HospitalInspections.org

Based on record review and staff interview the facility failed to protect the privacy of patient information by leaving a patient's medical record accessible to non-medical personal and by documenting patient's last name, room number and first initials ( for name alert patients) on white boards on all patient units.

The findings included:

1. An observation on the general surgical unit on April 8, 2013 at 11:20 a.m. revealed a patient's medical record lying on the top portion of the nurse's station desk. The patient's medical record was accessible to anyone that approached the nurse's station. The surveyor observed intervals when none of the unit staff was at the nurse's station and any one could have opened and accessed the medical record.

At approximately 11:44 a.m., a visitor approached the nurse's station and stood there while trying to decide the location of the patient he/she was there to visit.

At approximately 11:52 a.m. on April 8, 2013, Staff #2 left the nurse's station to locate a patient scheduled for discharge from the unit, the patient's medical record remained accessible.

At 11:55 a.m., Staff #2 returned to the nurse's station and the surveyor informed him/her related to the medical record being accessible. Staff #2 was informed the medical record had been on the top of the nurse's station desk from the time we approached the desk.

An interview was conducted on April 8, 2013 at 11:55 a.m., with Staff #2. Staff #2 stated, "This should not be on the top of the counter where the patient's name or the chart itself could be accessed." Staff #2 acknowledged staff had failed to protect the privacy of the patient's medical information.

2. During the entrance conference on April 8, 2013 at 10:01 a.m., Staff #2 reported the facility had "10 - 12 nursing units."

A tour was conducted on April 8, 2013 from 11:00 a.m. to 1:10 p.m. of nursing units from which a patient could be directly discharged. Staff #2 accompanied the surveyor during the tour. On each of the four units an observation revealed a large white board, which had patient's name, room number and for some patients their first initial. On all four units the white boards were located on the wall of a hallway and were accessible for viewing by anyone that walked by.

An interview was conducted on April 9, 2013 at 9:01 a.m., with Staff #2 on a patient care unit and Staff #12. Staff #12 reported the unit's patients were listed in the electronic system and each nurse selected his/her assigned patients to create their assignment. Staff #12 reported nursing assistants and other ancillary staff created their assignments in the same manner. Staff #12 reported any alerts or new orders were all designated electronically. Staff #2 and the surveyor reviewed the large white board on the unit, which was placed in a location where anyone passing the board could see the patients' last name, room number and the first name initial for patients with the same last name. Staff #2 stated, "We've had discussion about this before." Staff #2 agreed the observable white board was not for nursing related to their "board assignment on their laptops." Staff #2 stated, "The boards are located on all nursing units. We will have to reconsider the privacy concern."