HospitalInspections.org

Based on a complaint, review of facility's event report, staff interviews, and policy review, the facility did not ensure the patient has the right to personal privacy.

Findings include:

Complainant and sister-in-law of Patient #1 reported that on the evening of 1/23/15, a family member noticed the IV Propofol connected to the patient. The label on the medication bottle had the name, date of birth, age, address, and physician name of another patient. Complainant felt this was a breach of patient privacy and confidentiality.

Review of Event Report dated 1/23/15 at 1930-40 PM located at Bedside 209 (Room of Patient #1). "Propofol labeled with patient sticker for 210 (Patient #2). Removed wrong label, placed new label with patient name ....Family stated that they dug the label out of the trash and took a picture of the label ..."

Interview with the Pharmacy Supervisor and Vice President, Nursing Services and Chief Nursing Officer on 3/5/15 confirmed a violation of patient's rights to personal privacy and confidentiality had occurred.

Review of the facility's Patient Rights Policy noted the purpose "To recognize the requirement to comply with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), as amended by the HITECH Act of 2009 (ARRA Title XIII) and to recognize the responsibility to protect individually identifiable health information under the regulations implementing HIPAA, other federal and state laws protecting the confidentiality of personal information, and under general, professional ethics. This policy governs all matters pertaining to patient rights for privacy and confidentiality of PHI" [Protected Health Information].

Based on a complaint, review of the facility's event report, complaint investigation, staff interviews, and policy review, the facility did not ensure medications were administered without errors.

Findings include:

Complainant and sister-in-law of Patient #1 reported that on the evening of 1/23/15, a family member noticed the IV Propofol connected to the patient. The label on the medication bottle had the name, date of birth, age, address, and physician name of another patient. Family member got nervous and called the nurse. The nurse went into Patient #1's Room 209 and removed the sticker which had Patient #2's (Room 210) name, date of birth, age, address, and physician name. The nurse put that sticker in the rubbish can and left the room. She returned and replaced the label on the IV Propofol with Patient #1's information.

A review of the facility's complaint summary was done on 3/5/15. The facility received a complaint from Patient #1's relative on 2/9/15 regarding "attitude/courtesy, appropriateness of comments; care/treatment, quality of care, technical skills of staff; communication, communication style, communication with family members; information, confidentiality, privacy; safety". Description of the event report from a RN noted "received patient from [name] RN. Report given propofol running along with IVF of LR. Patient to be taken to CT before 2030. Allowed patient family to see patient before being taken down. Propofol labeled with patient sticker for [Room] 210. Assured patient family the label was only used to show date and time hung. Patient supposed to be on propofol while vented. Removed wrong label, placed new label with patient name". "...Spoke to RN [name] who stated that doesn't recall making this mistake but must have mislabeled the bottle of propofol".

Interview with the Pharmacy Supervisor and Vice President, Nursing Services and Chief Nursing Officer on 3/5/15 acknowledged that a medication error occurred as the Propofol bottle labeled with Patient #2's information was given to Patient #1.

A review of the facility's Policy No. 6255 Bar Code Medication Administration (BCMA) noted the policy is "to employ bar code enabled medication administration technology in the administration of medications to improve patient safety and the accuracy of medication administration and documentation". Further review of the policy noted "the person administering the medication is still responsible to ensure that the "Seven Rights" are followed: that the Right Patient receives the Right Drug, and the Right Dose, at the Right Time, by the Right Route, for the Right Reason, with the Right Documentation".