Select Specialty Hospital-Dallas

“PATIENT RIGHTS: PRIVACY AND SAFETY CFR(s): 482.13(c) Patient Rights: Privacy and Safety This Standard is not met as evidenced by: 33589 BASED ON record review and interview, the facility failed to ensure the patient’s right to privacy and confidentiality of information when 29 patients’ information was erroneously / unintended forwarded to Patient #1’s wife on 1/22/2025. On 1/23/2025 Patient #1’s wife notified the facility of the violation. (29 of 29 / Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, and #29). The facility failed to follow their policy to assess and remedy the breach from the 1/23/2025 notice until the 4/01/2025 surveyor injuiry. Findings The 1/22/2025 forwarded email to Patient #1’s wife contained 35 pages of the 29 patients in the hospital on 1/21/2025 list of patients, individually listed patient supplies, services, and associated fees. The information included patient name, patient number, date of service, amount of charge for room and board, as well as individual charges per patient of hemodialysis, feeding pump, oxygen, wound dressings, isolation supplies, wound vac, wound gel, trach supplies, suction, reagent strips, mattress, bariatric bed, intravenous solutions, irrigation, abdominal binder, gait belt, speaking valve, sling, male/female catheter, bladder scan, assorted x-rays, Angiography, assorted laboratory testing, telemetry, doppler, ventilator, trach care, suctioning, therapy (physical, occupational, speech), and each listed medication. Patient #1’s wife and receiver of this patient information forwarded the 1/22/2025 email to the facility CEO on 1/23/2025 to notify the facility of the violation. No actions were completed or documented by the facility since the time of notification of the violation. During an interview in the education conference room on 4/01/2025 at 1:20 PM, Personnel #1 was asked about the 1/23/2025 email that showed a 1/22/2025 violation of HIPAA and what was done to correct the violation when she received it. Personnel #1 stated she forwarded to the Compliance Officer but had not heard back on it. Personnel #1 was asked for the forwarded email to compliance. Personnel #1 stated she could not find it but forwarded it again. Personnel #1 stated I thought I sent it but am not able to locate it in my sent file. Personnel #1 was asked to confirm that it appears today that this is the first compliance heard of the violation. Personnel #1 agreed. The facility’s 1/27/2025 last reviewed “Uses and Disclosures of Protected Health Information (PHI)” policy required, “federal HIPAA regulations on patient privacy and confidentiality place restrictions on our ability to use and disclose that information...” The facility’s 1/27/2025 last reviewed “Beach Notification” policy required, “all employees will access, use and disclose protected health information only as permitted...in the event that a breach of unsecured PHI occurs...Reporting a Breach - Any workforce member, business associate, or data owner who believes that a breach has occurred, should immediately notify their supervisor and or Select Medical representative of the occurrence. The potential breach should then be reported to the Privacy Officer...determine the appropriate breach notification requirements...proceed with required notifications...””

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50856 Based on interview and record review, the hospital nursing staff failed to evaluate the nursing care for two out of five patients (Patient D and K). Patient D’s and patient K’s IV dressing was not changed every seven days per the hospital policy. Findings included: Record review of Patient D’s IV flow sheet dated 01/29/2024 through 03/04/2024 did not reflect any evidence that the dressing was changed every seven days. Record review of Patient K’s IV flow sheet dated 9/28/2024-9/30/2024 did not reflect any evidence that the dressing was changed. Staff #4, #5, and #6 were interviewd on 09/30/2024 and did not know what “Other (comment)” meant in the “dressing intervention” box in the medical record. Additionally, any actual comment it seemed to refer to could not be located. Staff #4 agreed that the documentation “did not appear to indicate a dressing change was completed.” According to the hospital policy Intravenous Therapy: Short Peripheral and Midline IV Therapy (dated 07/01/2024) Dressing changes a. Whenever the dressing becomes damp, loosened or visibly soiled. b. TSM [transparent sterile membrane] dressing every 7 days.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 27128 The nursing service must ensure that patients receive ongoing assessments of their needs and provide nursing staff to meet those needs. Based on interviews and record review the hospital failed to ensure there was an ongoing assessment and evaluation of 1 of 1 (Patient #1) patient’s PICC line. After the patient received a PICC line, the patient was found to be laying in blood. Findings included: On 01/16/24 a complaint was submitted to the hospital alleging Patient #1 was left bleeding after his PICC line placement (Peripherally inserted central catheter). After reviewing the medical record with Personnel #1 on 05/15/24, it was determined there was no documentation reflecting the patient’s PICC line site was assessed, monitored, or was bleeding after the line was inserted on 01/16/24. Interviews confirmed the incident. During an interview on 05/15/24 at 1:00 PM with Personnel #2 he said he remembered Patient #1. He had placed a PICC line in the patient on 01/16/24. When he left the patient following the placement, the patient was not bleeding. He was notified the patient was bleeding about 1-1 ½ hours after he left the hospital. He immediately returned to the hospital. He placed a pressure dressing on the PICC line site. He said the nurse should have placed a pressure dressing on the site. He said maybe the nurse didn’t see the blood because the patient had covers on him. Blood had seeped under the patient. He was able to stop the bleeding. During an interview on 05/15/24 at 1:15 PM with Personnel #3 she said nurses should monitor the PICC line site after insertion to make sure there was no bleeding. She said she called Personnel #2 after she learned Patient #1’s site was bleeding. She couldn’t remember who told her about the bleeding. The surveyor asked if nurses should document their findings after monitoring a PICC line site. She confirmed the findings should be documented. During an interview on 05/15/24 at 2:00 PM with Personnel #1 she confirmed there was no documentation of monitoring, assessment or of bleeding after Patient #1’s PICC line was inserted on 1/16/24. Policy The hospital’s Central Venous Access Devices policy, with a revision date of 10/01/22 reflected, “...RN staff will be responsible for care and maintenance of all central lines...””