MERCY HOSPITAL OF FOLSOM

Report ID: L0OV11, California Department of Public Health

Reported Entity: MERCY HOSPITAL OF FOLSOM

Issue:

Based on observation, staff interview, clinical record review and document review, the facility failed to ensure patient's rights to personal privacy for 2 of ten Intensive Care Unit (ICU) patients (Patients 1, 2) when:1) two of ten ICU patients (Patients 1, 2) were videotaped/photographed without their consents, and2) the electronic census board in the Emergency Department (ED) noted names of patients that were visible to the public.These actions resulted in the violation of patient's basic rights to respect, dignity and comfort during hospitalization.Findings:In an Initial Tour of the ICU on 2/4/13 at 9 a..m., eight private rooms were noted for managing patients with critical conditions requiring close observation and monitoring. The Risk Manager (RM) stated patients may be placed on ventilators with sedation for short periods of time. At the time of the observation, the census in the ICU was six and there were no patients on mechanical ventilators.1a) Review of a a medical record revealed Patient 1, a 28 year old, was admitted to the hospital on 10/19/12 for epiglottitis (an inflammation of the windpipe, a tube to the lungs) with difficulty swallowing and sepsis. Patient 1 was placed in the ICU on a mechanical ventilator (equipment used to assist or replace breathing). Review of Patient 1's medical record revealed an order for a Propofol infusion (an anesthetic used to induce sedation). Review of a root cause analysis (a hospital investigative report), dated 12/4/12, revealed that on 11/29/12 at 1:28 p.m., the Folsom Police Department (FPD) informed the hospital they were investigating an ICU nurse for possible domestic sexual misconduct. The FPD stated that, in the course of their investigation, they had identified pictures and videos from Licensed Nurse (LN) 1's home computer that showed sexual misconduct with what appeared to be a young, female who appeared to be a hospitalized patient on a ventilator. The Vice President for Ancillary Services (VPAS) was interviewed on 1/14/13 at 1:34 p.m. and stated the hospital had confirmed the identity of the patient (Patient 1) in the ICU. The VPAS stated the video (dated and timed on 10/19/12 at 10 a.m.) revealed Patient 1 in the ICU and the right breast was exposed. LN 1 was further noted to expose Patient 1's vaginal area and pinch and open Patient 1's labia (the lips of the vaginal vault) and insert his fingers into this area. The VPAS stated LN 1 was identified to have been assigned to the care of Patient 1 on 10/19/12 for the day shift from 7 a.m. until 7 p.m.1b) Review of a medical record revealed Patient 2, a 30 year old, was admitted to the hospital on 11/18/09 for acute pancreatitis with surgical complications following a cholecystectomy (removal of the gallbladder) that required her to be placed in the ICU on a mechanical ventilator. Review of Patient 1's medical record revealed that Patient 2 had an order to be sedated with Propofol.The VPAS, in an interview on 2/4/13 at 10 a.m., stated that the FPD came back to the hospital on 1/29/13 and showed them a picture of another vented patient from LN 1's home computer. In this photo, the patient's (Patient 2) breast and vaginal area were exposed. The VPAS stated the hospital confirmed the identity of this patient (Patient 2). The VPAS stated both Patients 1 and 2 had been informed by the FPD and the hospital of the violation of privacy. The VPAS produced a letter written to Patients 1 and 2 informing them their privacy had been breached.In review of LN 1's assigned ICU patients between 2/3/09 and 11/29/12, 12 patients were noted to have been on a mechanical ventilator and sedated with propofol. Of these 12 patients, eight were female and four were male. Of the eight female patients only three were under the age of 55, two of these were Patients 1 and 2. The third patient was a 48 year old cared for by LN 1 the day he was arrested in the ICU. b) During an Initial Tour of the ED on 2/4/13 at 8:45 a.m., an electronic board, approximately four feet wide and four feet high was noted to be mounted on the wall at the rear of the nursing station. The board displayed the census in the ED and included the patient's first initial and last name, the chief complaint and other miscellaneous references to procedures or lab work to be done or the status of discharge. The board was visible to anyone passing by or standing at the nursing station. The ED Manager (EDM), in an interview on 2/5/13 at 9 a.m., stated she was not aware the names of the patients in the ED were visible on the board. She revealed, however, the staff had access by a mouse to adjust the lines on the graph and they may have expanded the column to expose the entire name. The EDM acknowledged the names of patients admitted to the ED should not be visable on the electronic board.

Outcome:

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