HospitalInspections.org

Based on policy review, review of an incident report, and interviews the facility failed to protect the personal privacy of 1 patient (Patient #1) of 20 patients reviewed.

The findings included:

Review of facility policy titled, "Patient Rights" last reviewed May 2021 revealed, "...You have the right to privacy..."

Medical record review revealed Patient #1 was admitted to the facility's Shock Trauma Intensive Care Unit (STICU) on 10/31/2022 with diagnoses which included Traumatic Intracranial Hemorrhage and Severe Traumatic Brain Injury. Continued review of a Neurosurgery Progress Note dated 11/1/2022 at 7:46 AM revealed, "...Patient's exam this morning appears to be without brainstem reflexes, suspect progressing to brain death...consistent with nonsurvivable brain injury...Patient sister at bedside updated..." Continued review revealed the patient expired on 11/5/2022 at 5:17 PM.

Medical record review revealed Patient #2 was admitted to the facility's Neuro Trauma Intensive Care Unit (NTICU) on 11/1/2022 with diagnoses that included Falls, Seizures, and Subdural Hematoma. Review of Neurology Consult Note dated 11/1/2022 at 4:05 AM revealed, "...brought to our ED by the patient sister for an evaluation of recurrent tonic-clonic seizure. Patient is well known to our neurology clinic...Patient sister denies any prior history of clustering of seizures...he had a CT [computer tomography, a computer enhanced x-ray imaging study] head which acute left subdural hematoma...in no acute distress...The patient is alert...Answering as yeah to all questions..." Continued review revealed the patient was discharged home on 11/5/2022.

Review of a facility incident report dated 11/1/2022 revealed, "...my sister came to visit our brother [Patient #2]...They took her to the wrong unit which was across the hall from the one that her brother was in...she asked for the room that her brother is in, and they told her [room number]. Once she walks into the room, the room is dark because of the brain damage. She goes into the room and the patient [Patient #1] in the room had a lot of tools [tubes] in them with bandages and the sister starts to freak out because earlier the patient [her brother] was fine...the nurse tells my sister that he had pressure in his brain, and they had to release the pressure which corresponds to why he was already there. A doctor comes in and gives her the diagnosis that the patient was brain dead and with no brain activity and for her to call the family and tell them this was the end of life...the family of the patient [Patient #1's real family] shows up. They asked my sister what she is doing in the room and my sister replied, this is my brother...my sister and the family of the patient go back and forth...a nurse steps in...to get my sister and takes her to her office...started to apologize that it was a mix up and that is not your brother. Your brother is on another unit...That's when they took my sister to the other unit, NTICU where my brother was..."

Nurse Manager #1 was interviewed in the Administration Conference Room on 11/18/2022 at 3:30 PM. Nurse Manager #1 confirmed the sister of Patient #2 was mistakenly directed to Patient #1's room in the STICU on 11/1/2022. Continued interview revealed Patient #1's medical condition and prognosis was disclosed to Patient #2's sister who continued to believe it was her brother's information. Continued review revealed alias/Doe identifiers were being used on both patients, so Patient #1's real name was never discolosed to Patient #2's sister. Continued interview revealed the mistake was not discovered until Patient #1's real family members arrived in STICU and confronted Patient #2's sister in the patient's room. Continued interview revealed staff then discovered Patient #2 was located across the hall in NTICU and Patient #2's sister was reunited with him there.

Registered Nurse (RN) #1 was the nurse caring for Patient #1 in the STICU on 11/1/2022. RN #1 was interviewed by telephone on 11/9/2022 10:18 AM. RN #1 stated she remembers a woman being in Patient #1's room on the morning of 11/9/2022. RN #1 stated the woman identified herself as Patient #1's sister and asked questions regarding Patient #1's condition. RN #1 stated she answered the woman's questions about the patient. RN #1 stated Patient #1 was identified by an alias John Doe identifier and his name was not disclosed to the woman. RN #1 stated she does not know how long the woman was in Patient #1's room, but she saw her there for at least 30 minutes before RN #1's shift ended and the woman was still there when RN #1 left.

RN #2 was the nurse caring for Patient #2 on the morning of 11/1/2022. RN #2 was interviewed in the STICU Break Room on 11/9/2022 at 10:30 AM. RN #2 stated she remembers a woman identified as the Patient #1's sister being in the patient's room when she was taking report at approximately 6:30 AM on 11/1/2022. RN #2 stated the woman was still in Patient #1's room when she returned to the room at approximately 8:30 AM. RN #2 stated she was in the room when the Neurosurgeon came in the room and asked the woman if she was related to the patient. RN #2 stated the woman identified herself as Patient #1's sister and the Neurosurgeon advised the woman regarding Patient #1's medical condition. RN #2 stated the woman made some statements regarding the patient which made RN #2 suspect the woman's relationship to the patient. RN #2 stated she went to her computer to research Patient #1's true name, as he was identified with an alias/John Doe indentifier, and it was not the same name the woman/sister had given her. RN #2 stated she found a patient with the name the woman had given her in the NTICU across the hall. RN #2 stated when she went to Patient #1's room she found Patient #1's family there confronting the woman who they said was not related to Patient #1. RN #2 stated she escorted the patient to her manager's office where they discovered the woman was not related to Patient #1, but was the sister of Patient #2 who was in the NTICU across the hall from the STICU. RN #2 stated the actual name of Patient #1 was never disclosed to the woman as he had only been identified by an alias identifier at that time.

Interview with the Neurosurgeon by telephone on 11/9/2022 at 11:33 AM revealed he remembered going to examine Patient #1 on the morning of 11/1/2022. The Neurosurgeon stated there was a woman in Patient #1's room when he arrived and he asked her if she was related to the patient. The Neurosurgeon stated the woman identified herself as Patient #1's sister and he proceeded to answer her questions and update her on the patient's condition. The Neurosurgeon stated the woman was with the patient when he left the room and he later learned she was not the patient's sister. The Neurosurgeon stated he never disclosed the patient's name to the woman, only answered her questions about his condition. The Neurosurgeon stated he returned to Patient #1's room later and updated Patient #1's family members on the patient's condition.

Interview with the Quality Director in the Administration Conference Room on 11/9/2022 at 3:30 PM confirmed the sister of Patient #2 was mistakenly directed to Patient #1's room on 11/1/2022. Contnued interview confirmed Patient #1's name was never disclosed to Patient #2's sister. Continued interview confirmed information regarding Patient #1's medical condition and prognosis was disclosed to Patient #2's sister, who believed this was her brother's medical condition and prognosis.