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Based on observations, interviews and record review, the facility failed to ensure confidential patient information was discussed privately for 2/2 patients in the Emergency Department (Patient IDs # 2 and 3).

Findings included:

HHSC Intake for Patient ID #2 stated "I believe multiple patients rights were violated including right to personal privacy." Complainant stated "His (ED NP staff ID #62) diagnosis was presented to us in the middle of a crowded waiting room with many more patients and families present. We were not prepared for this very public discussion about her personal care. Once he began delivering news, my mother requested a private conversation in a more secluded area. NP staff ID # 62 response was to place her in a corner of the same waiting room to discuss her condition." The complaint further stated "This entire scenario recounted was repeated upon completion of the second round of testing in the ER. We had to again request privacy to receive information about testing results. Both instances are a violation of patient's rights to privacy as on both occasions, other people were able to hear conversations regarding my mother's health, without her consent."

Observation in ED waiting room on 1/17/2024 at 0815 am, surveyor was seated in chair in hallway approximately 20 feet away from results waiting area, down hallway. Patient ID #3 was seated in a wheelchair with male family member accompanying her. There were 5 other patients/families present in adjacent area, some seated closer to patient ID #3 than surveyor was seated. Staff physician ID # 61 entered the results waiting area and confirmed patient's name. He pulled an adjacent chair up and sat down to patient's level and introduced himself. He asked multiple medical historical questions including patients visits to doctors, urine testing and treatments and proceeded to discuss options for treatments including invasive procedures. Surveyor could hear the entire medical history, symptoms, labs results, options for treatments as well as patient/family questions.

During an interview on 1/17/2024 at 08:20 am with ED Triage Nurse #68, she was asked to identify Physician Staff ID 61. She stated she thought he was a "resident." She then went and asked him for his name and identified him as Staff Physician ID #61.

Interview on 1/17/2023 at with ED Medical Director Staff ID #63, she was asked how patient's confidentiality and privacy were maintained when care was being provided in the ED waiting room areas or results pending areas. She stated that patients should be moved by staff to the adjacent small cutout in the area behind the triage desk or pulled into an adjacent triage or rapid treatment space.

Review of the facility's "Patient Rights and Responsibilities" brochure, revised 07/2023, stated "To have his/her medical records, ... kept confidential ..."

Review of facility's "Notice of Privacy Practices", dated September 2017, stated "Our responsibilities: We are required by law to maintain the privacy of your health information, provide you a description of your privacy practices and to notify you following a breach of unsecured protected health information. We will abide by the terms of this notice."

Based on interview and record review the facility failed to:
A. ensure nursing staff consulted wound care professional(s) for all pressure injuries stage 3 and above per facility policy (Patient ID #12).
B. ensure nursing staff reported pressure injuries acquired during hospital stay through facility-specific event reporting system to be investigated, tracked and trended per facility policy (Patient ID #1, 11, 12, 13).
C. ensure nursing staff documented provider notification of new wounds per facility policy. (Patient ID #1, 11, 12, 13).
D. ensure nursing implemented and documented interventions and care plan changes based on changes in patient wound condition as appropriate (Patient ID #1, 11,12, 13).

Findings included:
Record review of electronic medical records was performed with Quality Manager, Staff ID #53 on 1/18/24 at 10:45 am:

Patient ID #1 - Patient #1 initial wound care consultation was performed on 4/13/23 and identified 2 small friction related skin tears on R/L buttock. Right measured 1x1x0.1 cm and left measured 1x5x0.2 cm. Wound care team re-evaluation was performed on 4/22/23 by Wound Care Staff ID #78. She identified 9 wounds/skin integrity issues. Four of these wounds were labeled deep tissue injuries by Wound Care Team member #78. Her consult reflects detailed instructions for bedside nursing wound care of her wound and says "Wounds stable, instructions placed in wound care for continued RN care. DC PT wound care following." Staff ID #53 was unable to locate physician notification of new wounds. There were numerous wound care team evaluations and treatments including surgical debridement of a Stage 4 sacral wound in June/July 2023. Facility records showed wound care team evaluations on 8/4/23 and 8/15/23. Patient ID #1 wound care records reflected wound care team member Staff ID #75 performed a thorough assessment with measurements and photographs of 9 wounds on 9/16/23 (a month after prior wound care team engagement), including a large 11x12x1.8 cm Stage 4 sacral wound. The next wound care assessment/note was on 10/5/23 (19 days later). Subsequently the wound care team saw patient on 10/9/23. There was no reassessment prior to patient's death on 10/22/23.

Patient ID #11 - Admission nursing assessment performed on 1/1/24 revealed "necrotic unstageable L heel wound, R heel stage 4 wound, beefy red, and Stage 4 sacral wound." There was no physician/provider notification noted for the wounds present on admission. The nursing plan of care did not reflect wound care treatment strategies and further wound prevention strategies in plan of care outside of an air fluid bed and turning every 2 hours which was inconsistently documented.

Patient ID # 12 - Admission nursing assessment which showed patient was admitted on 12/5/23. Assessment performed on 12/5/23 at 5pm by nursing showed patient's only wound was a "puncture site to right groin" which corresponded with patient's recent endovascular procedure. Staff ID #53 confirmed the patient had been discharged to a skilled nursing facility on 1/17/24. She confirmed that that the nursing note on 1/15/24 mentioned patient had a "Stage 3 anterior sacral wound with eschar, necrotic tissue and foul odor." She confirmed there was no evidence of wound care team consult ordered, no evidence of wound care team involvement and the physician's notes and discharge summary failed to mention the wounds in their assessment or as a part of their discharge diagnosis. Staff ID #53 was unable to locate any orders related to wound care or wound care team consult. There was no evidence of nursing notification to the provider or unit based leadership regarding patient's wound. There was no evidence of electronic incident reporting and therefore no quality analysis.

Patient ID #13 Reviewed Patient ID #13 electronic record. She had a Stage 3 sacral wound, which progressed to Stage 4 sacral wound and was currently an inpatient in the facility. There was no evidence of provider notification or notification to unit based leadership. There was no evidence of electronic incident reporting and therefore no quality analysis.

Record review of facility policy titled "Pressure Injury Prevention", last reviewed 12/2022, stated, "All patients will be evaluated for skin breakdown through completion of a risk assessment process. This will occur upon admission; minimum of once per shift, following a change in medical condition and/or level of care and at discharge. Based on level of risk, nursing interventions will be initiated and will be captured on the patient's plan of care. Regardless of risk, standard of care pressure injury prevention elements should be implemented on all patients." The policy also states "Pressure Injury Interventions: Preventative measure should be applied based on individualized risk factors. Hospital Acquired Pressure Injury: 1. Prevalence of hospital acquired pressure injuries should be tracked, monitored, and reviewed regularly with an interdisciplinary team. 2. Root cause review should be done for all hospital acquired pressure injuries, Stage III and above, including DTIs. 3. The attending provider/practitioner, unit based leader and patient's guardian will be notified as soon as possible. 4. Pressure injuries acquired throughout the hospital stay should be reported via the facility-specific event reporting system."

Interview with Wound Care Team member Staff ID #78 on 1/18/2024 at 08:55 am. She reviewed medical record and wound care photographs for Patient ID #1. She explained that the wound care team would be initiated via consultation entered in the medical record. She stated the wound care team would be consulted on all patients with stage 3 or greater wounds identified. She stated that the wound care team would then follow weekly unless they had a wound vac or required intervention necessitating increased frequency. She stated the bedside staff was responsible for shift skin care interventions/treatments and prevention strategies. She stated the patient was admitted on 4/11/23. She reviewed her progress note and wound photographs on 4/13/23 which was obtained for wound care consult for "sacral decubitus." She stated the patient "did not have evidence of sacral decubitus at that point." She stated the patient had 2 small friction related skin tears on R/L buttock. Right measured 1x1x0.1 cm and Left measured 1x5x0.2 cm. This was consistent with the wound photographs displayed in the GE photo system. She said the skin tears were likely moisture related as well as friction shearing from being dragged across bed/mattress for hygiene/cares. She stated photographs on 4/20/23 clearly showed wounds were "getting worse." She stated that the patient had 9 wound diagnoses on her assessment on 4/22/23 and are reflected in her note. She stated her note at that time stated that wound care would be performed by bedside nurses and that the wound care team would discontinue involvement despite significantly increased number of pressure injuries because the "wounds were stable." She reviewed wound care team documentation on 9/16/23 by her colleague Staff ID #75. She agreed patient had acquired significantly more complex wounds, a total of 9 wounds, including a Stage IV sacral decubitus that measured 11x12x1.8 cm and 3 unstageable pressure injuries. She was asked to show evidence in wound care team documentation of collaboration/notification with bedside staff, physicians and/or re-evaluation of interventions and she was unable to locate this information in the medical record. She was unsure of which staff member should be entering the acquired pressure injuries into the facility's electronic reporting system.

Interview with Unit Registered Nurse Staff ID#67 on 1/17/24 at 11:15 am. He stated that units had "Skin Care Champions". He described these as unit-based nurses who had clinical interest and additional education related to wound care. He stated they round weekly in the unit. However, he stated there was no formal documentation of their skin assessments being performed on patients. He stated the bedside nurses were responsible for assessing and documenting skin care as well as providing most interventions. He confirmed there was a Braden Skin Assessment Scale utilized by the facility for skin risk assessment but stated he was not aware of a policy which correlated between patient's risk factors and how that influenced or amended the nursing care plan.

Interview 1/17/24 at 3:10 pm with ACNO Staff ID #58. She confirmed the facility had started a "CSIP" program which stands for Clinical Safety Improvement Program which is targeting wound care. She stated the facility is in the process of creating overarching structure for wound care program. She stated that the facility had implemented the use of "Wound Care Champions" on the units. She stated the facility was still in the process of creating a comprehensive wound care program with infrastructure.

Interview 1/18/24 at 11:00 am with Staff ID #53, Quality Manager. She confirmed that the facility's pressure injury prevention policy required patients who acquired Stage 3 or greater pressure injuries while in hospital, should have variances entered through Vigilanz electronic system, to facilitate quality tracking and follow-through. She confirmed there was no Vigilanz report entered for Patient ID #1, 12, 13 and 14 and therefore no quality or root cause analysis had been performed.