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Based on a review of the clinical record, review of policies and procedures, review of hospital documentation, observation and interviews the hospital failed to protect one minor patient's (Patient #4) right for privacy and to provide care in a dignified manner.

Patient #4 was admitted to the hospital's Emergency Department after sustaining multiple gunshot wounds and expired after life support measures were unsuccessful. In the presence of numerous staff members, RN #7 took a photograph of Patient #4's chest wound with his/her personal cell phone during post-mortem care. This photograph was subsequently circulated to seven staff members and two non-employees.
Please refer to A143.

Based on a review of the clinical record, review of policies and procedures, review of hospital documentation, observation, and interviews the hospital failed to protect one minor patient's (Patient #4) right for privacy and to provide care in a dignified manner. The finding includes:

1. Patient #4, a minor, arrived via ambulance at the Emergency Department (ED) on 6/25/11 at 10:18 P.M. after sustaining multiple gunshot wounds. The patient was unresponsive, pulseless, and apneic with cardiopulmonary resuscitation (CPR) in progress upon arrival. Review of the clinical record reflected that advanced cardiac and pulmonary life support measures, including a chest thoracotomy and cardiac massage, were carried out by the interdisciplinary trauma team, however, was unsuccessful and the patient expired at 10:46 P.M.

2. Interview with the Director of Quality, on 9/13/11 at 7:35 A.M., identified that the hospital was informed via a message on the anonymous hotline on 6/27/11 that a hospital employee took a picture of Patient #4 with his/her personal cellular telephone during post-mortem care and sent the photograph to others.

3. Review of hospital documentation dated 6/29/11 at 12:22 A.M. and observation of hospital ED trauma room video surveillance, on 9/13/11 at 9:55 A.M. with the hospital's general counsel, identified that seven staff members were observed standing around the stretcher that contained Patient #4's body. Interview with the Nurse Manager and the Nurse Director of the ED, on 9/13/11 at 10:10 A.M., identified the staff members as RN's #6, 7, 8 and 9, ED Technicians #1 and 2 and ED Transporter #2. RN #7 stated he/she wanted to take a photograph of the patient's chest wound, RN #6 (assigned nurse) responded to "go ahead", and RN #7 left the area shortly returning with his/her personal cellular telephone. RN #7 proceeded to obtain a photograph of the patient's open chest wound. ED Technician #1 asked RN #7 to send the photograph to his/her cellular telephone and RN #7 did. ED Technician #1 identified that he/she sent the image to the personal cellular telephones of ED Transporters #2 and 3. ED Transporter #2 identified that he/she sent the image to the personal telephones of two family members, Unit Secretary #1, Admit Staff #2, ED Transporter #3, ED Transporter #4 and Clinical Technician #2. The hospital ' s investigation further identified that three other employees, including PA #1, were interviewed regarding this incident.
Staff present in the room failed to intervene to ensure the patient's privacy and/or promote care in a dignified manner.

4. Interview with RN #7, on 9/13/11 at 1:27 P.M., identified that he/she took a photograph of Patient #4's chest wound with his/her personal cellular telephone while the patient was in the ED trauma room for his/her personal learning due to the open chest wound and sent that image to ED Technician #1's personal cellular telephone.

5. Interview with ED Technician #1, on 9/19/11 at 11:50 A.M., identified that he/she observed RN #7 take a photograph of Patient #4 during post mortem care while in the ED trauma room and asked RN #7 to send the photograph to him/her. RN #7 sent the photograph to ED Technician #1's personal cellular telephone. ED Technician #1 would not respond to the question of what he/she did with the image and terminated the interview at 11:56 A.M.

6. Interview with ED Technician #2, on 9/13/11 at 10:50 A.M., identified that he/she witnessed RN #7 take the photograph of Patient #4 while he/she was preparing Patient #4's body to go to the morgue. ED Technician #2 identified that he/she assumed the RN had the authority to take the patient's picture, therefore, didn't intervene.

7. Interview with ED Transporter #2, on 9/19/11 at 12:00 Noon, identified that he/she observed RN#7 take a photograph of Patient #4 with his/her personal cellular telephone during post mortem care while in the ED trauma room. ED Transporter #2 then terminated the interview at 12:05 P.M.

8. Interviews with RN #6 (nurse assigned to care for the patient) and RN #9 declined interviews with the surveyor.

9. Interview with RN #8 (charge nurse), with Person #3, on 9/15/11 at 8:00 A.M., identified that he/she observed RN #7 take a photograph of Patient #4 with his/her personal cellular telephone during post mortem care while in the ED trauma room.

10. Interview with ED Transporter #3, on 9/14/11 at 2:07 P.M., identified that on 6/26/11 while working at the hospital during his/her assigned shift, he/she observed the photograph of Patient #4 on ED Technician #1's personal cell phone. ED Transporter #3 identified that ED Transporter #2 sent him/her the photograph of Patient #4 to his/her personal cellular telephone, however stated he/she deleted that photograph and did not send and/or forward the photograph to anyone.

11. Interview with Unit Secretary #1, on 9/13/11 at 8:01 A.M., identified that ED Transporter #2 sent him/her the photograph of Patient #4 to his/her personal cellular telephone, however stated he/she deleted the photograph and did not send and/or forward the photograph to anyone.

12. Interview with ED Transporter #4, on 9/13/11 at 3:28 P.M., identified that a photograph of Patient #4 was sent to his/her personal cellular telephone by ED Transporter #2 although the photograph was not received.

13. Interview with Clinical Technician #2, on 9/14/11 at 8:08 A.M., identified that a photograph of Patient #4 was sent to his/her personal cellular telephone by ED Transporter #2, however stated he/she did not send and/or forward the photograph to anyone. Clinical Technician #2 stated that the hospital information services staff deleted the photograph from his/her personal cellular telephone.

14. Interview with PA #1, on 9/15/11 at 1:50 P.M., identified that a photograph of Patient #4 was sent to his/her personal cellular telephone by RN #7, however stated he/she deleted the photograph and did not send and/or forward the photograph to anyone.

15. Review of the Release of Information to Communications Media reviewed 9/09, identified that on the basis of the patient's right to privacy , photographs of patients are not permitted to be released without the written permission of the patient and/or the parent/guardian in the case of a minor.
Review of Patient #4's clinical record and interview with the Director of Quality, on 9/13/11 at 8:15 A.M., failed to identify that the Consent to Hospital Admission and Medical Treatment form was signed by the patient's guardian.
Additionally, review of the Consent to Hospital Admission and Medical Treatment (form #100689) identified consent to have photographs for the purpose of medical documentation, education, knowledge, research and/or media publicity, which the hospital deem proper. The patient will be allowed access to view the photographs or obtain copies. The images will be stored in a secure manner that will protect the patient's privacy. Images that identify the patient will be released and/or used outside the institution only upon written authorization from the patient and/or the patient's legal representative.

16. The hospital nursing structure standards, revised 10/18/05, identified that the nursing standards for patient care include that each patient can expect that their privacy and confidentiality will be protected and maintained and nursing staff are patient advocates.

17. Review of the hospital Code of Conduct, revised 3/25/10, identified that the hospital is committed to maintaining the confidentiality of the patient, employees should access only the minimum necessary information to perform their job and confidential information may not be shared without authorization.

Review of the personnel files of RN #6, 7, 8 and 9, Unit Secretary #1, Clinical Technician #2, ED Transporters #2, 3, and 4, and ED Technicians #1 and 2 identified that although each employee signed a receipt annually that they received and understood the Code of Conduct, the hospital failed to ensure the employees maintained compliance to this code.

18. Review of the Patient's Rights and Responsibilities booklet, not dated, reflected that each patient is treated with respect and has the right to expect that all aspects of medical care and clinical records are kept private.

19. Review of the policies and procedures, titled Confidentiality (E6 reviewed 8/1/06) and Confidentiality (C30, reviewed 4/10) identified that it is the policy of the hospital to safeguard and protect the patients against indiscriminate and unauthorized access to confidential information. The employees are prohibited from obtaining patient information for which they have not received access authorization. In addition, the employees are required to acknowledge understanding of the Confidentiality policy by signing a form.
Review of the personnel files of RN# 6, 7, 8 and 9, Unit Secretary #1, Clinical Technician #2, ED Transporters #2, 3, and 4, and ED Technicians #1 and 2 identified that each employee signed a receipt that they understand and will uphold the hospital's confidentiality policies and procedures upon hire.

20. The Employee Code of Behavior revised 10/10, identified that employee conduct is prohibited including violation of the confidentiality policy and inappropriate use of cell phones and other personal communication devices during work. In addition, employees are expected to maintain the confidentiality of patient information and treat all patients with respect.

21. Review of the policy and procedure, titled Use of Cellular Telephones and Two way Radios (E-60, approved 1/29/08) identified that the use of camera phones for taking pictures is prohibited in the hospital unless authorized by security department personnel.

RN #7, ED Technician #1, and ED Transporter #2 were terminated from employment on 6/29/11 and 6/30/11 respectively, based on violations of the Employee Code of Behavior and the Confidential Policy.
Review of the personnel files identified that ED Technician #2 and RN's #6, 8 and 9 received written warnings for failing to intervene and/or report the incident to appropriate hospital contacts and were all re-educated to applicable hospital policies and procedures.