HospitalInspections.org

Based on observation, document review and interview, the facility did not ensure access to patient Protected Health Information (PHI) was restricted and not accessible to individuals walking by.

These lapses in the protection of patient information placed patients at risk for the accidental disclosure of their PHI to unauthorized individuals and staff.

Findings:

The facility policy and procedure titled "Patient Health Information Privacy Policy," last revised 11/9/16, contained the following statements: "Every inpatient and outpatient of the facility is guaranteed by law to the right of privacy. All facility staff must respect this right and treat all protected health information properly or in the most confidential manner possible. Protected health information can be written or oral, it can be recorded on paper, computer or other media."

Observations in the facility's ED on 1/8/20 during a tour between 10:22AM and 2:30PM identified the following:

Labels containing Patient # 6's name, date of birth, medical record number and other information was found visible, unsecured and unattended on a portable computer near the trauma room, in the hallway where over overflow ED patients were placed.

Labels containing Patient #7's name, date of birth, medical record number and other information was found visible, unsecured and unattended on a counter top in the trauma room near the hallway used to provide care to overflow ED patients.

Similar observations of unsecured patient PHI were noted on triage cards at the ED triage window.

These observations were made in the presence of Staff A (Director of Quality), who confirmed the patients' PHI should have been secured.

Based on Medical Record (MR) reviews, document reviews and interviews, the Emergency Department (ED) staff did not (a.) implement the Emergency Department (ED) policies and procedures to ensure that the Sexual Offense Evidence Collection Kits were completed at the time the patient presented to the ED in two (2) of four (4) MRs reviewed and (b.) consistently include the chief complaint/reason that the patient presented to the emergency department for six (6) of six (6) dates reviewed.


Findings related to (a.) include:

The facility's Policy and Procedure (P&P) titled "Sexual Assault " last revised August 2019 stated:" ...when a patient presents to the ED with a chief complaint of sexual assault the Triage Nurse will notify the Charge Nurse immediately ... the patient will be brought to the treatment area immediately and provided a private exam room ...the ED physician is notified immediately ... after the initial assessment the Rape Crisis Counselor and appropriate Police will be noted ... with patient consent... a detailed history is obtained by the physician of how the attack was committed ... clothing that is removed from the patient should be placed in a paper bag ... a complete physical exam should be done with special emphasis and measuring of abrasions, contusions and lacerations ...the Sexual Offense Evidence Collection Kit is used to collect the necessary evidence ...[and] ... the Kit will be completed by the physician ...".
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Review of Patient # 4 MR identified the following information: The patient presented to the ED on 7/27/19 at 11:38 AM with complaint of possible sexual assault. The triage nurse documented the patient stated she remembers waking up in a stranger's car alone. The ED nurse documented all clothing placed in brown paper bag for evidence collection. Patient prep for exam. Staff B (Physician) documented the patient complained of a headache and knee pain. The patient had a CAT Scan of the head and cervical spine that revealed a left scalp hematoma and the patient required repair of a scalp laceration with staples. Staff B then documented the police were notified and the patient was transferred to another hospital for a Sexual Assault Nurse Examiner (SANE) evaluation.

There was no documented evidence that a Sexual Offense Evidence Collection Kit was completed per facility policy.


Review of Patient #16 MR identified the following information: The patient presented to the emergency room on 11/8/19 stating she was a rape victim two day earlier. The Physician Assistant (PA) documented at 9:53 PM that the patient reported she was raped while incarcerated but was unable to recall who raped her. The patient reported she had not washed and would like to be evaluated and have evidence tested.

The attending physician then documented at 9:59 PM "attempted to see patient for sexual assault...when explained process to patient about transfer to hospital for forensic exam, patient decided to leave the ED, stated she was just going to go there herself and did not want us to call an ambulance or transfer her properly."

There was no documented evidence that a Sexual Offense Evidence Collection Kit was completed per facility policy.

During interview of Staff B (Physician) on 1/8/19 at 2:00 PM, when questioned about the process for sexually assaulted patient she stated "the patient would be triaged by the nurse, then the ED physician to determine if the patient was stable or not ...placed [the patient] in a private room ...then offered a transfer to a hospital with a SANE nurse for a Rape Kit to be performed ...".

During interview of Staff K (Nurse Manager) on 1/9/2020 at 1:30 PM, she stated the patient is given the choice to be transferred to a SANE hospital, I'm not sure why the physician's documention did not indicate the patient was give a choice."

During interview of Staff J (Medical Director) on 1/10/2020 at 10:30 AM, he stated" the ED physician can do it ( the Sexual Offense Evidence Collection Kit) here but offer to transfer the patient to a hospital with a SANE Nurse where staff there do it (the Kit) all the time. "

However, the policy does not include offering the patient the choice of being transferred to a hospital with a SANE Nurse as described by the facility staff.


Findings related to (b.) include:

The facility's Policy and Procedure (P&P) titled "Emergency Medical Treatment and Labor Act Policy" last revised 6/18/18 stated: "...Procedures: Emergency Department Central Log : upon arrival all patient seen in a system hospital emergency department must be entered into the ED Central Log ...the following information must be recorded ...complaint and disposition of the case ...".

The ED Central Log dated 10/15/19 revealed for 27 patients entered into the log the chief complaint/reason for coming to the emergency room was documented as "other".

The ED Central Log dated 7/27/19 revealed for 13 patients entered into the log the chief complaint/reason for coming to the emergency room was documented as "other".

The same lack of documentation of a chief complaint for patients presenting to the ED was identified in the ED Central Log for 7/25/19, 10/27/19, 11/8/19 and 12/4/19.

Interviews on the morning of 1/9/2020, with both Staff J (Medical Director) and Staff K (Nurse Manager) confirmed the chief complaints were not consistently documented.