The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

NORWOOD HOSPITAL 800 WASHINGTON STREET NORWOOD, MA 02062 March 8, 2011
VIOLATION: COMPLIANCE WITH LAWS Tag No: A0021
Based on interview and documentation review it was determined the Hospital failed to ensure all disposal of protected health information (PHI) was performed in a manner to ensure compliance with Federal laws.
Findings included:
The Director of Environmental Services said the landfill staff ripped open the clear plastic trash bags and had sent pictures of the bag's contents to the Hospital.

Review of the pictures provided to the Hospital by the landfill indicated two 100 milliliter IV bags were found by the Landfill staff. Labels were affixed to the bags and printed on the labels was protected health information (the Patient's name, medical record number, dates and medication infused in the IV solution).

The Infection Control Manager (Manager) was interviewed in person on 2/22/11. The Manager said the IV bags had been appropriately discarded in the regular trash.

The Hospital Policy titled Safeguard and Management of Protected Health Information for Disposal of Protected Health Information (PHI) was reviewed. The Policy stated all hospital medical staff, employees, volunteers and students safeguard protected health information by ensuring appropriate disposal of all hard copy documentation containing protected health information. Documents containing PHI will be either shredded or placed in a locked confidential containers. All Hospital medical staff, employees, volunteers and students will be responsible for the disposal of any documentation that contains PHI.

The Hospital Policy titled Protecting Patient Privacy was reviewed. The Policy stated PHI is any information which identifies an individual and the provision of health care to the individual. The Policy listed information that identifies an individual. This information included but was not limited to: Name, service dates, and medical record number. The section that addressed disposing of PHI stated Personnel must dispose of paper PHI by shredding or placing in locked recycle bin. The Policy did not address how labels affixed to IV bags or other items, that were labeled with PHI, during the course of an individuals stay as a patient at the Hospital, would be disposed of.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on interview and documentation review it was determined the Hospital failed to ensure the method utilized for the final disposal of used supplies that included patients' individually identifiable health information was effective and in compliance with Standards for Privacy related to protected health information.

Findings included:

Refer to Tag # A-021