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Based on record review, observation, and interview, the hospital failed to ensure that the patient's right to dignity was met as evidenced by:
1. Failing to provide privacy during wound care for 1 Patient (#1) of 2 Patients (#1, #3) sampled for wound care from a total sample of 5 Patients (#1 - #5); and
2. Failing to provide bedside commode in a timely manner and the patient urinating on herself for 1 Patient (#1) of 2 current Patients (#1, #3) sampled from a total sample of 5 patients (#1 - #5).

Findings:

Review of the hospital policy number XI.A.11.0 titled "Patient Rights & Responsibilities" presented as current policy stated in part: all disciplines within the hospital are expected to demonstrate respect for the human rights and individual dignity of each patient in the delivery of all aspects of health care and services.

1. Failed to provide privacy during wound care for Patient #1 as evidenced by:

Review of the medical record revealed Patient #1 was a 33 year old admitted on 10/18/19 for wound care and antibiotics.

An observation on 10/28/19 at 9:43 a.m. revealed surveyor and S5RTD approached Patient #1's room. The door to Patient #1's room was observed to be completely opened. S5RTD knocked and S7Staff stated, "Yes". S5RTD introduced himself and surveyor as approached the bedside. Surveyor noted the patient was lying supine with her gown pulled up as S7Staff was performing wound care. Patient #1 pulled her gown down.

In an interview on 10/28/19 at 12:33 p.m. with S7Staff in the presence of S3DQRM, S7Staff stated she couldn't explain why the door was open while she was doing wound care and did not know why she did not inform surveyor and S5RTD she was doing wound care before we entered the room.

In an interview on 10/28/19 at 2:54 p.m. with S3DQRM, she revealed she counseled S7Staff regarding continuing education titled Patient Advocacy: Preserving Human Dignity.



2. Failed to provide a bedside commode in a timely manner for Patient #1 which resulted in Patient #1 urinating on herself and "embarrassed" as evidenced by:

Review of the medical record revealed Patient #1 was a 33 year old admitted on 10/18/19 for wound care and antibiotics. Patient #1 in continent of urine.

Review of the nursing progress notes by S10Staff on 10/26/19 at 6:15 p.m. stated, "Asking to be changed. Was asleep as walked in. CNA on her way in ..."

In an interview on 10/28/19 at 9:51 a.m. with Patient #1 revealed on 10/26/19 at approximately 6:00 p.m. she pushed the call bell. She stated it took 15 minutes before S10Staff came into the room to check on her. Patient #1 stated she asked for the bedside commode and S10Staff walked out of the room. Patient #1 said her mother tried to get her the bedside commode but she was disabled and struggled with the commode. Patient #1 stated at approximately 7:00 p.m. she urinated on herself, was embarrassed, and pushed the nurse call bell again. S9Staff answered the bell this time and cleaned her up. Patient #1 had a large clock on the wall directly across from her bed.

In an interview on 10/29/19 at 9:30 a.m. with S3DQRM, she revealed she was aware that a patient complained over the weekend about having to wait for an hour for a bedside commode and then urinating on herself. She further stated she spoke with the staff about reporting incidents like these.

In an interview on 10/29/19 at 9:50 a.m. with S9Staff, she stated on 10/26/19 when she came back from break, Patient #1 called for assistance. When she went into the room, Patient #1's mom was struggling with the bedside commode and Patient #1 had urinated on herself. She stated S10Staff did not inform her Patient #1 needed her assistance.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure of the RN to follow the Blood Transfusion hospital policy for 1 Patient (#4) from a total sample of 5 Patients (#1 - #5).

Findings:

Failure of the RN to follow the Blood Transfusion hospital policy.

Review of the policy number 1710 titled Blood Transfusion presented as current policy revealed in part:
MANAGEMENT OF REACTION
1. Signs of reaction include but are not limited to fever, flushing, chills, dyspnea, hives, itching, diffuse rash, laryngeal edema, hypotension/shock, hypertension, nausea, symptoms of circulatory overload, back pain hematuria, pain at infusion site.
2. Should any of these symptoms occur, the following should be performed:
a. Blood transfusion is to be immediately stopped
b. Compare patient's Blood Bank armband with the blood tag label
c. Notify the patient's physician STAT
d. Notify Blood Bank STAT
e. Complete Suspected Transfusion Reaction Report
f. Normal saline is to be infused through a different tubing than was being used for the blood
g. Continue to monitor the patient
h. Blood bag and remaining blood and attached IV solutions are to be packaged Send to Blood Bank with a copy of Transfusion Record and Suspected Transfusion Reaction Report to the blood bank for analysis.
i. Obtain urine specimen, label as Transfusion Reaction, Urine #1 and send to lab.
j. Obtain urine specimen two hours after the reaction and label Transfusion Reaction Urine #2 and send to lab.

Patient #4
Patient #4 was a 59 year old admitted on 8/23/19 for medical management, nutritional management, nursing care, education, discharge planning, antibiotics, respiratory management and wound care.

Review of the Blood Transfusion Record revealed the transfusion started at 10:00 a.m. and stopped at 10:32 due to rapid response and Code Blue. Transfusion reaction was circled "NO".

Review of the medical record failed to reveal any of the following steps to a transfusion reaction were followed:
The physician was not notified of a transfusion reaction;
The Blood Bank was not notified of a transfusion reaction;
The Suspected Transfusion Reaction Report was not completed;
Blood was not sent back with a Suspected Transfusion Reaction Report; and
Urine specimen was not collected.

Review of the rapid response team record revealed on 8/27/19 at 10:27 a.m. patient noted to be in Ventricular Fibrillation on the telemetry monitor. 10:34 a.m. Code Blue called.

On 10/28/19 at 2:50 p.m. in an interview with S8Staff in the presence of S4NM, S8Staff revealed she did not know why she did not complete the transfusion reaction report because she stated they did mention him getting a transfusion. No transfusion reaction was identified by S8Staff before this interview.