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Based on observation, review of facility policy and and interview with staff (EMP), it was determined the facility failed to ensure the privacy of Personal Health Information displayed on hallway computer monitor screens in the Emergency Department for MR1 through MR9.

Findings include:

A review of facility policy "Patient and Family Rights and Responsibilities" dated November 17, 2014, revealed " This Bill of Rights and Responsibilities describes Children's Hospital of Philadelphia's (CHOP) commitment to partnering with you and your family as active members of the care team. ... Dignity and Respect:... . Keep information about your medical care and family information private."


Observation on August 14, 2018, at approximately 9:36 AM to 9:49 AM in the Emergency Department with EMP1, EMP2 and EMP3 revealed the following Personal Health Information was displayed on the hallway computer monitor screen for MR1, MR2 and MR3 as follows:
MRI, first and last name, gender, age, admitting diagnosis of Diarrhea.
MR2, first and last name, gender, age, admitting diagnosis of Psychiatric Emergency.
MR3, first and last name, gender, age, admitting diagnosis of Respiratory Distress.
____

Observation on August 14, 2018, at approximately 9:49 AM to 9:52 AM in the Emergency Department with EMP1, EMP2, and EMP3 revealed the following Personal Health Information was displayed on the hallway computer monitor screen for MR4, MR5 and MR6 as follows:
MR4, first and last name, gender, age, admitting diagnosis of Seizures.
MR5, first and last name, gender, age, admitting diagnosis of Seizures and Fever.
MR6, first and last name, gender, age, admitting diagnosis of Respiratory Distress.
____

Observation on August 14, 2018, at approximately 9:57 AM to 10:00 AM in the Emergency Department with EMP1, EMP2 and EMP3 revealed the following Personal Health Information was displayed on the hallway computer monitor screen for MR7, MR8 and MR9 as follows:
MR7, first and last name, gender, age, admitting diagnosis of Respiratory Distress.
MR8, first and last name, gender, age, admitting diagnosis of Diarrhea.
MR9, first and last name, gender, age, admitting diagnosis of Psychiatric Emergencies.

An interview conducted on August 14, 2018, at 10:30AM with EMP1, EMP2 and EMP3 confirmed that the Personal Health Information which included the first and last name, gender, age and admitting diagnosis of MR1 through MR9 was displayed on the Emergency Department hallway computer monitor screens. Further interview confirmed that the "Time-Out" process on the Emergency Department hallway computer monitor screens failed to ensure privacy of the Personal Health Information for MR1 through MR9.

On-Site facility visits were completed by the "Department" on October 4, 2018, and October 8, 2018.

Based on review of facility policies, documents and interview with staff (EMP), it was determined the facility failed to ensure a clean and safe environment was maintained in Room Five (Safe Room) in the Emergency Department for one of one medical record reviewed (MR10).

Findings include:

Review of facility policy "Care of the Boarded Behavioral Health Patient in the ED/EDECU" dated October 2, 2018, revealed " 3. Procedure: Care, treatment and services for the boarded behavioral health patient... . Consider Room ED Room 5... for highly agitated patients if not already admitted there."

Review of facility policy "Patient Room Discharge Cleaning (Unoccupied) " last revised June 2015 revealed "... . Reason for Task Performance: To effectively clean and disinfect the patient room (unoccupied) in accordance with department standards and to standardize normal cleaning procedures and quality assurance... . Make sure that all furniture is back in its proper place. Remove all Environmental Services equipment from room and mark the room clean.. . Ensure Departmental cleaning procedures and room presentation have been followed.."

Review of facility policy "General Discharge Cleaning' last revised February 2004, revealed "To effectively clean and disinfect discharged patient rooms in accordance with department standards and to standardize normal operating procedures and quality assurance while increasing user confidence. A systematic approach to prepare a patient's room for a new admission/transfer must be followed... . IV Final Check of Room-Aesthetics/Room Review. a. Maintenance Requirements-Report to supervisor."

A review on August 14, 2018, of facility documents (photographs) of Room Five (Safe Room) revealed "Photograph One revealed a hole in the wall by the floor board, Photograph Two revealed a black substance on the floor, Photograph Three revealed multiple pieces of trash on the floor, Photograph Four revealed a wall cabinet with tape across cabinet doors, Photograph Five revealed multiple areas on the walls of Room Five (Safe Room) with brown and red substance on the walls. The "Department" received the photographs one through five via mail. The "Department" confirmed the facility received the photographs during an on-site visit to the facility on August 14, 2018.


An interview conducted on August 14, 2018, at 3:30 PM with EMP3 and EMP4 confirmed the facility had received and reviewed Photographs One through Five of Room Five (Safe Room) and confirmed the findings identified in each of the photographs. EMP6 also confirmed the receipt and review of Photographs One through Five and that the facility had failed to complete a final check of Room Five (Safe Room) prior to the admission of MR10. In addition, EMP6 stated the facility failed to comply with the facility's policies for cleaning and maintenance of Room Five (Safe Room).

On-Site visits were completed by the "Department" on October 4, 2018, and October 8, 2018.

Based on review of facility policies, medical records (MR), and interview with staff (EMP), it was determined that the Governing Body failed to ensure the Emergency Department Registered Nurse supervise, evaluate and/or document clinical care events for patients with At-Risk Behaviors for one of one medical record reviewed (MR10).

Findings include:

Review of facility policy "Patient and Family Rights and Responsibilities" dated November 7, 2014, revealed "... . Provide respectful, high quality care given by qualified staff (including supervised residents, students and trainees) and maintain high professional standards, while respecting your values, beliefs and preferences. ...Provide care in a safe and secure setting..."

Review of facility policy "Nursing Department Overview" dated January 15, 2013, revealed "Scope Of Nursing Practice... . Registered nurses at The Children's Hospital of Philadelphia have responsibility and accountability for nursing activities, which include, but are not limited to:... Delegating appropriate patient care activities to Licensed Practical Nurses, Nurse/OR/ED Techs, Nurse Externs, Senior Nurse Aides, and Psychiatric Care Technicians, sitters (any unlicensed care providers), and supervising their practice. Execution of diagnostic and therapeutic regimens prescribed by licensed providers... . Under the direction and supervision of the Registered Nurse, non-licensed care providers perform a variety of tasks in order to assist in the delivery of patient care."


Review of MR10 revealed "Visual Observation order" dated and timed: August 7, 2018, at 11:15 PM revealed "Visual Observation: The patient is observed by an assigned staff person within eyesight at all times. Nursing Assessments of At-Risk Behaviors are documented by a nurse approximately every 60 minutes after consultation with observer. When the observation is suspended, the nurse documents assessments each shift. Standing Count: Until Specified. Reason for Observation: The patient is at risk to harm others related to potential aggression."

Review on October 4, 2018, of MR10 revealed no evidence of documention completed by EMP18, a registered nurse of hourly nursing assessment for at-risk behaviors on August 8, 2018, at 7AM, 8AM and 9 AM. Further review revealed no evidence of documentation that a staff member had been assigned to observe MR10 within eyesight distance at all times.

An interview conducted on October 4, 2018, at 3:50 PM with EMP3, EMP4 and EMP5 confirmed that EMP18 had failed to document hourly nursing assessment for at-risk behaviors for MR10 on August 8, 2018, at 7AM, 8AM and 9 AM. Further interview confirmed there was no evidence of documentation that a staff member (observer) had been assigned to MR10 to complete the visual observations within eyesight distance at all times.