HospitalInspections.org

Based on observation and interview, the provider failed to maintain patient confidentiality in one of one pre-operative (pre-op) consultation area outside of the operating room (OR). Patient and physician pre-op consultations took place in the connecting corridor outside of the OR. Findings include:

1. Observation on 9/24/19 from 9:45 a.m. to 10:00 a.m. revealed a patient in an operative gown sat in a recliner and a companion sat in a chair next to the patient. The surveyor spoke to that patient and the companion, and they acknowledged the surveyor. A room divider curtain had been placed on the ceiling in that corridor. The curtain was not in use to petition off that patient and the companion from the people who passed through the corridor.

Interview on 9/25/19 at 8:30 a.m. with the central sterilization technician (CST) revealed:
*She was aware patients and their companions were placed in that corridor outside of the OR.
*She was in charge of accompanying the patients from the upstairs pre-op patient rooms to the corridor pre-op consultation area.
*That process was done as the physician wanted to do cataract surgeries very quickly and did not want to take the time to go upstairs to conduct the pre-op consultation with the patients.
*She confirmed there was a post-operative room where the physician would reveal the results of the cataract surgery with the patient and their companions.

Interview on 9/25/19 at 4:00 p.m. with the director patient services and the chief operating officer confirmed the above observation and interview with the CST. The director of patient services revealed they had not considered it as a privacy issue, as the physician and patient consultation took place with the curtain closed. She had not considered the voices would carry through a room divider curtain. She stated they did not have a patient privacy policy except for the Health Insurance Portability and Accountability Act policy.

Based on observation, record review, interview, and policy review, the provider failed to ensure:
*Pressure injury documentation had included measurements, staging for one of one current swing bed patient (6) and one of one sampled discharged swing bed patient (18) who had pressure injuries.
*The care plan for one of one current swing bed patient (6) had included pressure relieving interventions.
Findings include:

1. Observation on 9/24/19 at 10:00 a.m. of patient 6 revealed she was seated in a straight back wooden chair in her room. There was no cushion noted on the seat of that chair.

Review of patient 6's swing bed medical record revealed:
*She had been admitted on 11/16/18.
*Her Braden scores included:
-A twenty (standard risk) on 11/6/17.
-A twenty-one (standard risk) on 2/13/18.
-An eighteen (mild risk) on 3/15/18, 5/13/19, 6/14/19, 8/13/19, and 9/12/19.
*The first documentation of a pressure injury was 11/19/17 on her left buttock and on 2/9/18 on her right buttock. Both of those pressure ulcers were still present on 9/25/19.
*Wound/incision assessments were to have been completed twice daily.
*Those assessments had been partially completed.
*There had been no staging or measurements taken for those pressure ulcers since 11/1/17.
*The only documentation completed had been:
-Wound appearance.
-Wound assessment type.
-Surrounding tissue appearance.
-Surrounding tissue erythema.
-Wound drainage amount.
-Wound dressing status.
-Wound dressing/closure/packing comment.
-Cleansing.

Review of patient 6's 11/1/17 skin integrity care plan revealed:
*The skin integrity would have been maintained or improved.
*That had been based on:
-Wound healing.
-Compliance with skin care regimen.
-Absence of new skin breakdown.
-Calmoseptine to coccyx as ordered.
-Change bed linen on bath day and as needed.
-Maintain weight between 102 pounds (lb) and 108 lb.
*There was no type of intervention for her seating or repositioning.

Review of the physician's assistant progress notes revealed assessment and plans that included:
*1/9/19: "Apply calmoseptine to open area on buttocks above her coccyx daily and when soiled."
*5/23/19: "Patient initially had some skin breakdown at her coccyx roughly 4 to 6 weeks ago and was treated with calmoseptine/nystatin topically and appears to be healed."
*6/26/19: "Apply calmoseptine to open area on buttocks above her coccyx daily and when soiled."
*9/20/19: "Continue to apply calmoseptine to open area on buttocks above her coccyx daily and when soiled."

2. Review of patient 28' medical record revealed:*She had been admitted to a swing bed on 4/19/19 and had been discharged to another provider on 4/23/19.
*A wound/incision assessment had identified a labial rash and a midline buttock wound.
-The only information that had been completed on the assessment included the wound appearance, wound assessment type, surrounding tissue appearance, wound drainage, and cleansing.
*Those assessments had been initiated on 4/22/19.
*She had a specific care problem for her renal failure with altered tissue perfusion.

3. Interview on 9/25/19 at 10:00 a.m. with registered nurse A revealed:
*Patient 6's left and right buttock wounds alternated between closed and opened.
*She would only sit in the hard backed chair in her room.
*There was no pressure relieving cushion in that chair.
*Patient 6's left and right buttock wounds would frequently be opened and then would close.
*RN A agreed:
-Wound documentation assessments completed did not have any measurements, and those wounds had not been staged.
-The nurses had only filled out part of the full assessment. The full assessment should have been completed.
-Their policy for wound care had not been followed for complete assessments, measurements, and staging of the wound.

4. Review of the provider's last revised June 2006 Wound Care Prevention/Treatment policy revealed:
*The policy addressed prevention, diagnosis, admission assessment, skin integrity/risk assessment, dietician review, wound definitions, and repositioning instructions.
*"Assessment and Documentation: Documentation will be done on the Wound/Incision-Complex Assessment in the electronic information system." That documentation would have included:
-Location and staging if appropriate, size, drainage, pain, wound bed, description of surrounding tissue, depth, undermining, and tunneling.
-"If wound/skin breakdown then reassess and measure every two weeks, notify provider if no improvement. Dates of reassessment will be documented on the nursing calendar."