HospitalInspections.org

Based on observations, interviews with staff, and review of the facility "Policy and Procedure for Proper Disposal of Protective Health Information", the facility failed to ensure the privacy and confidentiality of patients' medical information.

The findings include:

1. Observation on the discharge unit on 9/27/10 at 10:45 AM, revealed two patient medical records that were placed within view of anyone who might be in the area. One of the medical records was opened and placed on the nursing counter facing the patient rooms, and the other medical record was placed on the printer/fax machine which was located outside of the nursing station.
Interview with the registered nurse who was assigned to one of the patients in the discharge unit on 9/27/10 at 10:50 AM confirmed the record was placed improperly and should not have been open. She stated it was "not usual" practice to leave patients' medical records open and placed within view of anyone who happened by. She stated she should have placed the chart behind the nursing station.

2. Observation of the Endoscopy Unit on 9/27/10 at 10:30 AM revealed the unit had eleven patient rooms, two of which were occupied.

Observation of the medication administration device, the pyxsis, located next to the wall and adjacent to the patient rooms revealed a printed list of patients who were scheduled for a procedure on 9/27/10. There were 10-15 patients on the list who were scheduled for a procedure on this day. The list was taped to the pyxis and visible to patients and/or visitors who might be in the area. The list consisted of the name of each patient, the patient's physician, and the procedure for which they were scheduled.

3. Observation of three trash cans located in the discharge unit on 9/27/10 at 11:30 AM revealed one of the cans was for recycling, one was for shredding, and the other was general trash. Closer investigation of the general trash can, revealed staff had discarded an empty patient belongings bag. The bag contained a printed label with the following patient information included:

a. The patient's name
b. The physician's name
c. The patient's date of birth
d. The patient's medical number
e. The patient's account number
Interview with three nurses at 11:45 AM on 9/27/10 revealed it is the policy of the facility to print labels for each of their patients. The labels are then stuck to a bag that contained the patient's personal belongings. Upon discharge, staff gives the patients back their belongings and the labeled bag is discarded in the general trash.
4. Review of the policy and procedure for "Proper Disposal of Protective Health information" revealed the printed labels should be placed in the general trash can. No documentation could be located relative to how staff were to discard the printed labels which contained personal and confidential patient information.