HospitalInspections.org

Based on document reviews and interviews, Waldo County General Hospital failed to ensure the patient's right to personal privacy, and the hospital failed to ensure the patient remained free from all forms of abuse or harassment for one (1) of ten (10) female patients reviewed (Patient #1).

Findings:

42 Code of Federal Regulations Part 485, Condition of Participation: Patient's Rights (§485.614)(c) Standard: Privacy and safety states in part:

"(1) The patient has the right to personal privacy.

(2) The patient has the right to receive care in a safe setting.

(3) The patient has the right to be free from all forms of abuse or harassment."

A review of Patient #1's medical record revealed the following entry showing that a Four-eyes skin inspection was performed on 10/28/2023 by RN #2, and RN #1. The entry was written by RN #2, and dated 10/28/2023. The entry reads as follows:

" ...19:00 Four-eyed skin inspection
Four-eyes skin inspection (Upon Admission and Transfer)
Four-eyes skin inspection complete?: Yes
Second Observer (enter name): [RN# 1]
[RN#2], RN ..."

At 2:25 PM on 11/20/2023 a telephone interview was conducted with RN #2 regarding the care of Patient #1 on 10/28/2023 which revealed the following information:

RN #2 confirmed [he/she] does remember caring for Patient #1 on 10/28/2023, and [he/she] stated that [he/she] remembers conducting a four eyed skin assessment on Patient #1 on 10/28/2023 with the assistance of RN #1.

RN #2 stated that the skin assessment that RN #1 performed, "..was a little to invasive..."

RN #2 stated the skin assessment RN #1 performed, " ...looked very thorough and it was more than I was oriented with. [He/she] looked through her pants area and down in her groin area ..."

RN #2 stated that during the four eyed skin assessment they didn't ask the patient anything. [He/she] stated it was a skin assessment, so they had to look at the patient's body for cuts or bruises. RN #2 stated, "It was just weird that [RN #1] had to go in depth with it."

RN #2 stated that during the assessment that [RN #1] made the patient bend over and open her buttocks up.

RN #2 made the following statement:
"We only kind of look at the tailbone area so it was kind of weird for me. When we asked the patient to lay down to look under her breast area for redness which was what we do, with the pannus and the groin area [RN #1] had to really open that open that up" RN #2 clarified that by, "open that up" he/she meant that [RN #1] opened the patient's labia.

RN #2 stated that he/she was concerned that the patient felt uncomfortable with the assessment. [He/she] stated [he/she] reported the incident to CHARGE NURSE.

At 3:17 PM on 11/20/2023 an in-person interview was conducted with NURSE MANAGER regarding the care of Patient #1 by RN #1 on 10/28/2023. The interview revealed the following information:

NURSE MANAGER was asked if it would be routine to have a patient stand and spread their buttocks during a 4-eyed skin assessment:

NURSE MANAGER stated they would have a patient stand and spread their buttocks if there was a concern for an injury or something suspicious when they are talking, they could. [He/she] stated that this is not something that occurs routinely on every patient.

NURSE MANAGER was asked if it would be routine for the nurse to spread a female patient's labia during a 4-eyed skin assessment:

[He/she] stated they would have a female patient lay on the bed and spread their labia if there was a concern or reported wound or injury there. He/she stated this would not be done routinely.

NURSE MANAGER stated regarding the 10/28/2023 incident involving Patient #1, that as manager it came across as a complaint and [he/she] did an investigation. NURSE MANAGER stated [he/she] first heard it from the charge nurse on 10/30/2023, because 10/28/2023 was on the weekend and [he/she] followed up when he/she came back in on Monday 10/30/2023. NURSE MANAGER stated Patient #1 was still at the hospital on 10/30/2023 so he/she stated he/she spoke directly with Patient #1, CHARGE NURSE and RN #2.

NURSE MANAGER stated his/her investigation revealed there was a four eyed skin assessment done where Patient #1, "was made to bend over, and had her private area touched."

NURSE MANAGER stated that RN #1, had the patient bend over and touched the patient's "private area," NURSE MANAGER stated that he/she would not say that he/she was concerned this was sexual abuse, but that this was inappropriate assessment technique.

NURSE MANAGER stated that when he/she followed up with Patient #1 that the patient was very upset and tearful, he/she stated [Patient #1] said she had been here before and that was not the normal routine for a four eyed skin assessment that she had done previously.

NURSE MANAGER was asked what actions he/she took as the unit manager in response to this incident:

NURSE MANAGER stated that beyond just initiating the investigation he/she tried to support the patient, to tell her to not feel bad about telling the hospital staff anything. NURSE MANAGER stated he/she notified human resources and spoke to SENIOR DIRECTOR OF QUALITY AND SAFETY to let him/her know they were doing the investigation.

NURSE MANAGER stated that he/she spoke with CHARGE NURSE and RN #2. NURSE MANAGER stated he/she spoke to the individuals that were involved in the incident.

At 3:35 PM on 11/20/2023 an in-person interview was conducted with CHARGE NURSE regarding the care of Patient #1 by RN #1 on 10/28/2023. The interview revealed the following information:

CHARGE NURSE stated that RN # 2 approached him/her on the evening of 10/28/2023 to say that [Patient #1] reported to him/her that, "[He/she] felt the skin check was not ok."

CHARGE NURSE stated he/she spoke to the patient shortly after RN # 2 reported the incident to him/her, and Patient #1 stated that she had been admitted to the hospital multiple times, was well aware the skin inspection had to be done, and that, "it had never been like this before."

CHARGE NURSE stated that Patient #1 told him/her that, "The nurse, RN #1, without warning spread her buttocks open very wide which then RN #1 rolled the patient over and [RN #1] spread her genital area open wide." CHARGE NURSE stated Patient #1 told [him/her] that she was in disbelief that it had occurred, and it had never been done like that in past admissions.

CHARGE NURSE stated Patient #1 was crying when Patient #1 spoke to him/her. CHARGE NURSE stated Patient #1 told him/her Patient #1 felt it was inappropriate and that CHARGE NURSE told the patient to report it.

CHARGE NURSE stated that when the patient reported the incident to him/her on 10/28/2023, he/she told Patient #1 he/she has been here for 5 years and the skin assessments he/she has been taught to do have not included not informing the patient if they are going to be more invasive than doing a quick check on their private area, buttocks, and or genitals. He/she stated he/she had never been taught to the 4 eyed skin assessment that way, and CHARGE NURSE stated that RN #2 told him/her that is not how he/she would do a skin assessment.

CHARGE NURSE stated that from what Patient #1 told him/her it was sudden and unexpected, and none of the skin inspections she had ever had were ever to that extent.

CHARGE NURSE was asked if he/she believes that the allegations the patient reported to her on 10/28/2023 would be considered abuse.

CHARGE NURSE stated that based on the reports he/she received from the patient he/she would say yes this would have been abuse. CHARGE NURSE stated that inappropriately touching someone would cross the line and would be considered abuse, especially in "those areas".

CHARGE NURSE stated "We do not know everyone's history and it could be triggering for someone if you do not announce your assessment and allow them to consent beforehand beyond would I would consider the normal skin assessment."

At 3:44 PM on 11/20/2023 CHARGE NURSE made the following statement, "I would consider it to be egregious inappropriate, invasive and potentially considered sexual abuse because its surrounding the genital area and the rectal area"

A document titled "[NURSE MANAGER] Investigation" was reviewed and contains the following entries:

"...I [NURSE MANAGER] went in and talked to [Patient #1]. When I went in the room she was just getting off the phone with someone, maybe her husband. She looked at me and just started crying. She said that he was upset because of the skin assessment and felt said she had never been touched or treated like that before in all her admissions here. She said [RN #1] came in and [RN #2] was standing there at the computer. [RN #2] had told [Patient #1] they were going to do a skin assessment and she said 'go ahead, been here before, take a look'. [Patient #1] said the nurse then spread my butt cheeks so far apart. [RN #1] didn't say anything, just pulled them apart. [RN #1] then roughly spread my legs apart in front spread my groin and labia right apart. "

A document titled, "RL Events: Care Team member statements related to events involving [Patient #1] (Date of Service 10/28/2023)" was reviewed and revealed the following information:

"1.[CHARGE NURSE]
I was acting charge nurse from 1900-2300. [RN#2], RN/Primary RN reported to me that this patient was upset about the four eyed skin inspection upon admission. As Charge Nurse, I spoke with the patient regarding her concerns. In speaking with the patient, the patient became teary and stated that 'I have been admitted to this hospital many times before and I have never been treated like that or touched that way.' The patient went on to explain that the second nurse [RN #1] who was to be present for the skin inspection 'just spread my butt cheeks open and then pulled down my underwear and put [his/her] hands all over my front and then walked out. I couldn't believe it and told the nurse [RN #2].' The patient continued to say that she felt she had been 'touched unnecessarily and inappropriately and it made me so upset and uncomfortable." The patient said she had called her husband and told him what happened and "he told me to report it.' I validated patient's concerns, offered guidance and emotional support.

2. [RN #2]

While completing a 4-eyed skin assessment with [RN #1], this writer observed that [RN #1] was performing the assessment that was beyond my understanding of a usual skin assessment. I was taken back as [RN #1] was doing this assessment. [RN #1] had the patient bend forward to spread her buttocks and also had searched and spread her groin/labia area. After the assessment and [RN #1] had left, the patient confides to me, concerned, states, 'I've been in the hospital a lot of times before, but this is the first time that I've been looked at that much.' This writer reported back to the evening charge nurse, [CHARGE NURSE] about the incident"

At 9:55 AM on 11/21/2023 an in-person interview was conducted with with RN #1 regarding performing a 4-eyed skin assessment on Patient #1 on 10/28/2023. The interview revealed the following information:

RN #1 stated he/she does not remember performing a 4-eyed skin assessment on Patient #1 on 10/28/2023.

At 10:56 AM on 11/21/2023 an additional in-person interview was conducted with NURSE MANAGER which revealed the following information:

NURSE MANAGER stated that the 10/28/2023 incident has not yet been addressed directly with RN #1.

NURSE MANAGER stated that no action has been taken because a meeting was supposed to be held with RN #1 on 11/20/2023 to discuss the 10/28/2023 incident, but the meeting did not occur. NURSE MANAGER stated that the meeting was instead going to be held on 11/21/2023.

Waldo County General Hospital failed to provide evidence that action has been taken to prevent a similar incident from occurring.

Waldo County General Hospital failed to provide evidence that the 10/28/2023 alleged incident involving Patient #1 and RN #1, had been discussed directly with RN #1 at all as of the date of the initiation of the complaint survey (11/20/2023).

The surveyor requested a copy of training materials that nurses receive for the 4 eyes skin assessment procedure. Waldo County General Hospital failed to provide a copy of training materials for the 4 eyes skin assessment procedure.

At 10 AM on 11/21/2023 an in-person interview was conducted with SENIOR DIRECTOR OF QUALITY AND SAFETY regarding the requested a copy of training materials that nurses receive for the 4 eyes skin assessment procedure which revealed the following information:

SENIOR DIRECTOR OF QUALITY AND SAFETY stated the nurse educator was not able to find anything specific other than to say that they have new training coming up in January where they are going to have new nurses spend time with the wound nurse. He/she stated that they will spend a day or two with the wound nurse.