17, 2014, of the facility's "Patient Safety Plan," dated reviewed March 2014, revealed "Scope ... The Patient Safety and Medical/Health Care Error Reduction Plan is designed to reduce risk and improve patient safety. The purpose of the patient safety plan is to provide a framework for the implementation of various complements of the Patient Safety Program at Pocono Medical Center. The plan includes all activities within the organization that contribute to patient safety and satisfaction. Attention to maintaining and improving patient safety and well being is inherent in Pocono Medical Center's commitment to the improvement in the quality of life to those served within the community. In committing to safeguarding individuals, Pocono Medical Center continuously works toward fully understanding the processes and systems utilized by the organization to deliver patient care. From this deeper understanding, Pocono Medical Center is able to analyze, evaluate, develop, and implement changes that will continuously improve the way we deliver care to patients. ..."

Review on December 17, 2014, of facility document "Root Cause Analysis," revealed a patient was admitted on March 7, 2014, with intractable nausea and vomiting, small bowel obstruction and rapid atrial fibrillation. The patient was on a Heparin (an anticoagulant) intravenous (IV) drip. The physician wanted a stat (immediate) dose and an every eight hour dose of Tetracycline (an antibiotic) to be given to the patient. The physician selected Tetradecyl Sulfate (a sclerosing agent) via the medication drop down in the Computerized Physician Order Entry (CPOE), not Tetracycline.

Review on December 17, 2014, of the facility document "Pharmacy and Therapeutics," April meeting minutes, revealed the pharmacy made changes to the high risk/low use medications list. There was no documentation the new protocols were forwarded to the medical staff for approval.

Interview with EMP16 on December 17, 2014, confirmed the stat dose of Tetradecyl was dispensed from the pharmacy. EMP16 confirmed Tetradecyl was rarely dispensed from the pharmacy. EMP16 confirmed no one contacted the physician or nurse to confirm the Tetradecyl was the correct medication. EMP16 confirmed the pharmacy re-evaluated their high risk/low use medications list, and certain physicians were allowed to order these medications. EMP16 confirmed the new protocols were not forwarded to the medical staff for approval.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure the governing body determined the number of distinct improvement projects that were to be conducted annually.

Findings include:

Review on December 17, 2014 of the facility's, "Performance Improvement Plan," last reviewed January 2014, revealed no requirement for the governing body to determine the number of distinct performance improvement projects to be conducted annually.

Review of the facility governing body meeting minutes dated January 24, 2014, revealed the governing body approved the performance improvement plan for the upcoming year. There was no documentation the governing body approved the program indicators selected or specified the frequency of the data collection.

Interview on December 18, 2014, with EMP1 confirmed there was no documentation the governing body reviewed or approved the improvement program indicators selected and the frequency of data collection for the upcoming year.