HospitalInspections.org

Intakes: TN00036652

Based on policy review, medical record review, observation and interview, it was determined the hospital failed to ensure patient privacy for 1 of 1 (9/2/15 Observation) ED observation days.

The findings included:

1. The hospital's "Confidentiality" policy documented, "...The purpose of this confidentiality policy is to protect the patient, the clinical team and the facility from the inappropriate use and dissemination of individually identifiable health information...Individually Identifiable Health Information (IIHI) is a subset of health information, including demographic information, collected from an individual that is transmitted or maintained in any form (including written, verbal or electronic)...Protected Health Information (PHI) refers to individually identifiable health information that is transmitted or maintained in any form (inlcuding written, verbal or electronic) which is protected under federal regulations..."

The hospital's "Patient Rights and Responsibilities" policy documented, "...Patients have the right to...Personal privacy, privacy of their health information..."

2. Observations on 9/2/15 at 3:24 PM in the ED, revealed a triage area with 4 bays separated by privacy curtains. Each bay contained an ED patient with the privacy curtains pulled around 3 of the patients and one privacy curtain opened while the ED staff performed the triage assessment. Protected health information from each patient could be heard by the other patients and visitors in the triage area. One ED staff asked personal health questions and took vital signs of a patient with the privacy curtain opened.

3. During an interview on 9/2/15 at 1:45 PM, when asked how the ED staff kept verbal health information confidential, ED Nurse #1 stated, "...you can't..." ED Nurse #1 stated the ED Technicians would bring patients back to bathroom in the triage area from the waiting room to get a urine specimen. The ED Nurse #1 confirmed patients walking to the bathroom could potentially hear protected health information being discussed in the triage bays.

During an interview on 9/2/15 at 3:30 PM, the ED Director stated maintaining privacy and confidentiality in the triage area was a problem. The ED Director stated the staff could use the Pediatric Exam Area to help maintain privacy (across the hall from the triage area was the Pediatric Exam Area, a room which was empty while the four patients were in the triage area).