HospitalInspections.org

Based on record review, observations, and interview the facility failed to meet the Condition of Participation to protect patient's rights:


A. The facility failed to maintain the personal privacy of patients. Refer to tag A-0143.

B. The facility failed to ensure that all patients remain free from neglect by failing to provide appropriate psychiatric care. Refer to tag A-0145.

C. The facility failed to ensure patients have the right to be free from restraints. Refer to tag A-0154.

D. The facility failed to ensure that restraint orders were not written on as an needed basis. Refer to tag A-0169.

E. The facility failed to ensure that restraint orders had a duration (timeframe). Refer to tag A-0173

Based on record review and interview the facility failed to provide all patient's or the patient's representative with the correct phone number for filing a grievance with the State agency. This failed practice increases the likelihood of patients not being able to report grievances.

The findings are:

A. Record review of facility's Patient Admission Packet, revised October 2018 had a phone number noted for Department of Health as 505-827-2613. The correct phone number is 1-800-752-8649.

B. During an interview on 01/16/24 at 4:44 PM, with Staff (S) 2 Regulation and Accreditation Director confirmed the Patient Admission Packet that was provided to patients had the wrong number to file a complaint with the New Mexico Department of Health.

Based on record review, interviews and observations, the facility failed to maintain the personal privacy of patients. The Protected Health Information (PHI) for 25 (P (patient) 6, P11, P13, P19 - P40 ) of 40 (P1- P40) patients. This deficient practice is likely to lead to a breach in patient confidentiality and privacy.

The findings are:

A. Record review of the facility's policy titled, "HIPPA [Health Insurance Portability and Accountability Act]: Protected Health Information (PHI) Minimum Necessary" with an effective date of 06/14/2023 under section 3 stated, "[Facility Name] shall maintain responsible administrative, technical, and physical safeguards to protect the privacy of PHI from any intentional or unintentional use or disclosure that is in violation of federal and state privacy law."

B. During an observation of the nursing station on 01/10/2024, at 9:46 AM, PHI for P6, including name, location in the hospital, date of birth, diagnosis, allergies, history and physical, language, vital signs, height and weight was displayed on an unattended computer screen.

C. During an observation of a nursing station on 01/10/2024, at 9:49 AM, PHI for P16 and P17, including patient name gender, date of birth, MRN (medical record number), primary problem, allergies, code status, COVID-19 (strain 19 of coronavirus) diagnosis, and restraints status was displayed on an unattended computer screen.

D. During an observation of a nursing station on 01/10/2024, at 9:55 AM, PHI for P18 including name, date of birth, location, allergies, vital signs, MRN, and nursing assessment was displayed on an unattended computer screen.

E. During an interview on 01/12/2024, at 5:06 PM, with Staff (S)15, Registered Nurse (RN), when asked if computer screens should be left unattended with patient information showing, S15 stated "We usually don't leave them [computers] open. We usually slide our badges across [the badge scanner] to lock them, but I guess it didn't work."

F. During an interview on 01/17/2024, at 9:00 AM, with S14, Registered Nurse, when asked if it is standard practice for computers to be left open with patient information, S14 stated, "We always close our computers when we walk away. I slid my badge [ID card] [across the badge scanner] and it did not work."

G. During an observation of a nursing station on unit 3F on 01/17/2024, at 9:55 AM, revealed accessible patient information for 24 patients (P11,P13, P19-P40) on a document titled "3F Census 01.17.24" was sitting on top of the nursing station accessible to anyone. This document included the following:
1. Patient room number
2. Isolation LDA [lines, drains, and airways] [restraints]
3. Patient Name
4. Day RN
5. Night RN
6. MD (medical doctor)

H. During an interview on 01/17/2024, at 2:22 PM, with S6, nursing director, confirmed that the census sheets are for nursing staff and are updated at the change of the shift and should not be available for anyone to grab from on top of the nursing station. S6 confirmed that patient information listed on the 3F Census did contain PHI.

Based on record review and interview the facility failed to ensure that all patients remain free from neglect by failing to provide psychiatric care prior to discharge for 1 (P (Patient)1) of 15 (P1-P15) patients being reviewed for patients rights. This deficient practice is likely to lead to serious harm, serious injury, serious impairment, or death.

The findings are:

A. Record review of P1's electronic medical record (EMR) revealed the following:

1. P1 was admitted on 08/06/2023 and discharged on 10/30/2023.

2. A document titled, "Discharge Summary" dated 10/30/2023 at 5:37 PM under "Brief HPI[history of present illness]/Hospital course" indicated the patient's diagnosis was bipolar disorder and depression. This section stated, "Today Psychiatry was consulted again, patient with worsening behavior and trying to harm the personal [sic]." Under the "Physical Exam" section of the discharge summary stated the patient was "Alert not oriented [not aware of time place or situation]." Under "Brief HPI/Hospital Course" the provider indicated 911 was called on the patient and patient was discharged to police custody.

3. A document titled, "Progress Note" dated 10/30/23 at 11:54 AM stated: "Pt [patient] has been misbehaving" and "Pt with hallucinations." Under the section "Hospital Issues" stated, "Psychiatry re-consulted 10/30 (10/30/23), pt may qualify for psychiatry admission."

4. The record did not contain any documentation of a psychiatry consult being done on 10/30/2023.

5. A "Discharge order" dated 10/30/23, at 5:37 PM, placed by Staff (S) 17, Hospitalist, [inpatient medical provider] with a disposition [place of discharge] to a "Psychiatric Hospital or Psychiatric Unit of a Hospital."

B. Record review of the facility's security report dated, 10/30/2023, revealed patients disposition was not a Psychiatric hospital or Psychiatric unit of a hospital and stated "At approximately 1730 hours [5:30 PM] [Name of Police Department] and nursing staff escorted [name of patient] off the unit and out to the lobby and placed her in custody and in the back of the police unit."

C. During an interview with the complainant on 01/08/2024, at 2:50 PM, it was explained that P1 was brought to the outside psychiatric facility on 10/31/2023 [sic] and admitted to psychiatry.

D. During an interview on 01/10/2024, at 3:00 PM, with S7, Case Manager, it was asked if P1 was medically cleared for discharge. S7 stated "All I asked was for her to be arrested. I never asked to have her taken to [outside psychiatric facility]. I thought he [police officer] was going to take her to jail."

Based on interview, observations, and record review the facility failed to ensure all patients have the right to be free from restraints for 3 (P (Patient) 1, P11, and P12) of 15 (P1-P15) patients. This deficient practice of using restraints without a duration, an accurate indication, and discontinuation at the earliest possible time is likely to lead to serious harm, serious injury, serious impairment, or death.

The findings are:

A. Record review of facility's policy titled, "Restraints Management" effective 02/28/2023 revealed:

1. Section 1 "[name of facility] uses restraint [sic] only when it can be clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, staff or others."

2. Section 1.3 stated, "Discontinuation of restraints at the earliest possible time regardless of the scheduled expiration of the order will be utilized."

3. Section 2.2 states "Physician orders for non-violent restraints remains in effect until . . . [Section] 2.2.2 the indication for discontinuation of the restraint are met"

4. Section 4.2 "Monitoring occurs at least every two hours or more frequently as the patient condition warrants."

B. Record review of a staff education Tipsheet titled "PATIENT SAFETY ALERT #24-002" under background stated "Restraint use and long term use of restraints has the potential to lead to additional harm if not monitored frequently. This harm can lead to longer hospital stays."

C. Record review of P1's electronic medical record revealed (EMR):

1. P1's restraint order dated 08/20/2023, at 8:09 PM indicated the reason for restraint was for keeping in bed for safety and to prevent patient from wandering.

2. P1 had been restrained continuously from 08/25/2023 to 10/30/2023 for 66 days. The discontinuation of restraints is not charted.

3. P1 remained in restraints while documented as calm and cooperative on the restraint timeline for the following dates and times:

a. On 09/20/2023 at 5:45 PM through 09/23/2023 at 9:45 AM (P1) was calm and cooperative.

b. On 09/24/2023 at 7:45 AM, the patient (P1) was calm and cooperative and additional restraints were applied at this time.

c. On 09/25/2023 at 7:45 AM to 11:00 AM. P1 was calm and cooperative.

5. The record did not contain any documentation of monitoring of restraints for the following dates and times:

a. On 08/28/2023 from 7:00 AM to 7:00 PM

b. On 09/08/2023 from 9:00 PM to 09/09/2023 at 7:00 AM

c. On 09/19/2023 from 11:00 AM to 7:45 PM

d. On 10/09/2023 from 6:45 PM to 10/10/23 at 8:10 AM

D. During an interview on 01/12/2024 at 1:29 PM, Staff (S)4, Nursing Director, confirmed that there was no documented restraint charting for P1 during the times listed above.

E. During an interview on 01/12/2024, at 5:07 PM, with S4, Nursing Director confirmed P1 had been restrained continuously from 08/25/2023 to 10/30/2023.

F. Record review of P11's admission "History and Physical" dated 08/06/2023 at 10:24 PM under physical exam revealed that P11 was "Alert, Oriented x (times) 4 [oriented to self, time, place, and situation]."

G. Record review of P11's discharge summary under physical exam revealed that at discharge patient is "alert not oriented" and patient had been hospitalized 86 days and had a cognitive decline (decrease in mental status).

H. Record review of P11's medical record revealed:

1. The restraint order dated 01/16/2024 was modified and indicated vest while sitting in a chair, and vail bed. This order did not have an end date and indicated "UNTIL DISCONTINUED".

2. P11 was admitted on 07/17/2023 and remained hospitalized as of 01/30/2024.

I. During an observation of P11's room on 01/16/24, at 4:50 PM, P11 had a vest restraint applied while sitting in a chair and the order for the vail bed restraint remained in place.

J. During an interview on 01/17/2024, at 9:00 AM, S12, Registered Nurse confirmed P11 had been restrained for over a month for the prevention of falls and wandering. When asked about the duration of P11s restraint S12 stated "this restraint order is a continuing order."

K. During an interview on 01/17/2024, at 4:50 PM, with S18, hospitalist, S18 confirmed the indication for P11's restraint order of "interference with medical treatment" is from seven months ago when the order was placed and has not been updated.
L. An observation on 01/17/2024, at 7:50 AM, revealed P12 was in a vail bed (netted in bed) restraint and the call light was placed outside of the vail bed where the patient could not access it.

M. During an interview on 01/17/2024, at 7:55 AM, with S19, Registered nurse, when asked how the patient can use the call light S19 stated, "I don't really know because I'm new to vail beds."

N. During an interview with S16 Charge Nurse, on 01/17/2024, at 8:00 AM, S16 stated, "There should always be a call light in the [vail] bed."
O. Record review of P1, P11, and P12's restraint orders do not have an end date and are ordered "UNTIL DISCONTINUED".

P. During an interview on 01/12/2024, at 12:40 PM, with S4, Nursing Director, S4 confirmed that restraint orders do not have a duration (timeframe). S4 stated "restraints can be ordered until discontinued per policy they do not have to expire."

Q. Record review of the facility's Clinical Performance Quality Committee meeting minutes from January 2023 to November 2023, revealed that restraints are not reviewed with leadership or the QAPI (Quality Assurance and Performance Improvement) committee.

R. During an interview with S2, Accreditation Director on 01/16/2024, at 4:44 PM, S2 confirmed, restraints are not reviewed through the hospital QAPI program.

Based on an observation, interview, and record review, the facility failed to ensure that restraint orders were not written on an as needed basis for 1 (P (patient) P11) of 15 (P1-P15) patients. This deficient practice is likely to lead to poor patient outcomes or patient injury.

The findings are:

A. Record review of facility's policy titled, "Restraint Management" effective date 02/28/2023 section 3 stated, Restraints are not written as a PRN (as needed) or standing order."

B. Record review of P11's medical record, the provider ordered a Vail bed (netted in bed) restraint placed on 1/16/24, at 8:03 AM, and stated in the comment section "Vest while up in chair." The restraint type on the order did not match the restraint type placed on patient and the vest was ordered on an as needed basis.

C. During an observation of P11's room on 01/16/24, at 4:50 PM, P11 had a vest restraint applied while sitting in a chair and the order for the vail bed restraint remained in place.

D. During an interview with Staff (S)13, Nurse Executive on 01/17/2024, at 4:06 PM, S13 confirmed that when a restraint is removed from a patient, the order should be discontinued and reflect what is currently applied to the patient.

Based on record review and interviews the facility failed to ensure that restraint orders had a duration (time frame) for 3 patients (P (patient)1, P11, and P13) of 18 (P1-P18) patients. This deficient practice is likely to lead to patients being restrained for extended periods of time.

The findings are:

A. Record review of the facility's policy titled "Restraint Management," effective date 02/28/2023, under "Central Delivery System," section 2.2.2 indicated the duration of restraint orders remain in effect until the indication for discontinuation are met. Time frames for the renewal of orders for restraint of the non-violent non-self destructive patient is not addressed in the facility's policy.

B. Record review of P1's medical record indicated the restraint order placed on 09/07/2023, at 5:25 PM, was discontinued on 10/3/2023, at 8:37 PM. The following restraint order was placed on 10/03/2023, at 8:37 PM, and was discontinued on 10/27/2023, at 12:26 PM. Both orders had no end date and stated "Until discontinued."

C. Record review of P13's orders revealed a restraint order dated 01/15/2024, at 3: 30 PM, had no end date and indicated "UNTIL DISCONTINUED"

D. Record review of P11's medical record under the restraint order dated 01/16/2024, at 8:15 AM, did not have an end date and indicated "UNTIL DISCONTINUED"

E. During an interview on 01/17/2024, at 9:00 AM, with Staff (S)12, Registered Nurse, confirmed that the restraint order for P11 is a continuing order.

F. During an interview on 01/12/2024, at 12:40 PM, with S4, Nursing Director, confirmed "restraints can be ordered until discontinued per policy they do not have to expire."