HospitalInspections.org

Based on observation, document review and interview, in three (3) of three (3) patients interviewed, the facility failed to ensure patients received information about their rights and other information needed to make informed decisions about their medical care.

These lapses in disclosure potentially place patients at risk of making uniformed decisions.

Findings include:

Observations in the facility pre-surgical area on 4/27/21 between 11:00 AM and 1:00 PM identified the following:

Upon interview of the facility's Registration staff at 11:00 AM, the staff stated that all patients are given information and notified regarding their patient rights, right to know and insurance authorization prior to signing the consent documents and preparation for surgery.

During interview of Patient #1, she stated that the only information she received prior to her pre-surgical preparation from the registration staff was information on insurance. She signed the consent authorizing the facility to bill her insurance company.

Similar findings of failure to inform patients about their rights and right to know, prior to their pre-surgical preparation, was identified for Patients #3 and #4.

These observations were made in the presence of Staff A, Associate Director of Nursing for Surgical Services, who confirmed that the patients should have received information on their rights and other need to know information.

The facility's policy and procedure titled "Consent for Treatment," last reviewed 3/3/2021, states: "Consent for treatment is obtained upon admission or as soon as possible thereafter .... The authorized provider must disclose to the patient or his/her authorized representative all information which would be disclosed by a reasonable practitioner under similar circumstances. This includes: ...risks of not receiving care, treatment or services."

The facility's policy and procedure titled "Patient's and Parent's Bill of Rights and Responsibilities," last revised 3/3/2021, states: " Documentation of Distribution of Patients' and Parents' Rights ... Patients admitted electively receive this information from the Admitting Department ...A copy of the statement of patient rights is included in the Patient Information Guide, which is given to every inpatient ...Ambulatory Care patients receive a copy of the Ambulatory Care Guide to Patient Services upon their first registered encounter."

Based on the observation and staff interview, the facility failed to maintain pressure differential in relation to adjacent spaces between the decontamination area and the clean area in the facility's Central Sterile area.

This failure is a potential risk for cross contamination in the Central Sterile of the clean instrument and equipment.


Findings include:

On 04/27/2021 at approximately 12:30PM -12:40PM, the facility's instrument was used to check the air flow. It was observed that:

a) The Decontamination Room (room where dirty instruments used for procedures/ surgeries are stored, cleaned and prepacked for sterilization) which is designed to have negative air flow, read positive air flow, in relation to the adjacent ante-room (room where staff remove and apply equipment such as gloves, masks, and gowns, and air flow is neutral).

b) The Clean Work Room (where clean instruments are packaged ready to be used in the Operating Rooms) which is designed to have a positive airflow, read negative airflow, in relation to the adjacent ante-room.


At interview on 04/27/2021 at 12:40 PM, Staff A, Administrator of Patient Safety, confirmed these findings.