HospitalInspections.org

Based on observation, document review and interview, the staff did not ensure patient information was free from public view.

The presence of patient-specific information in public view prevented the patients' right to maintain privacy.

Findings included:

Observations in the facility's 3Main Unit during a tour between 10:30AM and 11:50AM on 12/16/19 identified the following:

A Patient Census Board behind the Nursing Station displayed the first and last names of patients.

Telemetry Monitors on the left side of the Nursing Station displayed the first and last names of patients.

Two (2) Telemetry Monitors, positioned on the walls of the hallway, displayed the first and last names of patients. These monitors were in full view of anyone waking in the hallway or presenting to the Nursing Station.

Patient Census Boards behind Nursing Stations displayed the first and last names of patients that were observed on the Hoag 1 Unit on 12/17/19 at 9:40AM, and the Hoag 6 Unit on 12/18/19 at 10:15AM.
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Observations in the facility's Hoag 1 Unit during a tour between 9:40AM and 11:30AM on 12/17/19 identified the following:

Two (2) Medication Carts, unattended in the hallway, displayed patients' first and last names and were visible to anyone in the hallway.

During interview of Staff F (Vice President of Nursing) at the time of the observations, Staff F confirmed these findings.

Observations in the facility's 4North Unit during a tour between 10:45AM and 12:30PM on 12/16/19 identified the following:

A computer monitor, located in the hallway between patient rooms #4803 and #4804, was left unattended and opened with Patient #6's electronic medical record (EMR) in full view of anyone in the hallway. Staff H (Nurse Practitioner) was logged into the computer at the time of the observation. Also left on the computer desk were printed medical record documents of Patients #6 and #7.

During interview of Staff H at 11:00AM, Staff H stated that she had gone to the restroom and forgot to log off/sign off [the computer] and remove the documents.

These observations were made in the presence of Staff I (Director of Nursing) who confirmed the findings.

The facility's policy and procedure (P&P) titled "Patients' Rights," last revised 02/2019, stated the following: "As a patient in a hospital in New York State, you have the right, consistent with law, to: Privacy while in the hospital and confidentiality of all information and records regarding care."

Based on observation, document review, medical record (MR) review and interview, in 4 (four) of 4 (four) observations, the Nursing Staff did not ensure that patients identified as a high risk for Falls had a yellow "Fall Alert" sign over their bed, as per facility policy and procedure (P&P).

This potentially placed patients at risk for adverse occurrences.

Findings included:

The facility policy and procedure (P&P) titled "Adult Patient Fall Assessment/Prevention Program," last revised 05/2018, stated the following: "High Risk: Score 51 or greater patients [will have a] yellow 'Fall Alert' sign outside room and over bed."

Observations in the facility's 3Main Unit during a tour between 10:30AM and 11:50AM on 12/16/19 identified the following:

Patient #17's MR identified that between 12/9/19 and 12/16/19, this patient had a Morse Fall Scale [a tool used to assess a patient's likelihood of falling] Score between 65-100, identifying that this patient was at a high risk for falls. There was no yellow "Fall Alert" sign over the patient's bed, as required by facility P&P.

The same lack of yellow "Fall Alert" signage over beds was found for high fall-risk Patients #s: 19, 20 and 22, on the 3Main Unit, between 10:30AM and 11:50AM on 12/16/19.

During an interview with Staff F (Vice President of Nursing) at the time of the observations, the staff member confirmed these findings.
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Based on observation, document review and interview, in 1 (one) of 2 (two) observations, the nursing staff did not ensure the implementation of the isolation precaution policy.

Observations in the facility's MIC [Medical Intensive Care] Unit during a tour between 12:35PM and 1:15PM on 12/16/19 identified the following:

A Contact/Droplet Isolation sign was posted on the door of Patient Room #3506 (Patient #8), which advised, "Everyone entering the room must: Wear mask, gown and gloves prior to entering room and remove prior to leaving room."

Staff J (Assistant Nurse Manager) was observed entering the room without first donning appropriate personal protective equipment (PPE) as required, and proceeding to turn off a monitor that was beeping.

These observations were made in the presence of Staff I (Director of Nursing) who confirmed the findings.

The facility's policy and procedure (P&P) titled, "Isolation Precautions: Contact Precautions," last revised 4/2017, stated, "Wear gloves if you anticipate that you will have contact with the patient, environmental surfaces, or items in the patient's room. Wear gown when entering the room ..."

The facility's P&P titled "Droplet/Contact Precautions," last revised 1/2019, stated "Surgical masks must be worn upon entering the room."

Interview with Staff K (Infection Preventionist) on 12/18/19 at 2:30PM confirmed that all staff entering these rooms should wear PPE.