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Based on review of the Life Safety Code survey report of the Life Safety survey conducted December 12, 2012, it was determined the hospital was not in compliance with 42 CFR Part 482: Conditions of Participation for Hospitals (Rev. October 11/2008) for Physical Environment.

Findings:

Please refer to the Life Safety Code report of December 20, 2012.

Based on observations, interviews, and document reviews, it was determined that the facility staff failed to protect the privacy of emergency room patients.

The findings include:

The facility staff failed to protect emergency room patients' privacy as evident by having an emergency room patient tracking board located in a walkway that was easily accessible by emergency room patients and visitors.

On 11/27/12 at 12:35 p.m., while touring the facility's emergency department (ED), a monitor/television screen was observed hanging in an area of the emergency department that was easily accessible and commonly used by patients and visitors. The monitor/television screen was being used as the emergency department patient tracking board. This patient tracking board included the following information on emergency room patients: the first four letters of a patient's last name, age, gender, bed assignment, and chief complaint (unless the chief complaint is one that is on a list to not be posted).

The aforementioned information about the ED tracking board was discussed during a survey team meeting, with the facility's Director of Risk Management/Quality and the facility's Emergency Department Manager, on 11/27/12 at 4:20 p.m.

The survey team was provided with a copy of facility policy entitled, Viewing: Safeguarding Patient Confidentiality in the Clinical Setting. This policy included the following information:
- "Patients trust (facility corporate name) with their health and health information. Their expectation is that (facility corporate name) staff will use the information appropriately and not disclose this information to others who do not have a need to know or who are not authorized to have access to that information."
- "Care must be taken to prevent inadvertent disclosure of patient information. If identification of a patient is necessary on white boards, room signs and attached clips, consider using the patient's first name only."
- "Reports, such as OR (operating room) schedules, should be posted in area that are accessible only to authorized staff members."

Prior to the conclusion of the survey the survey team was provided a list of chief complaints that were marked as to whether or not they would be included or excluded from being posted on the emergency department tracking board. Chief complaints that would NOT be posted included, but were not limited to: active labor, anxiety, assault, depression. Chief complaints that WOULD be posted included, but were not limited to: constipation, confusion, delirium tremens, fecal impaction, and needle stick. The facility's ED Manager reported, prior to the conclusion of the survey, that the ED tracking board has been turned off and that the facility staff was reviewing the use of the ED tracking board.