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Based on observation, interview and record review, the facility failed to provide personal privacy for one out of 30 sampled patients (Patient 24), when patient 24's room door was not closed, nor curtains drawn, to ensure Patient 24's privacy during a medical procedure, in accordance with the facility's policy and procedure regarding Patient rights.

This deficient practice resulted in Patient 24's personal privacy being exposed to the general public within the care area, which could have negatively affected Patient 24's right to dignity and privacy.

Findings:

During a review of Patient 24's "Face Sheet (a document containing a patient's medical and demographic information)," undated, the face sheet indicated Patient 24 was admitted to the facility on 5/15/2024 at 11:25 p.m., with a medical diagnosis of vertebral fracture (broken back).

During an observation on 5/28/2024 at 3:30 p.m. on the fifth-floor unit, the door to isolation room 5050 was noticed to be wide open. A staff member (Phlebotomist, (PL) - a medical professional trained to perform blood collection) was inside the patient room, collecting blood from Patient 24 with no curtains drawn nor the door closed.

During a concurrent observation and interview on 5/28/2024 at 3:32 p.m. with the Director of Risk Management and Patient Safety (DRM) on the fifth-floor unit, in front of isolation room 5050, the DRM stated the door or curtains should be closed to protect patient privacy. The DRM stated Patient 24 was in isolation, so no curtains were available for the room, but the patient's room door should have been closed.

During a concurrent observation and interview on 5/28/2024 at 3:34 p.m., with the PL in front of room 5050, the PL was questioned regarding patient right and privacy. The PL stated he was aware the room door should be closed, or the curtains drawn closed when doing a procedure with a patient. The PL stated, he closed the door for Patient 24's procedure in room 5050, but someone else came in the room and left the door open. The PL stated he should have asked them to close the door while the procedure was still being completed for Patient 24.

During a review of the facility's policy and procedure (P&P) titled, "Patient Rights and Responsibilities," revised April 2023, the P&P indicated, "The patient has the following rights to: have personal privacy respected ...have privacy curtains used in semi-private rooms."

Based on observation, interview and record review, the facility failed to obtain a physician's order for the use of restraints (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) for one of 30 sampled patients (Patient 14) when all four side rails of Patient 14's bed were raised, in accordance with the facility's policy and procedure regarding restraints use.

This deficient practice resulted in Patient 14 being restrained without a physician's order and had the potential to compromise patient safety with complications such Patient 14 attempting to get out of the bed and falling to the ground or strangulation (obstruction of blood vessels and/or airflow in the neck resulting in asphyxia [lack of oxygen]), skin tear, etc.

Findings:

During a concurrent observation and interview on 5/29/2024 at 10:39 a.m., at Patient 14's room, with Director of Nursing Operations (DNO) 1, Patient 14 was observed awake with all 4 side rails of her (Patient 14) bed up. DNO 1 stated the following: All 4 side rails for Patient 14 should not be up. It is considered a restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely) when 4 side rails are up. Does not know why all 4 side rails are up for Patient 14 at this time.

During an interview on 5/29/2024 at 10:43 a.m., at Patient 14's room, with Registered Nurse (RN) 4. RN 4 stated the following: 4 side rails up for Patient 14 is considered a restraint (a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely). There are other alternatives to used beside a restraint to prevent Patient 14 from falling. RN 4 said he (RN 4) will drop the one of the side rail for Patient 14 at this time. There is no order for restraint for Patient 14.

During a review of Patient 14's "History and Physical (H&P, a formal and complete assessment of the patient and the problem), dated 5/2024, the H&P indicated Patient 14 was admitted to the hospital on 5/05/2024 with pain and weakness. The H&P also indicated Patient 14's mental status was alert and oriented with no acute distress but appears very tired.

During a concurrent interview and record review on 5/29/2024 at 12:26 p.m. with the Manager of Hospital Operations (MHO) 1, Patient 14's "RN Flow Sheet Assessment (RFSA)," dated 5/2024 was reviewed. The RFSA indicated, on 5/22/2024 to 5/29/2024, there was no assessment documented for restraints use on Patient 14. MHO 1 stated the following: Confirmed no physician order for restraint use in Patient 14's medical record. There should be an order for restraint use for Patient 14.

During an interview on 5/30/2024 at 10:20 a.m. with Director of Nursing Operations (DNO) 1, DNO 1 stated the following: Confirmed there needs to be a physician order for restraint use. Should not have all 4 side rails up for Patient 14 because it a form of restraint. Potential for Patient 14 to injure self when trying to get out of bed. We will re-educate the staff with the policy of Restraint.

During a review of the facility's policy and procedure (P&P) titled "Restraint Use," dated 2022, the "P&P" indicated "All patients have the right to be free from restraint or seclusion (involuntary confinement of patient alone in a room or an area from which the patient is physically prevented from leaving), of any form ... A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. Under this definition, commonly used devices and other practices could meet the definition of a restraint, such as: Using four side rails to prevent a patient from voluntarily getting out of bed. The responsible physician must be notified as soon as possible from the initiation of the restraint, and the physician will provide a telephone or written order for the restraint."

Based on interview and record review, the facility failed to ensure hospital staff followed their Informed Consent Policy for one of 30 sampled patients (Patient 13) when staff who consented Patient 13 for a procedure did not accurately complete Patient 13's consent form in accordance with the facility's policy and procedure.

This deficient practice had the potential for Patient 13 to have an incorrect procedure done.

Findings:

During an interview on 5/29/2024 at 10:24 a.m., with Registered Nurse (RN) 2, RN 2 stated the following: Patient 13's preferred language is Spanish. A translator is used to obtain consent for procedures ordered for Patient 13 whose preferred language is Spanish.

During a review of Patient 13's "Face Sheet (FS, a document that gives a patient's information at a quick glance and includes the patient's name, date of birth, address, etc.,)," dated 5/2024, the FS indicated Patient 13 was admitted to the facility unit on 5/15/2024 for Severe Sepsis (a condition that happens when the body's response to an infection damages vital organs and, often, causes death). The FS also indicated Patient 13's spoken language and written language was Spanish.

During a review of Patient 13's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 5/2024, the H&P indicated Patient 13 was admitted to the hospital on 5/15/2024 for generalized body pain.

During a review of Patient 13's "Consent Form," dated 5/2024, the CF indicated Patient 13 was consented for the procedure "Right Thigh Biopsy," on 5/16/2024 in Spanish. The title of the procedure was written in Spanish as "Biopsia muscular del quadriceps derecho." The CF indicated the signature and date by an Allied Health Practitioner (AHP) of the hospital.

During a review of Patient 13's "Operative Note," dated 5/2024, the Operative Note indicated Patient 13 had a right thigh muscle biopsy procedure done on 5/17/2024.

During a review of Patient 13's "Physician's Orders," dated 5/2024, the Physician's Orders indicated Patient 13 had order on 5/16/2024 for right quadriceps muscle biopsy for purpose to study muscle on right leg.

During a concurrent interview and record review on 5/30/2024 at 10:35 a.m. with the Director of Nursing Operations (DNO) 1, Patient 13's " Consent Form (CF)," dated 5/2024, was reviewed. The CF indicated title of the procedure was written in Spanish "Biopsia muscular del quadriceps derecho." DNO 1 stated the following: The title of the procedure in the consent form should be written in English so that the staff can understand it during their time out meeting prior to starting the procedure.

During a concurrent interview and record review on 5/30/2024 at 10:57 a.m. with the Director of Perioperative Services (DPS) 1, Patient 13's " Consent Form (CF)," dated 5/2024, was reviewed. The CF indicated title of the procedure was written in Spanish "Biopsia muscular del quadriceps derecho." DPS 1 stated the following: DPS 1 confirmed Patient 13 was consented by a physician assistant of the hospital. If the consent form is not accurate, the staff will have to contact the physician to redo the consent. Confirmed consent is not correct due to physician who consented Patient 13 wrote the title of the procedure in Spanish instead of English.

During a review of the facility's policy and procedure (P&P) titled "Informed Consent, Written Consent and Refusal of Consent" dated 2023, the "P&P" indicated, " informed consent is required for complex treatments and procedures. The patient's physician is responsible for providing the information the patient needs in order to make an informed decision and for obtaining patient's informed consent or informed refusal for the recommended treatment procedure. Physicians and Allied Health Practitioner (AHPs, for the purpose of obtaining informed consent for the procedure or treatment AHPs are practitioners such as physician assistant nurse practitioner or certified nurse midwife) must accurately document informed consent and refusal discussions.

During a review of the facility's policy and procedure (P&P) titled "Qualified Interpreter Services for Limited English Proficient Person," dated 2024, the "P&P" indicated, " Standards for Qualified Interpreter Services: Qualified Bilingual Staff (QBS): Those designated as QBS 1 or 2 are not authorized to provide language assistance services beyond the scope of their qualifications.

During a review of the facility's policy and procedure (P&P) titled "Comprehensive Linguistics Program: Qualified Bilingual Staff (QBS) Program Guide," dated 3/2024, the "P&P" indicated, " The Qualified Bilingual Staff (QBS) program allows Kaiser Permanente to further provide culturally and linguistically appropriate services by qualifying and recognizing bilingual staff that use their linguistic skills to provide language assistance services. The QBS employee should be able to use their language of service to directly communicate or interpret for another individual as appropriate for either level one or level 2 scope of practice. QBS employees cannot translate as they have not been qualified to do so. Translation is converting written text from one language to another written language.