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Based on interview and record review, the facility failed to ensure staff (Staff 1) practiced the facility's policies and procedures related to patient rights. As a result, a graphic picture of an object surgically removed from Patient A, was posted on a social media website.

Findings:

On 11/9/15 at 8:02 P.M., the facility received a report through their online anonymous reporting system that on 10/24/15, Staff 1 posted, "Inappropriate comments and pictures pertaining to a patient's procedure on Facebook."

An onsite visit was conducted at the facility on 1/5/16 at 11 A.M., with the Director of Regulatory Affairs (DOR), the Senior Director of Nursing (SDON), and a Human Resources Representative (HRR).

According to the DOR, on 10/24/15, Patient A came to the Emergency Department (ED) to have a plastic bottle surgically removed from the rectum. Staff 1 assisted in the operating room during the surgery. The DOR stated the surgery was completed at 6:58 A.M. and by 7:56 A.M., Staff 1 had posted a picture of the plastic bottle on her Facebook page. The picture was posted on a "Closed" group page with over 800 members. The group was titled, "Scrubs Taking No Sh**." "Scrubs" refer to technicians who assist with surgical instruments in the operating room.

The DOR stated she requested an employee (Employee 1) to try and infiltrate the group. Employee 1 was interviewed on 1/5/16 at 11:20 A.M. Employee 1 stated he was not a surgical technician and he did not know Staff 1.

Employee 1 stated on 11/9/15, he requested membership into the "Scrubs" group. Employee 1 further stated within 15-20 minutes, he was granted membership by Staff 1. Employee 1 stated he was able to take a picture of the posted PHI of Patient A. The picture depicted a plastic bottle covered with a red substance, in a specimen container. The caption above the picture read, "Thirsty, anyone?!?!?!?!" The DOR gave the picture to the SDON, who called Staff 1 and arranged a meeting with her and her Union Representative on 11/11/15.

According to the SDON, Staff 1 confirmed she posted the PHI of Patient A on her Facebook page. Staff 1 stated she thought it was "funny" and did not feel there was enough information to identify the patient. Staff 1 further stated the group was a "closed" group. Staff 1 confirmed the SDON was able to obtain the patient's PHI even though she was not a member of the group.

According to the facility policy revised 8/13 and titled Cellular Phones & Other Wireless Electronic Digital Devices Use Of: "Physicians and staff usage of camera, video or audio recording features of a cellular phone...is not permitted at any time."