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Based on record review and interview, the facility failed to protect the patient's right to privacy in 1 (Patient #51) of 3 patients reviewed.

The facility failed to ensure that patients have physical privacy to the extent consistent with their care needs during personal hygiene activities (e.g., toileting, bathing, dressing), during medical/nursing treatments, and when requested as appropriate.

This deficient practice had the likelihood to cause harm to all patients receiving surgical and invasive procedures at the facility.


Findings include:



A review of medical records was conducted on 11/21/19 after 9:30 a.m. in the administrative offices. The findings were as follows:


Patient # 51

Review of the patient #51's medical record revealed he was admitted to the outpatient day surgery at 6:47 a.m. on 10/24/2019. Documentation revealed the patient's representative was listed as "Friend."

Review of nursing documentation from 10/24/2019 revealed an entry where the nurse stated: "Patient arrived to unit at 0726. Pt able to ambulate to bed independently. CHG bath completed by pt at bedside as per unit protocol."

CHG bath being a chlorohexidine gluconate bath to kill germs.

The above findings were verified by RN # 66 at the time of review.

Review of a document provided by the facility titled "CHG Bath Fact Sheet," revealed the following: Under section titled "Ask Patients These Questions Before Giving CHG Bath: Is the patient allergic or sensitive to lotions, creams, fragrances, perfumes (suntan lotion, aloe, etc.? Does the patient have dry skin, eczema, or naturally sensitive skin? Is the patient light-skinned (i.e. redhead or very blonde hair)? Has the patient shaved at home prior to arriving for surgery? If the patient answers YES to any of these questions, notify RN caring for patient. A site test should be administered. Check or ask patient if there are any areas of skin that are excoriated or red upon arrival to pre-op - Instruct patient to not use cloth on these identified areas; Inform RN so this can be documented on skin man; Pay close attention to folds of skin for example - under breasts, abdomen, axilla. Instruct patient to allow air circulation to these areas to promote complete dry time - under breasts, abdomen, axilla. IMPORTANT TO REMEMBER: Use laminated sheet for educating patient. Remind patient: 1. Wipes have an exfoliative nature so educate patient to gently wipe skin. 2. Please always reinforce to patient they will use all six wipes. 3. Not to use above jawline, on face, genital or rectal area."

Further review of the medical record revealed no documentation that the questions listed in the facility document titled "CHG Bath Fact Sheet," were asked or that the nurse educated the patient or caregiver on how to properly perform the "CHG" bath, or that the patient or caregiver's ability or willingness to perform the "CHG" bath was assessed.

An interview with Staff # 44 was conducted on 11/21/19 at 11:45. Staff # 44 was asked about the protocol referred to in the nursing documentation. Staff # 44 stated, there was no actual protocol, or written process regarding patient's using the "CHG Bath," only the document "CHG Bath fact sheet."

A confidential interview was conducted. It was stated when the patient arrived at the facility for his procedure, they were shown to the "intake" area. The nurse arrived at the pre-op area with a gown and four packages of antibacterial cloths to bathe the patient. The nurse pointed to a diagram on the wall that had a man with dots on it. The nurse opened one package to show the wipes and instructed the (friend) to use one wipe per dot on the man on the picture. The nurse told the (friend) to change the patient into the gown after the bath was completed. The question was asked who performed the bath and it was stated she did (the friend). The question was asked if the nurse asked the patient if he gave permission for the (friend) to perform the bath and the answer was "no," nor did the nurse ask if the (friend) was comfortable with performing the bath. The question was asked if the patient made any statements regarding the bath he received. The patient was concerned the bath had not been thorough enough. It was stated the patient, in his usual state, was alert and oriented and able to follow commands, however he had balance issues due to a previous medical condition and would not have been able to perform the bath on this day as the patient was very nervous due to the procedure he was to have.

The question was asked if the staff knew the (friend) was not a family member or primary caregiver and it was stated the patient told them when he was admitted. The question was asked what duties did the (friend) perform for the patient. It was stated the (friend) prepared meals, washed clothes, cleaned the patient's home, took him to doctor appointments and grocery shopped as needed. The question was asked if the (friend) performed any personal care needs for the patient and it was stated no he can usually performed those himself.