Scripps Mercy Hospital

Report ID: QPGJ11.02, California Department of Public Health

Reported Entity: SCRIPPS MERCY HOSPITAL

Issue:

Based on observation, interview and record review, the hospital did not maintain one patient's (52) right to personal privacy in accordance with hospital policies, as he was rolled down a hallway in a bed. Patient 52's blanket was down around his lower legs, his gown was up, and his left thigh was exposed. Patient 52 was physically and mentally unable to cover himself on his own. The hospital's failure to ensure the personal privacy of Patient 52 placed him, and potentially other patients, at risk for a loss of dignity. The patient census was 302.Findings:On 1/23/12 at 3:50 P.M., Patient 52 was being rolled in a bed down a corridor of the 11th floor by a patient transporter (Transporter 69). As he was rolled past the surveyor, Patient 52 was not completely covered. Administrative Director of Pharmacy (ADM 57) and Senior System Director of Pharmacy (ADM 58) were walking with the surveyor at the time. A blanket was down around his lower legs and his gown was raised which exposed approximately 12 inches of his left thigh. Administrative Director of Pharmacy (ADM 57) told Transporter 69 to cover Patient 52. An interview with the Transporter and patient was deferred so as not to interrupt care.On 1/23/12 at 3:56 P.M. in an interview, a Registered Nurse, 11th Floor (RN 68) said Patient 52 was her patient and had just returned from Radiology. She explained that Patient 52 was confused and aphasic (unable to speak). She said she noticed that he tugs at his gown and exposes his legs. She explained that when she sees this behavior she says, "Let's cover you up."On 1/23/12 at 4:00P.M. in an interview, ADM 58 said "I saw his gown up. I saw his thigh ...nothing else."On 1/23/12 at 4:05 P.M. in an interview, ADM 57 said, "I did not see any private parts. I would not see it as a gross violation of his dignity. You lose your dignity when you come to a hospital. "On 1/25/12 at 10:27 A.M. in an interview, the Director of Patient Logistics (Director 73) said, "[Transporter 69] was taking Patient 52 back to his room from Radiology. Director 73 said the hospital's investigation showed Patient 52 was "very agitated and going through alcohol withdrawal." She elaborated, "We expect transporters to maintain privacy at all times, including physical self."On 1/25/12 at 10:27 A.M. in an interview conducted with the Director of Risk Management (ADM 61), ADM 61 said in reference to Patient 52, "We have to take extra precautions for someone who's confused. He can't speak and can't act for himself." In the same interview, Chief Nurse Operating Executive (ADM 67) said it is a Service Standard of the hospital to create a clean, safe, private environment and to respect the dignity of all patients. She said staff receives two hours of training on hospital standards and core values including personal privacy, but not all staff had completed training. A review of Attachment A of the hospital's policy, Patient Rights and Responsibilities, Approved Model Content Access to (Hospital A's) Care and Services, Patient Rights and Responsibilities shows patients should expect, "Respect for your personal privacy." A review of the hospital's Position Description and Performance Evaluation of Transporter/Lift Team showed under the subheading, Safety/Security, that the transporter staff, "Maintains privacy of patient's physical self and medical record."

Outcome:

Deficiency cited by the California Department of Public Health: PATIENT RIGHTS: PRIVACY AND SAFETY

Related Reports:

The report containing this deficiency also includes information about 1 other violation. Note that these may be related to the same event: QPGJ11.01