HospitalInspections.org

Based on observation, interview, and policy review staff failed to protect personal privacy for 13 patients on units: 7600 (six of 32 patients); unit 7700 (three of 27 patients); unit 8600 (two of nine patients), unit 8700 (two of 28 patients) with patient medical records exposing the last name of the patient printed in large print that was clearly visible and distinguishable from public areas, and around the central nurse's stations, and failed to protect personal patient information on computer screens exposed and visible to public hallways for 10 patients on: unit 9700 (four of 20 patients), Medical-Surgical Intensive Care Unit for (two of 10) patients, and (four of 33) patients on 6600 unit. The facility census was 244.

Findings included:

1. Record review of the facilities policy titled, "Information Security," dated 02/11 showed the following staff direction:
-Any person maintaining, accessing, using or disseminating information should safeguard the data integrity, confidentiality, and availability of information.
-St. Luke's controls access to patients records, both computerized and paper, by limiting access to those who have a need to know and individuals who have proper authorization from the patient or the patient's legal guardian.
-The St. Luke's Notice of Privacy Practices educates patients about their right to privacy and the confidentiality of their health information.
-Secure physical access to your computer. Turn screen/monitor off to avoid displaying sensitive information when unauthorized personnel are in the room.

2. Record review of the facilities undated policy titled, "St. Luke's Hospital Confidentiality Statement," showed the following staff direction:
-All employees will read and sign the confidentiality statement.
-St. Luke's Hospital employees shall maintain patient and all other confidential information in compliance with applicable legal and ethical standards. St. Luke's Hospital employees possess and have access to confidential, sensitive and proprietary information. Every employee has an obligation to protect and safeguard confidential, sensitive and all other St. Luke's information to prevent its unauthorized disclosure. All St. Luke's Hospital employees shall conduct themselves in accordance with the principle of maintaining confidentiality of patient information and in compliance with all applicable laws and regulations.
-I understand that patient care information, whether in written, verbal, or electronic form, may be accessed only by authorized St. Luke's employees and other authorized individuals.
-I understand that I am the caretaker of private patient information and must guard it appropriately.
-Reasonable safeguards include, but are not limited to, keeping patient information secure, private, and out of public viewing.

3. Observation on 02/28/11 at 1:55 PM, unit 7600, at the central nurse's desk showed a wall mounted rack holding a binder with paper documents regarding the care and services provided to each patient admitted to the unit. Further observation showed self adhesive labels applied to the spine of each binder with the name of each patient in large black lettering allowing clear identification of approximately six patient names from the public areas around the desk.

During an interview on 02/28/11 at 1:55 PM, Staff B, the Vice President for Patient Services, stated that he/she had tested the ability to see and distinguish patient names written on the binders from public areas. Staff B noted the use of finer felt tip pens had been acceptable, however these labels (approximately six) were written with a wider (at least one quarter inch felt tip pen ), making the patient names clearly visible from public areas around the desk.

4. Observation on 02/28/11 at 2:09 PM, unit 7700 at the central nurse's desk showed a wall mounted chart rack, similar to unit 7600's chart rack with patient names labeled on the binders. Approximately three of the patient names were distinguishable from public areas around the desk.

During an interview on 02/28/11 at 2:09 PM, Staff B, stated that the wider felt tip pen point was used to create patient labels and those were visible from public areas.

5. Observation on 02/28/11 at 3:05 PM, unit 8600 at the central nurse's desk showed a wall mounted chart rack similar to units 7600 and 7700 with patient names labeled on binders. Approximately two of the patient names were distinguishable from public areas around the desk.

6. During an interview on 02/28/11 at 3:05 PM, Staff B, agreed that some of the patient names were distinguishable from public areas around the desk.

7. Observation on 03/01/11 at approximately 1:10 PM, unit 8700 at the central nurse's desk showed a wall mounted chart rack similar to the ones on units 7600, 7700 and 8600. Patient names were labeled on the binders, and approximately two of the patient names were distinguishable from public areas around the desk.

8. During an interview on 03/01/11 at 1:05 PM, Staff C, the Director of Nurses, stated that some of the patient names written on the binder labels were distinguishable from public areas around the desk.


27727


9. Observation on 03/01/11 at 10:15 AM, unit 9700 at the nursing station showed computer monitors facing the hallway being used by facility staff. These computer monitors showed the patient's name, date of birth, admission date, physician and medical record number. This hall way is used by visitors and other patients. Patient information on the computer monitors is visible to all visitors and patients using the hallway.

During an interview on 03/01/11 at 10:20 AM, Staff C stated that the hallway was used by visitors and patients, and the names of patients were clearly visible.


29117


10. Observation on 02/28/11 at 3:15 PM, showed two computer monitors on each end of a table facing the main hallway in the Medical-Surgical Intensive Care Unit. The two computer monitors displayed electronic patient health record information. These computer monitors were clearly visible to the main public hallway.

During an interview on 02/28/11 at 3:20 PM, Staff O, Medical-Surgical Head Nurse, Intensive Care Unit, stated that the hallways that the computer monitors were facing were the hallways visitors were encouraged to use.

During an interview on 02/28/11 at approximately 3:20 PM, Staff N, RN (Registered Nurse), Quality Analyst and Staff P, RN, Director of Nursing, both stated they were able to see patient names on the electronic record displayed on the computer monitor when standing in the hallway in which visitors passed by.

Observation on 03/01/11 at 9:00 AM, showed two computer monitors facing the main public hallway in the Medical-Surgical Intensive Care Unit had been removed.

11. Observation on 03/01/11 at 9:36 AM, unit 6600 showed four computer monitors, two on one side of the nursing station and two on the other side, all facing and visible to the public hallways.

During an interview on 03/01/11 at 9:37 AM, Staff II, RN, Head Nurse 6600, stated that the computer monitors were visible and facing the main hallways that visitors were encouraged to use.

During an interview on 03/01/11 at 9:40 AM, Staff P and Staff II both stated that the electronic medical record used on unit 6600 had the same size letters and print for patient names as those on the Medical-Surgical Intensive Care Unit.

Based on record review, interview and facility policy review for reporting an occurrence, the facility failed to follow facility policy in regard to reporting an unusual occurrence for one patient (#15) of one patients identified with an occurrence. The facility census was 244.

Findings included:

1. Record review of the facility policy titled, "Reporting An Occurrence" dated 04/08, showed direction for facility staff to document and appropriately investigate any unusual occurrence, incident, accident or variance from typical procedure involving patient care, safety and security and/or visitor injury while on any premises owned or operated by St. Luke's Hospital's. Occurrences are to be reported electronically via St. Luke's Hospital's Occurrence Report Management Program.

2. Record review of the facility policy titled, "Fall Prevention Program" dated 10/08, showed direction for facility staff to appropriately manage those patients who do fall.
Definition of a fall is defined as an unexpected, inadvertent change in position that causes a person to land at a lower level, either on an object, the floor or the ground. A fall can be witnessed or not witnessed. If a patient is found on the floor, it may be assumed that he or she has fallen.

3. Review of Patient #15's medical record on 02/28/11 at 3:20 PM, showed no documentation of a fall during his/her hospital stay of 01/06/11 to 01/17/11.

4. During an interview on 03/01/11 at 9:00 AM, Staff BB, Registered Nurse (RN), stated
that Staff LLL, sitter for Patient #15, called for assistance in Patient #15's room at 10:15 PM on 01/16/11. Staff BB stated that Patient #15 was observed sitting on the floor with legs crossed in front of him/her. Staff BB stated that Staff LLL called for assistance at 1:00 AM on 01/17/11. Staff BB stated that Patient #15 was on the floor. Staff BB stated that no occurrence report could be found for the 01/17/11 incident. Staff BB stated that he/she should have placed a note on Patient #15's medical record and an occurrence report should have been completed.

5. During an interview on 03/02/11 at 8:40 AM, Staff MMM, RN, stated that when he/she charted "I should have charted a fall under "Falls" during hospitalization on 01/17/11". Staff MMM stated that during shift report on 01/17/11 the nurse from the previous shift had reported two incidents with Patient #15 being found on the floor.

Based on interview, record review, and policy review the facility failed to document the least restrictive measures attempted with the patient prior to application of restraints in one patient (#9) of two current patients with restraints. The facility census was 244.

Findings included:

1. Record review of the facility policy titled, "Restraint Policy," dated 07/10 showed the following staff direction:
-Restraints will be used only when alternative methods are not sufficient to protect patients or others from injury.
-Prior to the application of a restraint, a patient will have an assessment performed to determine:
-the safety and protective needs of the patient;
-the specific behavior and medical condition that present a risk;
-steps that have been or will be taken as alternatives to a restraint;
-should a restraint be medically necessary, the least restrictive device possible would be used.
-Restraints are not a substitute for less restrictive forms of protective care.

2. Review of Patient #9's medical record on 02/28/11 at approximately 3:00 PM, showed no documentation of the least restrictive approaches attempted on 02/26/11, prior to initiation of restraints.

3. During an interview on 02/28/11 at 3:35 PM, Staff O, Medical-Surgical Intensive Care Unit Head Nurse, stated that there was no documentation of the least restrictive approaches attempted prior to initiation of the restraints.