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Based on the nature of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 484.13, PATIENT RIGHTS, was out of compliance. The hospital failed to protect and promote patient rights by failing to ensure the personal privacy of patients in the Intensive Care Unit, by neglecting to provide a call mechanism to patients in the Intensive Care Unit, and by failing to provide a call system, throughout the facility, that could be heard by direct care staff in all areas of the facility. In addition, the facility failed to provide a visible means of patient identification and a verification of patient identifiers prior to performing a blood glucose test. The failures had the potential to affect all patients.

Cross-reference:

482.13(c)(1) - Standard: Privacy and Safety - the patient has the right to personal privacy. The facility failed to ensure the personal privacy of patients who received care in the Intensive Care Unit (ICU) by providing therapeutic treatments to a patient without using privacy curtains and without ensuring the door from the ICU to the hallway was closed when treatments were provided.

482.13(c)(2) - Standard: Privacy and Safety - the patient has the right to receive care in a safe setting. The facility failed to provide care in a safe setting by providing a patient call system that could not be heard by direct care staff in all areas of the facility. Direct care staff could not, at all times, hear the call system when providing care in patient rooms. The facility failed to provide a call mechanism to patients who received care in the Intensive Care Unit.
In addition, the facility failed to provide a visible means of patient identification and a verification of patient identifiers prior to performing a blood glucose test.

Based on observations, interviews, and document review, the facility failed to ensure the personal privacy of patients who received care in the Intensive Care Unit (ICU).

This failure created an instance in which a patient received treatments that were able to be viewed by other individuals in the ICU who were not associated with the patient.

FINDINGS:

REFERENCE

According to the facility's Patient Rights and Responsibilities, the patient has the right to personal privacy.

1. The facility did not ensure the privacy of a patient in the ICU while the patient was receiving therapeutic treatments.

a) On 05/26/15 at 11:34 a.m., observation was conducted of the ICU, which was one large room with 4 patient beds. The beds were arranged as 2 beds, side-by-side, on one wall and 2 beds, side-by-side on the opposite wall with the nurses' station located in the middle of the room and toward one end of the room. Each patient bed area had curtains, on rails, that could be opened and could be closed to provide patient privacy. Two patients were observed in ICU beds, Patient #1 and Patient #2.

Upon entering the ICU at 11:34 a.m., it was noted the door from the ICU to the main hallway was open and Patient #2 was receiving a therapeutic treatment (respiratory treatment) with approximately 4 staff members present at his/her bed. The treatment could be seen from the hallway as well as from inside the ICU as curtains were not drawn to provide privacy during the treatment. Patient #1 was in a bed opposite Patient #2 and had curtains drawn around his/her bed. Even so, Patient #2 could be seen once inside the ICU as the curtains had gaps between the curtain sections.

A visitor was observed leaving the bedside of Patient #1 and as s/he left the ICU, Patient #2, receiving a treatment, was fully visible to the visitor.

This observation of the ICU was conducted over 20 minutes and during this time direct care staff did not attempt to close the curtains for Patient #2 to provide privacy during the respiratory treatment.

b) On 05/26/15 at 1:06 p.m., observation was conducted of the ICU. At this time the door from the ICU to the main hallway was open and Patient #2 was fully visible, from the hallway, in his/her bed with no curtains drawn.

c) On 05/26/15 at 2:03 p.m., an interview was conducted with Registered Nurse (RN) #7 who stated s/he was unaware of any privacy concerns in the ICU and that patient privacy was ensured by pulling the curtains around each patient bed. RN #7 stated visitors were allowed in the ICU. S/he stated that earlier on 05/26/15, when Patient #2 was receiving therapy, the curtain was drawn around Patient #1 in order to provide privacy to Patient #2. RN #7 stated s/he did "not know what to say" about the visitor who left the bedside of Patient #1 being able to observe the treatment being provided to Patient #2. RN #7 stated s/he could not recall patient privacy in the ICU being discussed in a nurses' meeting or at any other time.

d) On 05/26/15 at 3:00 p.m., the ICU was observed and it was noted the door to the hallway was closed. A laminated sign posted on the door, and visible from the hallway, stated to knock before entering and to check in with the ICU nurse, who was located inside the ICU. At this time Patient #2 was observed receiving therapy in the second bed located on the side of the room in which s/he was seen earlier, with no curtain closed around the bed to ensure patient privacy. The curtain was not drawn around Patient #2's bed during this observation and the patient's therapy treatment was fully visible. The surveyor had no way to gain permission to enter the ICU prior to knocking on the door and entering, as the ICU nurse was stationed inside the ICU. The posted process for visitors to gain access to the ICU, meant that visitors would have to enter the ICU in order to check in with the ICU nurse, and that visitors would be able to see patients, and patient treatments of individuals they were not associated with.

e) On 05/29/15 at 9:25 a.m., an interview was conducted with the Director of Quality and with the facility's Nurse Manager. The Director stated there was no facility policy directing staff how patient privacy would be achieved in the ICU, which was one large room, with 4 patient beds. The Director confirmed the statement in Patient Rights and Responsibilities that patients have the right to personal privacy. The Director stated that patients and families were oriented to the ICU by nursing staff who were then responsible for ensuring patients' personal privacy. The Director stated any time personal care of patients occurred, for example when patients were being turned, repositioned, or "being cleaned," curtains in the ICU should be closed to ensure personal privacy. The Director stated this expectation would include when therapies or treatments were provided to patients in their beds or their specific area of the ICU.

The Nurse Manager stated s/he addressed individual breaches of patient privacy with individual nurses when s/he observed this occur. The Manager stated s/he did not document these conversations, did not have a formalized audit or way to monitor breaches of patient privacy, and so did not report these instances to others in the facility for review. The Manager could not state the last time the issue of patient privacy was discussed with ICU nursing staff as a whole.

Based on observations and interviews, the facility failed to ensure the safety of all patients by neglecting to provide a call mechanism to patients in the Intensive Care Unit (ICU) and by utilizing a call communication system that did not provide immediate contact with nursing staff in all areas of the patient care units, causing slower response times for patient, family member, and staff requests for help. In addition, the facility failed to provide a visible means of patient identification and a verification of patient identifiers while performing a blood glucose test.

The failure created the potential for an increased risk to patient safety and negative patient outcomes.

FINDINGS:

POLICY

According to the facility document, Hospital Plan for the Delivery of Patient Care Services, it is the philosophy of the facility to create an environment that supports safe and effective delivery of patient care, treatment and services. Patient care services occur through an organized and systematic process designed to ensure the delivery of safe, effective and timely care, treatment and services.

According to the facility document, Patient Rights and Responsibilities, the patient has a right to care in a safe setting.

According to the policy, Patient Call Devices, appropriate devices shall be available to help facilitate the patient's needs. Upon admission, the nurse shall assure there is a functional call light easily accessible by the patient. If the patient is unable to demonstrate appropriate use of the standard call light, the nurse shall evaluate the patient's ability to use alternate call devices such as "sip and puff" and "soft touch."

If the patient is unable to demonstrate the ability to use an alternate call device, the nurse shall develop a plan of care for the patient's safety and observation, refer the patient to rehabilitation services for screening, and document these findings in the medical record.

According to the facility policy, Two Patient Identifiers, the two recommended patient identifiers are the patient's full name and date of birth. Staff are to immediately clarify or correct any discrepancies in data prior to care delivery according to facility policy if, at any point, patient identification fails in any way. The facility specific patient identification process shall include but is not limited to the following process elements: the patient identification band shall be utilized for patient identification, and verification that the patient identification band information corresponds with the information in the patient medical record. The procedure stated: staff introduced self and explains purpose of identifying patient, then the patient verbally states the two patient identifiers out loud to the care provider, and lastly the staff verify the patient's stated identifiers with the patient's identification band.

1. The facility failed to provide a call communication system that ensured timely nursing staff responses to patient, family, and staff requests for help on the patient care units.

a) On 05/27/15 at 10:19 a.m., an observation was conducted on the 4th floor unit. At 10:19 a.m., Patient #13's call light (room 410) was activated. The call light was observed to ring at the nurses' station, but there were no staff visualized in the hallway or other visible areas of the unit. A visitor from the patient's room was observed to come out to the hallway and look for staff. No staff were visible to respond to his/her needs.

At 10:22 a.m., the visitor returned to the hallway and came to the desk saying "we need a nurse, something is not right." No nurse or other staff was available to respond to the visitor's concerns. The Nurse Manager (RN #2), who was touring with the surveyors, went into the room to check on the patient. The patient was observed sitting on the side of the bed appearing diaphoretic and shaking. The Manager stated that s/he would find someone to assist the patient and was observed going into the hall and calling for a nurse or Certified Nursing Assistant (CNA).

At 10:25 a.m., the patient's visitor stated again to the surveyor, "something is not right." At 10:27 a.m., the visitor went into the hall a third time looking for a staff member. At 10:28 a.m., Registered Nurse (RN) #12 went into the patient's room and introduced himself/herself to the patient. At 10:30 a.m. the patient's temperature was taken and was found to be 103 degrees F. At 10:32 a.m., the patient and visitor were left alone in the room with the surveyor. The patient and visitor stated it had been difficult to get staff to respond when they called for assistance, including when they used the call mechanism, and expressed concerns that there might not be enough staff. They stated that they had difficulty getting staff to help that morning when the visitor found the patient on the toilet shaking and sweating. The visitor stated that "something wasn't right, but I could not find anyone when I went out into the hall. It seems like they are understaffed. At this point we want to go back to (the previous hospital)."

At 10:38 a.m. CNA #9 came to the room and took another set of vital signs, including another temperature. The temperature was 103.8 degrees F. and then 104.2 degrees F. The patient was transferred back to the previous facility through the Emergency Department (ED) that same day at the request of the patient and family.

On 05/29/15 at 9:10 a.m., a telephone interview with Clinical Liaison (CL) #18 was conducted and the CL confirmed that the patient had been readmitted to the transplant unit of the previous hospital with a diagnosis of sepsis.

b) On 05/29/15 at 8:59 a.m., Patient #14 in room 412 and a family member were interviewed about care received. Both stated they had experienced long waits in response to call lights, particularly for patient requests to be taken to the bathroom. They stated the patient had to wait as long at 40-45 minutes to be taken to the bathroom. They stated that in one instance, a nurse popped his/her head into the room in response to the call light and told the patient that s/he did not have time to take the patient to the bathroom at that time. They stated the delayed call responses were worse in the evenings and on weekends and the 40-45 minute waits to go to the bathroom "had happened more than once."

c) On 05/27/15 at 2:49 p.m., the Nurse Manager was interviewed regarding complaints and grievances received by the facility. S/he confirmed that of the 5 most recent complaints received and reviewed, all had a component related to patient or family dissatisfaction with timely staff responses to call lights. The Manager stated that s/he was not aware of any quality initiatives related to call light responses in the 3 years that s/he had worked at the facility, but acknowledged that call light response time was an issue that was frequently noted on complaints.

d) On 05/29/15 at 8:38 a.m., RN #10 was interviewed about care issues including responses to call lights. The RN stated s/he could not hear a call light while providing care in another patient room with the door closed. RN #10 stated s/he tried to keep the patient door to the hallway open and then would open the bathroom door into the room to partially block the view from the hall way to provide some privacy for the patient. S/he stated that at times, the door to the hallway had to be closed and this would possibly inhibit hearing a call from another patient room.

e) On 05/26/15 at 2:49 p.m., RN #13, a nurse in 4th week of orientation, was interviewed about a variety of issues, including training received as a new employee regarding expectations for call light responses. RN #13 stated that the expectation was that all staff would respond to call lights and that all patients would have a call light of some kind to summon for help.

f) On 05/29/15 at 9:42 a.m., the Nurse Manager and the Director of Quality were interviewed about effectiveness of the call light system and staff statements to surveyors that call lights were not always audible from other patient rooms. The Director stated that RN's would at times open the door to the hall way and open the bathroom door in a patient's room to provide privacy and will still be able to hear the patient call light while in another patient room. S/he also stated that some of the difficulty hearing call lights from other patient rooms was due to the sound from the patient's televisions (TV). The Director stated staff were encouraged to turn off the TV when entering a patient's room, to make it easier to hear call lights. S/he then qualified the statement by saying it was the patient's right to have the TV on and that also had to be considered.

Both the Manager and the Director stated the inability of direct care staff to hear calls from the patient call system from all parts of the patient care floors was a safety concern. Both stated they had not been notified by staff of recent concerns about the inability to hear calls and other audible alerts from patient rooms, as relayed to the surveyors by staff.

g) On 05/27/15 at 1:45 p.m. Staff #16, a telemetry monitoring technician was interviewed regarding duties and specifically about how to notify the patient's nurse on the unit when a patient was having a change in rhythm that required nurse assessment. The technician stated it was more difficult to notify the nurse timely since the nurses no longer carried phones to allow for immediate contact. The technician stated that if an abnormal rhythm occurred, the nursing station at the patient's floor was called. S/he stated that if the floor nurses' station phone was not answered, s/he would try to contact the house supervisor. The technician stated that if the house supervisor could not be reached, s/he would have to leave the monitoring station, put someone else at the console to monitor patients, then go to the floor/unit where the patient was located to alert the nurse.

h) On 05/28/15 at 2:30 p.m., Staff #17, a telemetry monitoring technician was interviewed regarding duties and specifically about how to notify the patient's nurse on the unit when a patient was having a change in rhythm that required nurse assessment. The technician stated s/he would notify the nurse on the patient's floor and during the day that could be done by overhead page or by calling the nursing supervisor. The technician stated s/he would never leave the monitoring station, but if the abnormal rhythm seemed serious and the nurse or supervisor could not be reached, then s/he might call a rapid response to the patient's room and if it appeared critical, then s/he might call a code.

i) On 05/26/15 at 9:20 a.m., Staff #1, a nurse and House Supervisor, was interviewed regarding rapid response procedures. S/he stated "everyone goes" when a rapid response was call. S/he stated the facility did not restrict who would respond to a rapid response, because staff could not always hear the overhead pages if they were in a patient's room, particularly if the door was closed or the television was on in a room.

2. Two ICU patients (Patient #1 and Patient #2) were observed without a call device available to them and instead were instructed to "tap" on their bed rails if they needed assistance from nursing staff.

a) On 05/26/15 at 1:06 p.m., observation was conducted of the ICU. Patient #1 was observed with curtains drawn around his/her bed, but with an opening between the curtain sections which allowed the patient to be seen. The patient made eye contact with the surveyor, then began tapping on his/her bed rail indicating s/he needed assistance. The ICU nurse, Register Nurse (RN) #7, was observed sitting at the nurses station with his/her back to Patient #1's bed and with the curtain completely drawn around the end of the bed not allowing the patient to be seen by the nurse. The patient's tapping of the bed rail could not be heard by the surveyor.

b) On 05/26/15 at 2:03 p.m., an interview was conducted with RN #7 who stated Patient #1 was not an ICU status patient but was placed in the ICU as an "overflow patient." RN #7 stated Patient #1 was less critical than an ICU patient. S/he stated Patient #1 was not able to "press the call light" and s/he learned this from hand off from another ICU nurse on 05/25/15. RN #7 said soft touch call devices did not work for all patients and stated she did not try to obtain a soft touch device for Patient #1 to determine if s/he could use this type of alternate device. S/he stated that Patient #1 had a pad and pencil to use to communicate as s/he was non-verbal.

RN #7 stated having patients in the ICU "tap" on their bed rails to signal for assistance was used frequently in the ICU. S/he stated Patient #2 was also instructed to "tap" for assistance and that the standard call mechanisms for both patients was secured away from the patients and so could not be accessed by either patient. RN #7 did not know if a soft touch device or other alternative device was made accessible to Patients #1 and #2 by other ICU nursing staff as this was not discussed or documented by nursing staff.

RN #7 stated that if ICU patients used the standard call light mechanism found at each of the 4 patient beds in the ICU, the nurse could not tell if the signal was coming from an ICU patient of from a patient room outside of the ICU. RN #7 stated s/he could not recall the issue of patients"tapping" instead of using a standard call mechanism or an alternate call device ever being discussed with ICU nursing staff or in nursing meetings.

c) On 05/29/15 at 9:55 a.m., an interview was conducted with the Director of Quality and the Nurse Manager. The Manager stated patients in the ICU were not given standard call devices because when used in the ICU, the signal did not register or go off in the ICU. Instead the sound registered at the main nurses' station in the hallway outside of the ICU. S/he stated the standard call devices were not made available to ICU patients for this reason.

The Director stated ICU patients were given a bell to use in lieu of a standard call device, and described a bell that one would pat the top of to make a "ding" sound. The Director stated these bells could be requested by nursing staff through the maintenance department and were also available in the ICU. The Director stated instructing ICU patients to "tap" on their bed rails was not an option for nurses to use as a call device. The Director and the Manager stated they were unaware of nurses instructing ICU patients to "tap" for assistance instead of using a bell. The Director and the Manager stated they had not noticed nurses documenting in ICU patient medical records the use of "tapping" as a call device. The Director stated the expectation of ICU nurses was that patients would be given access to a call bell and that patients and their family members would received education on the use of bells.

3. The facility staff failed to verify patient identification while performing a blood glucose test.

a) On 05/26/15 at 11:26 a.m., CNA #11 was observed while s/he obtained the 5th floor patients' blood glucose. CNA #11 entered Patient #15's room (room 509). Patient #15 did not have a patient identification (ID) band on his/her wrist. Patient #15 stated it fell off earlier in the morning. CNA #11 requested a new printed ID band from the Telemetry Technician for Patient #15. Before CNA #11 received the new ID band, s/he scanned patient labels located on the wall in room 509. CNA #11 did not review any patient identifiers with Patient #15 before s/he obtained his/her blood glucose.

b) On 05/26/15 at 4:37 p.m., an interview was conducted with CNA #11 who stated s/he scanned the patient's label that was posted by the door inside the patient's room. CNA #11 stated s/he verbally referenced the patient's first name as a patient identifier when s/he obtained the patient's glucose. CNA #11 stated s/he would scan the patient's ID band if the patient had one on, but if a patient's ID band fell off, s/he would scan the labels located on the wall by the door in the patient's room.

c) On 05/29/15 at 9:44 a.m., an interview with the facility's Nurse Manager was conducted. The Manager stated facility staff should never use labels located by the door to scan for patient identification. S/he stated if a patient did not have an ID band on, the staff remember should immediately call to have one made for the patient. The ID band should be verified with the patient to ensure it was the correct band for the patient. The Manager stated if facility staff were going to obtain a blood glucose, they would need to ensure a band was present on the patient.