HospitalInspections.org

Based on facility policy, observation, record review, and interview the facility failed to ensure that privacy was provided during medical treatments for 1 of 3 (Patient #3) sampled patients.

The findings included:

Review of the facility's "Patient Rights/Responsibilities" policy revealed, "...The patient (surrogate) has the right...to consistently be treated with dignity in a manner that supports dignity and in an environment that preserves dignity and contributes to a positive self- image...to have the right to privacy..."

Observation in the radiology/ultrasound department on 11/5/18 revealed a long hallway with 2 doors. One of the doors has a sign indicating it is the radiology office. The other door has signage on the front of the door indicating "Do not enter, test in progress" that can be turned around when a patient is in the room. The room was lit by a small lamp. It was dim in the room. There is a small bed against the right wall. The privacy curtains close from the back of the room to the front, around the front of the door and could be pushed aside if the door is opened wide enough. The Ultrasound machine was located off to the side near the middle of the bed. During the tour the Administrator stated the sign had been placed on the door on 9/11/18.

Review of the medical record for Patient #3 revealed the patient arrived to the ER via private vehicle on 9/10/18 at 3:35 PM with a complaint of pelvic and perineal pain. The patient was triaged at 3:35 PM and seen by the physician at 3:43 PM.

Review of the ER orders dated 9/10/18 revealed orders that included a Computerized Tomography (CT) of the abdomen pelvis and an Ultrasound (US) Pelvis and Endovaginial. The US was completed on 9/10/18 at 5:03 PM. The CT was completed on 9/10/18 at 8:13 PM.

Review of (Name of Hospital) complaint and grievance form dated 9/10/18 revealed the Administrator documented, "...Details of the Complaint): (Name of Patient #3) went to radiology for Ultrasound approx (approximately) 1630 (4:30 PM). Around 1640 (4:40 PM) or so (Name of Environmental Service (EVS) Technician #1) heard a page - he was working in the north stairwells, due to no phone in the area he came down the stairwell to radiology department tried to call the number he thought he was paged to and no one answered. He went to the radiology office but no one was there either. The next door was closed so he knocked on it and ask did you page me? He opened the door and went into the room where the patient (Patient #3) was receiving a vaginal ultrasound. Tech (radiology technician) told him no, she didn't need him and motioned for him to leave the room. Patient became very upset that employee saw her and the tech (radiology technician) reassured patient that she was fully covered he didn't see anything but when the patient went back to the ER she was still very upset. Staff notified (Name of EVS Manager) of the incident at that time and (Name of EVS Manager) called me (Administrator)..."

Review of (Name of Hospital) complaint and grievance form revealed on 9/10/18 the DON documented "...I spent about 10 minutes with (name of Patient #3) telling her how sorry I was that it happened. She (Patient #3) said she felt violated. I assured her that the male employee didn't have a clue what was going on and probably didn't see anything because of the gown that was covering her top part and the other gown covering her bottom half. She told me that even though she was covered with the gowns she felt a "breeze down there" when he opened the door. She said she felt "dirty"..."

On 9/11/18 the DON documented, "...it was noted that there is no sign on the US door saying DO NOT enter or test in progress and (name of EVS Technician #1) didn't even know that was the US room, he says he was just looking for an employee to see what they needed from him, this door was closed and he knocked on the door then entered the room and said the curtain was not pulled. Tech (Radiology technician) stated that the door was closed, curtain pulled, lights on dim and patient fully covered..."

In an interview in the conference room on 11/5/18 at 10:22 AM, the Director of Nursing (DON) stated she had spoken to (Name of Patient #3) on 9/10/18 in the ER. The DON stated, "...She (Patient #3) was very upset...she said she was having an US and the Environmental Service (EVS) Technician guy came in. She (Patient #3) had a gown on top and a sheet on the bottom with the tech (radiology technician) in front of her...She told me she felt violated..."

In an interview in the conference room on 11/5/18 at 10:30 AM, EVS Technician #1 was asked about the incident in the radiology department on 9/10/18. EVS Technician #1 stated, "...It was x-ray, about a month ago. I assumed it was x-ray where they do test with all the magnets. I was cleaning in the north stairwell and get a page overhead. I thought it was radiology. I went there it was down the hall from the stairs. There's 2 doors, didn't have a sign up. The first door I knocked and it was locked. The next door I knocked, stuck my head in and asked if they called me. I didn't know then there was a patient in there. Then somebody went to my boss and (name of DON) I got into some trouble. They said the patient got upset...." When asked if he saw the patient when he opened the door, EVS Technician #1 stated, "...No, it was too dark and there was a curtain that was closed. I heard the tech (radiology tech). I didn't go all the way in. I think the patient got upset because she heard my voice. Come to find out it was the ER that called me..." When asked if he spoke to the patient at any time, EVS Technician #1 stated, "...I don't know who she was, never did see her. I didn't talk to her. Now I always knock on the door and wait on somebody to let me in..."


In an interview in the conference room on 11/5/18 at 11:10 AM, the Radiology Technician stated, "...She (Patient #3) was being seen in the ER for pelvic pain. The doctor ordered a pelvic ultrasound. We brought her back to the ultrasound room (located next to the ER), the door was closed and the curtain pulled. It's very dim in that room so we can see the images better. I had finished the first half on the exam and had started on the second half, the vaginal part. She had a gown on covering the top half and I had draped a sheet over her lower part. Someone knocked on the door and I thought it might be one of my coworkers asking a question so I said hello. I had my back turned toward the door and like I said the curtain was pulled so anyone at the door could not see the patient. It was housekeeping (EVS Technician #1) and he asked if someone paged. I told him I was with a patient and had not paged him. I don't think he realized what was going on. The patient (Patient #3) got upset. I did explain to her that she was covered and the curtain was pulled. I finished the test and she went back to ER...". The radiology technician verified there was not a sign on the door or wall that indicated the room was occupied.

In a telephone interview on 11/5/18 at 4:25 PM, Name of Patient #1 stated, "...I went to the ER because of abdominal pain...I waited in the ER waiting room for a few minutes then the nurse took me back to a room. There was a janitor, an older man doing something with the trash in the hallway outside my door. The nurse came in and told me she needed me to pee in a cup for a urinalysis. The door was opened and I know he heard her. He came in the room and picked up laundry. He said hi and I said hi back. The nurse came in and handed me a cup and told me to pee and then I was going to have a vaginal ultrasound. I went to the bathroom and when I got back the janitor came back in the room and got the trash. He didn't knock. The nurse took me to get the US. I went in the the bathroom attached and undressed. I got on the table, the tech covered my legs with a sheet but my feet were up in the stirrups. The curtain was pulled but the bed is on the right side of the room and the curtain is closer to the left side. She (radiology technician) was doing the exam. The janitor opened the door and walked in. He asked if the tech had called him. She told him no and to leave at least 3 or 4 times. He finally left the room and she finished the exam. She didn't say anything to me. I made a report to some lady, don't know her name. They wouldn't tell me anyone's name when I asked. The lady apologized to me and gave me a gift card to Subway. The janitor knew I was in this room...Patient #1 stated she had not heard anything from the hospital since the incident..."