| 1454 |
HELEN PORTER HEALTHCARE & REHAB |
475017 |
30 PORTER DRIVE |
MIDDLEBURY |
VT |
5753 |
2014-02-12 |
164 |
D |
0 |
1 |
751Y11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure that 5 residents (Residents #190, #191, #1, #6, #2) have the right to personal privacy and confidentiality of his or her personal information and clinical records. The findings include: 1. Per direct observation on 2/10/14 at 3:23 PM on the sub-acute rehabilitation unit, the off going day nurse, along with the the on coming nurse and the on coming licensed nursing assistant, entered room [ROOM NUMBER], a semi-private room. At the time of the observation both Residents (#190 and #191) that resided in the room were present. The nurses and aide approached Resident #191 and proceeded to give bed side report. (Discussion of the resident's diagnosis, rehabilitation status, review of medical history at hospital prior to admission, cognitive level, behaviors exhibited, medications resident takes, assistance level needed by resident by staff and the resident's discharge status.) At the time of bedside report, Resident #190 was sitting approximately 5 feet away from the group only separated by a privacy curtain. The verbal volume of the discussion of the bedside report was loud enough that the surveyor sitting 5 feet away was able to hear all details of Resident #191's bedside report. The same group of staff went to the bed of Resident #190 on the other side of the privacy curtain and proceeded to review this resident's bedside report. At the time of bedside report, Resident #191 was sitting approximately 5 feet away from the group only separated by a privacy curtain. 2. Per observation on 2/11/14 at approximately 3:15 PM, on the sub-acute rehabilitation unit, the off going day nurse, along with the on coming evening nurse and the on coming evening licensed nursing assistant, entered room [ROOM NUMBER], a semi-private room. At the time of the observation both Residents (#6 and #1) that resided in the room were present. The nurses and aide approached Resident #6 and proceeded to give bed side report. The verbal volume of the discussion of the bedside report was loud enough that the surveyor standing approximately 5 feet away on other side of room was able to hear all details of Resident #6's condition. The same group of staff went to Resident #1's bedside and proceeded to review this resident's bedside report. The conversation was loud enough that it could be heard from the doorway. 3. Per interview on 2/10/14 and 2/11/14, 5 residents were interviewed (#2, #191, #190, #6 and #1) regarding their knowledge of bedside report. None of the residents interviewed indicated that staff had informed them that bedside report was going to be conducted daily by the nursing staff. None of the 5 residents interviewed received any verbal or written documentation on admission from the facility explaining bedside report, and all 5 indicated that no consent was obtained by staff from them allowing the review of confidential resident information at the bedside. Per interview, 1 of the 5 residents (#2) verbalized that if he/she was aware that he/she could refuse to allow this information from being discussed at the bedside he/she would have refused. Per interviews on 2/11/14 with the Unit Manager (UM) and Director of Nursing (DNS), he/she indicated that bedside report was conducted daily with the day and evening oncoming and off going shift to discuss diagnosis, medical, cognitive and behavioral conditions and disposition plan of each resident on the subacute unit. The UM and DNS indicated that the purpose was to provide information from one shift to another regarding residents. The UM confirmed that report is also given in written form and verbal form at the nurse's station. Per review of the facility Admission packet provided to all residents in the facility upon admission, there was no evidence in the admission information that bedside rounds would be conducted for residents admitted to the subacute rehabilitation unit. The information provided to the resident on the subacute rehabilitation unit regarding general information, kept in a binder and given to the resident for their review, had no information that bedside rounds would be conducted and no information indicating to the resident that they could refuse to participate in bedside rounds if they wish. See also F241. |
2017-05-01 |