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.

THE HOSPITALS OF PROVIDENCE - SIERRA CAMPUS 1625 MEDICAL CENTER DR EL PASO, TX 79902 July 19, 2016
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to provide a required Notice of Privacy Practice (NPP), a federally-required notice to patients identifying their health privacy rights and remedies under federal law to (1) one of (10) patient's records reviewed for Patient's Rights. (Patient #5)

Findings include:

Review of Patient #5's, medical records revealed a [AGE] year old male was admitted on [DATE] with a diagnosis of Acute Renal Failure and COPD (chronic obstructive pulmonary disease) exacerbation.

Review of the Patient #5's medical records dated 7/17/16 revealed he did not receive a Notice of Privacy Practices.

During an interview on the morning of 7/19/16 in the facility's conference room Staff #14, Patient Access Director stated, "When the patient signs the NPP it is good for a year, when the patient is readmitted we ask them if they want a copy of the NPP." When asked about Patient #5's missing NPP, Staff #14 stated, "I don't have a NPP for him ....the registrars are supposed to check each patient has a current NPP on file ..."

Review of the facility provided document Notice of Privacy Practices (NPP) Standard (dated 4/4/16) reflected " ...Tenent provides each patient with a NPP that is written in plain language and that contains the elements required by HIPPA Privacy Regulations ....The Tenet Facility must make a good faith effort to obtain the patient's acknowledgment in writing ...3. If despite good faith efforts, written acknowledgment is not obtained, then the efforts and the reason(s) why the acknowledgment of receipt could not be obtained will be documents ...F. A Tenent Facility that has a direct treatment relationship with patients must: 1. Provide the NPP no later than the date of the first service delivery ... I. The Tenet Facility must document compliance by retaining copies of the NPP issued ...2. Tenet Facility Leadership will: a. Adopt this standard and where necessary develop specific written procedures ...to operationalize this standard; b. Develop appropriate methods to monitor adherence to the written procedures ..."

Review of the facility provided document Patient Access Policy and Procedure Manual Registration (dated 5/14/14) reflected " ...NPP; A federally-required notice to patients identifying their health privacy rights and remedies under federal law ....The NPP is provided to patients at their initial visit and each time the NPP is updated ..."
VIOLATION: CONFIDENTIALITY OF MEDICAL RECORDS Tag No: A0441
Based on observation, interview and record review the facility failed to protect patient's right to medical information when (2) two, unattended, computer screens were left open with patient medical information on the display screens. The computers were in a public hallway.

Findings include:

Observations on 7/18/16 at 12:25 p.m. on the facility's Inpatient Medical units, accompanied by the facility's Director of Quality, Risk Manager and Performance Improvement Coordinator, revealed an unattended portable computer monitor sitting on a public hallway. The monitor displayed a patient's medical information.

During an interview on 7/18/16 at 12:35 p.m.on the Inpatient Medical unit, Staff #1, RN (Registered Nurse) confirmed she was using the computer and she was supposed to protect the information. When asked why the computer was left open, Staff #1 stated, "I guess I was just in a hurry."

Observations on 7/18/16 at 12:45 p.m., on the facility's Inpatient Orthopedic unit, revealed an unattended portable computer monitor sitting in a public area in front of the nursing station. The monitor displayed a patient's medical information. Staffs were observed walking in front of the monitor; they did not alert the nurse of the breech and did not close the computer monitor to protect the patient information.

During an interview on 7/18/16 at 12:55 p.m., on the Inpatient Orthopedic unit, Staff #2, RN confirmed she was using the computer, "I should have logged off the computer ....leaving patient information is not acceptable."

During an interview on 7/18/16 at 2:00 p.m., in the conference room, Staff #12, Market Director of Quality Improvement and Patient Safety stated, "All staff are trained on Patient Privacy practices during the new hire general orientation and annually through the online Healthstream program."

Review of the facility provided document Healthstream training revealed "Confidentiality: HIPPA (Health Insurance Portability and Accountability Act of 1996) ...The HIPPA Privacy Rule protects a patient's right to privacy of health information ...To comply with HIPAA Discuss a patient's case only with people who are directly involve ...Do not leave patient charts out where they might be seen ...Do not display protected patient information where it might be seen ...Confidentiality ...Always use a private place for Patient examination and treatment ..."

Review of the facility provided document Patients' Rights (undated) revealed " ...The hospital respects your rights and recognizes that you are an individual with unique health care needs and because of the importance of respecting your personal dignity, provides considerate, respectful care ...10. The right to expect that all communications and records pertaining to care will be treated as confidential ....12. The right ...to personal privacy and to expect that any discussion or consultation involving care will be conducted discreetly, and that individuals not directly involved in your care will not be present without your permission ..."


Review of the facility provided document Risk Management Safety Flyer addressing Privacy reflected "What is considered protected health information?
- All information about a patient is considered confidential.
- Anything that is received maintained or transmitted in any format.
- Anything that related to the patient's past, present or future medical condition, treatment or payment for care.
- Anything that identifies the patient or could be used to identify a patient.