The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|JEWISH HOSPITAL & ST MARY'S HEALTHCARE||200 ABRAHAM FLEXNER WAY LOUISVILLE, KY 40202||Oct. 10, 2017|
|VIOLATION: PATIENT RIGHTS: PRIVACY AND SAFETY||Tag No: A0142|
|Based on observation, interview, record review, and facility policy review, it was determined the facility failed to maintain patient privacy while providing Physical Therapy in the pool area for one (1) of ten (10) sampled patients, Patient #1. A tour group entered the Physical Therapy pool area while Patient #1 was receiving therapy without Patient #1's consent. In addition, staff failed to knock before opening the door of an occupied shower/changing room.
The findings included:
Review of the facility's policy, Patient Rights and Responsibilities, dated December 2016, revealed the patient had a right to personal privacy. The patient had the right to refuse recording or filming for purposes other than the identification, diagnosis, or treatment. The patient had the right to present complaints and expect corrective action taken, when indicated.
Review of the facility's policy, Notice of Privacy Practices, dated November 2014, revealed the patient had a right to request a restriction or limitation on how much of their health information was disclosed for treatment, payment, or health care operations.
Review of the facility's Grievance Log, dated 2017, revealed Patient #1 notified the facility on 08/30/17, that the facility did not maintain his/her privacy during pool therapy and while in the shower/changing room on 08/16/17.
Review of a facility Grievance Response letter, dated 09/05/17, revealed an outside group toured the Physical Therapy pool area while Patient #1 was in the pool, without obtaining the patient's prior approval. The letter verified the tour group took pictures of the pool area, but not of the patient. In addition, it was identified the shower/changing room door did not have a lock on the door to ensure patient privacy.
Observation of the sixth floor Therapy Area, on 10/09/17 at 10:45 AM, revealed a reception area, a Physical Therapy workout area, and a room with two (2) therapy pools. The pool area contained two (2) shower/changing rooms.
Review of Patient #1's clinical record revealed the facility admitted the patient for Out Patient Physical Therapy Services on 08/01/17, for a diagnosis of Chronic Low Back Pain.
Interview with the Office Coordinator, on 10/09/17 at 11:15 AM and 10/10/17 at 1:15 PM, revealed a tour group requested to see the Therapy Pool area on 08/16/17. She stated she tried to the call the Therapy Pool area but no one answered the phone. The Office Coordinator stated she went to the pool area to let staff know about the tour group and when she turned around, the tour group was right behind her and went on into the pool area prior to staff obtaining patient permission.
Interview with the Physical Therapy Assistant (PTA), on 10/09/17 at 11:22 AM, revealed the Office Coordinator came to the door of the pool area and informed her and the Aquatic Technician that a tour group wanted to come into the pool area. She stated the tour group was directly behind the Office Coordinator at the time and did not wait for them to obtain Patient #1's permission prior to entering the pool area. The PTA stated Patient #1 was in the Therapy Pool wearing a bathing suit when the tour group entered on 08/16/17. She stated the patient was upset and made the group aware of his/her dissatisfaction. The PTA stated to ensure patient privacy, the facility must ask for the patient's permission prior to allowing visitors, or others not involved in the patient's care, into the pool area.
Further interview with the Physical Therapy Assistant (PTA), on 10/09/17 at 11:22 AM, revealed after Patient #1 finished Pool Therapy, he/she went into the shower/changing room area. The PTA stated the outer door to the shower/changing room did not have a lock and a Therapy Student escorted another patient to the same shower/changing room and opened the door while Patient #1 was in the room, without knocking first. The PTA stated she informed the student a patient was in the shower room and the student shut the door.
Interview with the Aquatic Technician (AT), on 10/09/17 at 11:05 AM, revealed he was on the phone when the Office Coordinator came to the door to inform them a group wanted to tour the pool area. The AT stated there was no time to ask Patient #1 for permission because he was still on the phone when the tour group entered right behind the Office Coordinator. He stated the group apologized for coming in after the patient made his/her dissatisfaction known. The AT stated the facility system of obtaining prior approval broke down that day. According to the AT, to ensure patient privacy, staff must obtain the patient's approval prior to allowing a tour group into the pool area.
Interview with the Physical Therapy Supervisor, on 10/09/17 at 11:25 AM, revealed he met with Patient #1 on 08/16/17, regarding a tour group coming into the pool area while he/she was receiving pool therapy services. The Supervisor stated the patient was very upset that the group was allowed into the area without his/her permission. He stated staff failed to ensure patient privacy in the pool area and should have obtained patient permission prior to allowing visitors into the pool area.
Interview with the Director of Patient Access, on 10/09/17 at 12:55 PM, revealed a group of potential buyers of the facility came to tour the pool area on 08/16/17. The Director stated it was a dignity and privacy issue to allow visitors into a patient care area without the patient's permission.
Interview with the Director of Rehabilitation, on 10/09/17 at 11:48 PM, revealed she conducted a brief investigation into Patient #1's grievance. The Director stated it was determined staff did not obtain Patient #1's permission prior to allowing a group of visitors into the pool therapy area while the patient was in the pool. She stated it was also determined the shower/changing room door did not have a lock to ensure patient privacy while showering or changing. The Director stated it was determined a Physical Therapy Student failed to knock on the shower room door prior to opening the door while Patient #1 was in the room. She stated staff must obtain patient permission prior to allowing visitors in the pool area and should knock before opening patient doors to ensure patient privacy.
Interview with the Vice President of Rehabilitation Services, on 10/09/17 at 10:50 AM, revealed she escorted a group of prospective buyers of the facility to the Physical Therapy Pool area on 08/16/17. She stated she believed prior permission to enter the area was obtained from Patient #1; however, it was determined later, after the tour, it had not been obtained. She stated it was also determined the shower/changing room door did not have a lock to prevent a Physical Therapy Student from opening the door while Patient #1 was in the room. The Vice President stated patients had the right to privacy and the facility should ensure staff was educated on policy and procedures related to patient privacy.