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Based on hospital policy review, medical record (MR) reviews, observation and staff interviews, the hospital staff failed to ensure the patient's right to privacy for 2 of 2 patients (Patient #5 and #2) with identified special needs.

The findings include:

Review on 03/29/2016 of the hospital's policy "Communications Services: Interpreter and/or Translator" (revised 09/2015) revealed "Procedure: ... Staff and /or healthcare providers should take precaution to ensure patient information is protected..."

Review on 03/29/2016 of the hospital's mandatory "Patient Rights" staff training syllabus revealed "Summary: Discussed the rights of the patient, effective methods of protecting patient privacy, ... Confidentiality of Health Information: patients have the right to privacy..."

1. Observation on 03/29/2016 at 1240 on Unit A revealed a "No Blood Pressure (BP) Sticks in the Right Arm" sign on the exterior side of Patient #2's door. Observation revealed the sign was visible from the hallway and both non-hospital employees as well as other patients walking the hall. Observation revealed information regarding Patient #2's special need was not protected.

Interview on 03/30/2916 at 1005 with Adm. Staff #1 revealed "Those signs are traditionally placed over the patient's bed and are intended to be confidential. They should not be hung on the outside of the door like that." Interview revealed signage is used to alert staff to the special needs of the patient as an extra measure to ensure awareness and consideration during the provision of patient care. "The signs should be kept inside the patient's room to protect their privacy. Interview revealed placing signs divulging a patient's special need in a manner that is visible to non-employees does not protect their privacy and is a violation of their rights.

Interview on 03/20/2015 at 1545 with RN #2 revealed "We hang those signs the outside of the patient's door so staff are aware of the patient's need." Interview revealed signs are also placed at the head of the bed. Interview revealed unit staff are trained to hang special needs signs at the head of the bed and on the outside of the patient's door.

2. Observation on 03/30/2016 at 1005 on Unit B revealed a "Hard of Hearing" sign on the exterior side of Patient #5's door. Observation revealed the sign was visible from the hallway and both non-hospital employees as well as other patients walking the hall. Observation revealed information regarding Patient #5's special need was not protected.

Observation on 03/30/2016 at 1045 on Unit B revealed a cabinet in the nursing station with various signage, laminated, and available for staff use. Observation revealed the cabinet contained signs stating, "Blind, HOH (Hard of Hearing), No BP Sticks in Right arm, No BP Sticks in Left arm, etc...) for staff use.

Interview on 03/30/2016 at 1045 with RN #1 revealed, "We have different signs on ___ (Unit B) we can get to alert staff to the special needs of the patient. Interview revealed when the need arises, a staff member or nurse supervisor obtains the appropriate signage and makes it available to the unit in need. Interview revealed placing signs divulging a patient's special need in a manner that is visible to non-employees does not protect their privacy and is a violation of their rights.

Interview on 03/30/2916 at 1005 with Adm. Staff #1 revealed "Those signs are traditionally placed over the patient's bed and are intended to be confidential. They should not be hung on the outside of the door like that." Interview revealed signage is used to alert staff to the special needs of the patient as an extra measure to ensure awareness and consideration during the provision of patient care. "The signs should be kept inside the patient's room to protect their privacy. Interview revealed placing signs divulging a patient's special need in a manner that is visible to non-employees does not protect their privacy and is a violation of their rights.

Interview on 03/20/2015 at 1545 with RN #2 revealed "We hang those signs the outside of the patient's door so staff are aware of the patient's need." Interview revealed signs are also placed at the head of the bed. Interview revealed unit staff are trained to hang special needs signs at the head of the bed and on the outside of the patient's door.

Based on hospital policy review, medical record review, observation, and staff interviews, the hospital nursing staff failed to ensure the continuity of care and safety of patients during transport for 2 of 2 patients (Patient #s 2 and 11).

The findings include:

Review on 03/30/2016 of the hospital's policy "Patient Transport within the Hospital" (Review 02/2013) revealed "Policy: Patients will be transported ... within the hospital ... Patients will receive the same level of care during transports within the hospital as they would on their assigned unit/department. A standard hand-off communication will occur when patients leave a unit ... and when they return... Procedure: 1. ... The unit secretary will then call the Nurse taking care of the patient and notify them the transport ticket and physican order are at the desk for their completion. 2. The Registered Nurse / Licensed Practical Nurse will compete the remaining sections...Please make sure that information is filled out appropriately on the transport ticket for the patient ..."

1. Review on 03/30/2106 of Patient #2's medical record (MR) revealed a 76 year old (y.o.) presented to the emergency department (ED) and was subsequently admitted on 03/22/2016 for Altered Mental Status. Complaints of shortness of breath (SOB) and chest pain (CP) were also noted with intermittent (not continuous) supplemental oxygen (O2) ordered and initiated. Review of the MR revealed Patient #2 was assessed as a "High Fall Risk" and noted to have a history of seizure activity. Review of the "Nurse Notes" tab/section revealed three (3) Patient Transport Tickets for various procedures. Ticket #1: Date not specified, drug allergies not indicated, no patient information provided regarding Patient #2's condition, Code status, Precautions (seizure and strict fall precautions), IV access, or supplemental O2. Review revealed Patient #2 left the unit to have an MRI (magnetic resonance imaging: provides detailed images) performed at 1610. Ticket #2: Initiated 03/28/2016 with no indication of code status, no strict fall precautions, or supplemental O2 noted. Review revealed Patient #2 left the unit to have a CT (computed tomography: provides detailed images) scan at 1110 and returned to the unit at 1125. Ticket #3: Initiated 03/30/2016 with no information regarding code status, seizure or strict fall precautions, or need for supplemental O2. Review revealed Patient #2 left the unit to have an x-ray completed at 0948 and returned at 1025.

Observation on 03/30/2016 at 0940 on Unit A revealed Patient #2 being escorted down the hall via wheel chair with supplemental O2. Observation revealed a sign posted on Patient #2's room door indicating he/she was at risk for falls.

2. Review on 03/30/2016 of Patient #11's MR revealed a 62 y.o. presented to the ED and was subsequently admitted on 03/29/2016 for Altered Mental Status, Urinary Tract Infection (UTI), and Slurred Speech. Review revealed a Patient Transport Ticket was initiated 03/30/2016 with no information regarding the the patient's condition or strict fall precautions status. Review revealed Patient #11 left the unit to have a CT scan performed at 0835 and returned at 0915.

Observation at 1030 on Unit B revealed a sign posted on Patient #11's door indicating he/she was also at risk for falls.

Interview on 03/30/2016 at 1400 with RN #4 revealed the patient transport tickets are used to ensure communication, in addition to verbal hand-off, with the department receiving the patient for continuity and safety of care. Interview revealed the transport ticket should completed in its entirety as it relates to the patient's condition and treatment modalities. Interview revealed the Patient Transport Tickets were not completed as outlined in the hospital's "Patient Transport within the Hospital" policy and not ensure the continuity and safety of ongoing patient care.

NC00114991