HospitalInspections.org

Based on observation, interview, and record review the hospital did not ensure personal privacy was provided to 24 of 24 Justice involved patients (inmates) when patients were video monitored without documented clinical need and patient awareness of the video monitoring. In addition, the hospital did not have a policy and procedure for video monitoring.
These failures violated the patients' privacy.

Finding:

A concurrent observation and interview were conducted on 10/22/24 at 10:55 A.M., in 3 North and 3 South (PCU - Progressive Care Unit) with the Charge Nurse (CN) 11. The nursing station was observed with video monitors that continuously monitored the patients in the 24 rooms of the unit. CN 11 stated the patients inside the rooms were continuously video monitored.

An interview was conducted on 10/23/24 at 3:40 P.M., with Unit Manager (UM) 11. UM 11 stated the PCU have 24 patient rooms and each room had a camera for video monitoring. UM 11 stated the hospital and PCU did not have a policy and procedure (P&P) on the use of the camera for video monitoring. UM 11 stated the video monitored patients did not have clinical indication/need documented in their Electronic Health Record (EHR). In addition, there were no documentation of patient awareness of the video monitoring. UM 11 stated video monitoring was not a requirement for justice involved patients, video monitoring can be turned off and would not be a conflict with security and custodial policies. UM 11 acknowledged that the hospital should have P&P on video monitoring, and the patients should have a documented awareness and clinical need for video monitoring but did not have. UM 11 further stated patient privacy was important because it was every patient's right.

A review of hospital's P&P indicated there was no P&P on video monitoring.

A review of hospital's policy and procedure titled, Patient Right and Responsibilities last revised on 8/2018 indicated "D. Related Documents: ...2. Justice Involved Patient's Rights and Responsibilities ... A patient's rights and responsibilities shall include but not limited to: ...2. Considerate and respectful care, including privacy in treatment and in care of personal needs, when not in conflict with security and custodial policies ..."

Based on interview and record review, the facility did not ensure staff follow its policy and procedure when:

1. Cardiac defibrillator pads were not remove prior going for MRI (Magnetic Resonance Imaging- test that creates clear images of the structures inside your body using a large magnet, radio waves and a computer) testing for
Patient 1.

2. Two patients (Patient 21 and Patient 22) were able to leave the Emergency Department (ED) without supervision.

These failures had the potential to compromise patient's health and safety.

Findings :

1.Patient 1 was admitted to the facility on 9/9/24 with chief complaint of back pain per History and Physical (H&P).

During a review of patient 1's physician order dated 9/9/24, Patient 1 had an order for MRI Spine Lumbar without contrast.

A concurrent interview and record review with the Radiology Manager (RM) on 10/22/24 at 2:27 P.M., was conducted. The RM stated it was reported to him that Patient 1 was scheduled to have MRI on 9/10/24. The RM also stated, Patient 1 had defibrillator pads while on the unit. The RM further stated Patient 1 was on an external defibrillator monitor on the way to MRI. The RM also stated, the Intensive Care Unit Nurse (ICU-N) transported Patient 1 to MRI, ICU-N then removed the portable defibrillator monitor, but did not remove the defibrillator pads prior to MRI procedure. The RM further stated, Patient 1 went into the MRI machine with defibrillator pads attached to his left lateral abdomen rib cage area and back area, he then felt something warm and press the emergency button. The RM stated, the MRI tech took him out of the machine and found the defibrillator pads on his left lateral rib cage area and back area. The RM stated each patient was to fill out a MRI screening online, the nurse on the unit fills it out online. The RM stated, once the patient arrives at the MRI trailer, MRI tech was supposed to review each question on the screening form to avoid missed items by the patients. The RM stated the ICU-N should have made sure everything was taken off of Patient 1 prior to sending them for MRI testing. The RM stated when the patient arrives in the MRI trailer, the MRI tech should have visually checked the patient and use a magnetic metal wand to screen Patient 1. The RM stated, it was important to make sure patient did not have anything on them because MRI machine heats up as it scan. The RM stated, the MRI tech assigned to this patient failed to visually check the patient and use a magnetic metal wand. The RM acknowledged by leaving the defibrillator pads on Patient 1's skin, it could have resulted in a burn.

An interview with MRI Technician (MRI-tech) 1 was conducted on 10/22/24 at 2:45 P.M. MRI tech 1 stated ICU-N told him the defibrillator pads were all plastic and patient was ready to go for an MRI. MRI -tech 1 stated he did not used the magnetic metal detector wand in screening Patient 1 prior to MRI testing. MRI-tech 1 stated he should have been more diligent in screening Patient 1 prior to MRI testing. MRI -tech 1 stated it's a safety issue, leaving the defibrillator pads on Patient 1's skin.

An interview with MRI Technician (MRI-tech) 2 was conducted on 10/22/24 at 2:55 P.M. MRI- tech 2 stated MRI-tech 1 should have done a visual check, taken the pads off and used the magnetic wand to scan patient 1 prior to MRI testing. MRI-tech 2 stated that by leaving the defibrillator pads on Patient 1's skin, it could have resulted in a burn.

An interview with the Intensive Care Unit Nurse (ICU-N) was conducted on 10/23/24 at 2:00 P.M. The ICU-N stated she was with Patient 1 when Patient 1 was sent for MRI testing. The ICU- N stated she should have read the packaging of the defibrillator pads prior to MRI testing. ICU- N stated the defibrillator pads packaging indicated it was not MRI safe. ICU- N stated she did not know what she was thinking and told MRI -tech 1, all the pads were plastic, and the patient was ready to go for MRI testing.

During a review of Patient 1's Wound Care Nurse notes on 10/25/24 at 10:25 A.M., with the Wound Care Nurse (WCON) 1, the note indicated, "Patient 1 had serous filled blister at left upper lateral abdominal rib back area 0.6 cm x 2 cm and erythema 4 cm x 8cm back area." The WCON 1 stated this image was taken the day after the incident, 9/11/24.

During a review of facility's policy and procedure titled, Procedure: MRI Metallic Object Screening 7633-112 ...undated, indicated, " ...A. Procedure 1. Metallic Object Screening shall be performed on all patients ...who enter MRI Safety Zone 3 ..."




45909

2 a. A review of Patient 21's first admission notes to the ED dated 9/27/24 at 6:56 A.M., indicated, Patient 21 had a medical diagnosis of hyperglycemia (elevated blood sugar), hypertension (elevated blood pressure) and suicidal ideation (SI- thought of taking own life). Patient 21 was discharged to home on 9/27/24 at 12:12 P.M.

Review of Patient 21's second admission to the ED, the ED Triage (EDT - process of prioritizing treatment) notes dated 9/27/24 at 4:32 P.M., indicated, Patient 21 was confused in a local store and was brought back into the ED by the police department (PD).

A concurrent interview and record review were conducted with Registered Nurse (RN) 21on 10/23/24 at 10:03 A.M. Per Patient 21's EDT notes dated 9/27/24 at 5:50 P.M., Patient 21 was called for registration three times in the waiting area but did not respond. The EDT comment dated 9/27/24 further indicated, Patient 21 eloped prior to registration. RN 21 stated Patient 21 had a history of confusion and should have been placed in a room and a hospital staff should have stayed with Patient 21. RN 21 further stated the ED staff should have called the PD when the unit found out Patient 21 eloped.

An interview was conducted with the Clinical Nurse Manager (CNM) 21 on 10/24/24 at 11:30 A.M. The CNM 21 stated staff should have continuously monitored the behavior of patients in the ED and to report changes in behavior to the physician. CNM 21 further stated Patient 21 should have been in a room with a hospital staff to provide safety check.

During an interview with the House Supervisor (HS) on 10/25/24 at 1 P.M. The HS stated Patient 21 was in the ED waiting area and should have been placed in a room in the ED unit for safety checks by hospital staff.

2 b. Review of Patient 22's first EDT notes in the hospital dated 9/24/24 at 1:17 A.M., indicated Patient 22 was in the ED for SI with her partner. The EDT notes also indicated, multiple attempts to locate Patient 22 within the vicinity were attempted but unsuccessful.

Review of Patient 22's second EDT notes dated 9/24/24 at 7:22 A.M., indicated Patient 22 was still having SI.

A concurrent interview and record review were conducted with RN 21 on 10/23/24 at 10:17 A.M. RN 21 stated per review of Patient 22's EDT notes, Patient 22 and her partner should have not been in the waiting area but should have been placed in a room with a hospital staff to prevent Patient 22 from eloping.

An interview was conducted with the CNM 21 on 10/24/24 at 1:45 P.M. CNM 21 stated Patient 22 should have been placed inside a room and should have been assigned a hospital staff to conduct safety checks. CNM 21 further stated there was no documentation Patient 22 was assigned a hospital staff for safety checks.

Review of the hospital's policy titled Emergency Department revised, 04/2023, indicated, "2. Appropriate steps shall be taken to attempt to prevent at risk patients from leaving the ED without authorization...2 Identifiers for patients at risk for elopement ... confusion or change in mental status. e. Request clothing and/or personal belongings, f. active 5150 hold ...3. Patient determined to be missing ...Attempts shall be made to locate the patient. Hospital security or law enforcement shall be notified as appropriate."

Based on interview and record review the hospital did not ensure that use of restraint to 1 of 1 patient (Patient 19) were in accordance with a physician order when:
1. Patient 19 was placed on soft limb bilateral restraint on 10/22/24 from 4:58 A.M. to 6:06 P.M. without a restraint order.
2. Patient 19's restraint monitoring and reassessment were not consistently done per physician order.
3. Patient 19 did not have documentation in EHR of restraint discontinuation and that restraint's release criteria was met.

These failures had the potential risk on Patient 19's care and well-being.

Findings:

1. Patient 19 was admitted to the hospital on 10/10/24 for diagnoses which included severe sepsis with septic shock (infection) per undated Admission Records.

A review of Patient 19's Restraint Evaluation dated 10/22/24 indicated that Patient 19 was placed on soft limb bilateral upper restraint on 10/22/24 at 4:58 A.M. until 6:06 P.M.

A review of Patient 19's Physician Orders on restraint did not indicate that Patient 19 had an order for restraint for soft limb bilateral upper restraint.

A concurrent interview and record review of Patient 19's Restraint Evaluation and Restraint Orders were conducted on 10/25/24 at 1:32 P.M., with Clinical Nurse Educator (CNE) 11. CNE 11 stated Patient 19's Restraint Evaluation indicated Patient 19 was placed on soft limb bilateral upper restraint on 10/22/24 at 4:58 A.M., until 6:06 P.M. CNE 11 further stated Patient 19 did not have a physician order for restraint of soft limb bilateral upper for 10/22/24 restraint initiation.

A review of hospital's policy and procedure titled, Restraint Used for Non-Violent/Non-Self-Destructive Behavior last revised 8/2019 indicated " ...F. Orders: 1. Restraint is used upon the order of a physician/AHP (Allied Health Professional) ...5. A written order, based on examination of the patient by a physician is entered into the EHR on the initiation of restraint ..."

2. Patient 19 was admitted to the hospital on 10/10/24 for diagnoses which included severe sepsis with septic shock (infection) per undated Admission Records.

A review of Patient 19's Restraint Evaluation indicated that Patient 19 was placed on restraint intermittently from 10/12/24 to 10/23/24. Further review indicated Patient 19's restraint monitoring and reassessment were not consistently documented every 2 hours per hospital policy while on restraint.

A concurrent interview and record review of Patient 19's Restraint Evaluation and Restraint Orders were conducted on 10/25/24 at 1:32 P.M. with Clinical Nurse Educator (CNE) 11. CNE 11 stated Patient 19 was placed on restraint intermittently between 10/12/24 to 10/23/24. CNE 11 further stated the same document indicated that nursing staff did not consistently document the restraint monitoring and reassessment every 2 hours per hospital policy. CNE 11 acknowledged that Patient 19's restraint monitoring and reassessment should have been documented but was not.

A review of hospital's policy and procedure titled, Restraint Used for Non-Violent/Non-Self-Destructive Behavior last revised 8/2019 indicated, " ...H. Ongoing Monitoring and Documentation: ...3. Patient Care: a. The RN or designee trained and competent in use of restraint shall address and document the following patient care needs approximately every 2 hours in the EHR i. Range of Motion ii. Elimination iii. Nutrition/Hydration iv. Allowance for the patient to have maximum movement ... 4. Assessment and Reassessment a. The RN shall reassess patient in restraint approximately every 2 hours or more frequently if necessary. i. The patient will be assessed for the following: 1. Need to continue to use restraints 2. Mental status and behavior 3. Physical/Emotional well-being 4. Respiratory Status 5. Limb circulation 6. Maintenance of the patient's rights, dignity and security 7. Monitoring of the correctness of the application, removal and reapplication of restraint 8. Skin ..."

3. Patient 19 was admitted to the hospital on 10/10/24 for diagnoses which included severe sepsis with septic shock (infection) per undated Admission Records.
A review of Patient 19's Restraint monitoring indicated the last restraint monitoring on 10/22/24 at 6 P.M., was "Restraint Activity: Continue restraint". The document further indicated that following the 6 P.M., documentation, there were no other documentation on restraint.

A concurrent interview and record review was conducted on 10/25/24 at 1:32 P.M., with Clinical Nurse Educator (CNE) 11. CNE 11 stated the restraint monitoring was last documented as continue restraint on 10/22/24 at 6 P.M. CNE 11 acknowledged that there was no documentation of Patient 19's restraint's discontinuation. CNE 11 also acknowledge that there was no documentation that criteria for release of restraint was met. CNE 11 further stated that discontinuation of restraint and criteria for release of restraint should have been documented but was not.

A review of hospital's policy and procedure titled, Restraint Used for Non-Violent/Non-Self-Destructive Behavior last revised 8/2019 indicated, " ...K. Discontinuation: 1. Restraint shall be discontinued when criteria for release are met or as soon as possible regardless of the length of time identified in the order. 2. Document discontinuation of restraint in the EHR ..."

Based on interview and record review, the hospital's Quality Assessment and Performance Improvement (QAPI) Committee, failed to develop a plan to ensure patient safety, risk reports generated from the Emergency Department's data of elopement activities.

As a result, this failure had the potential to place patient safety at risk in an emergency department which receives patients with psychosocial needs.

Finding:

A review of the hospital's monthly Risk Report by the events for the period of January - April 2024 indicated; patient elopement was identified as a high risk area for patient safety concerns.

During an interview and record review with the Emergency Department Director (EDD) on 10/25/24 at 1:30 P.M., the EDD stated the total number of elopement cases that happened in the ED for the last three months were to be documented, submitted, and discussed at the QAPI quarterly meeting. A review of the facility's QAPI committee tracking sheet dated 10/15/24, did not indicate there was a comprehensive discussion or accurate gathering of data related to ED elopements. The EDD further stated the description of elopement cases in the ED should have been entered accurately into the event report system to identify if the event was related to medical, behavioral or lack of resources.

During the QAPI meeting on 10/25/24 at 3:00 P.M., the Chief Nursing Executive (CNE) stated, the ED should have submitted the accurate number with the specific description of elopement cases through the hospital's process of filing an event report for discussion during the QAPI meeting. The CNE, stated the QAPI committee could have discussed further and could have implemented specific methods to address the specific issues on elopement as it was considered to be a high-risk area of concern in the hospital's ED unit and when pertaining to patient safety.

A review of the hospital's policy titled, Quality Assessment Performance Improvement (QAPI) Plan Administrative Patient Care, 2023 & 2024, indicated, " ...D. CULTURE OF SAFETY ...3. Priorities are identified and categorized based on the Institute of Medicine (IOM) Six Aims of Healthcare: ...d. Efficient: (timely data analytic, clinical documentation improvement ...f. Patient Centered (e.g. Patient Rights and values guide all clinical decisions) ..."

Based on interview and record review, the hospital failed to continuously monitor the psychological (mental health) needs when two of two patients (Patient 21 and Patient 22) were able to leave the emergency department (ED) without supervision. This failure had the potential to affect the patient's wellbeing.

Findings:

1. Review of Patient 21's first admission notes to the ED dated 9/27/24 at 6:56 A.M., indicated, Patient 21 had a medical diagnoses of hyperglycemia (elevated blood sugar), hypertension (elevated blood pressure) and suicidal ideation (SI- thought of taking own life). Patient 21 was discharged to home on 9/27/24 at 12:12 P.M.

Review of Patient 21's second admission to the ED, the ED Triage (EDT - process of prioritizing treatment) notes dated 9/27/24 at 4:32 P.M. indicated, Patient 21 was confused in a local store and was brought back into the ED by the police department (PD).

A concurrent interview and record review were conducted with Registered Nurse (RN) 21 on 10/23/24 at 10:03 A.M. Per Patient 21's EDT notes dated 9/27/24 at 5:50 P.M., Patient 21 was called for registration three times in the waiting area but did not respond. The EDT comment dated 9/27/24 further indicated, Patient 21 eloped prior to registration. RN 21 stated Patient 21 had a history of confusion and should have been placed in a room for continuous psychological monitoring and a hospital staff should have stayed with Patient 21. RN 21 further stated the ED staff should have called the PD when the unit found out Patient 21 eloped.

An interview was conducted with the Clinical Nurse Manager (CNM) on 10/24/24 at 11:30 A.M. The CLM stated staff should continuously monitor the behavior of patients in the ED to report any changes to the physician. The CLM further stated Patient 21 should have been in a room with a hospital staff to provide safety check.

During an interview with the House Supervisor (HS) on 10/25/24 at 1:00 P.M. The HS stated Patient 21 was in the ED waiting area and should have been placed in a room in the ED unit for safety checks by hospital staff.

2. Review of Patient 22's first EDT notes in the hospital dated 9/24/24 at 1:17 A.M., indicated, Patient 22 was in the ED for SI with her partner. The EDT notes also indicated, multiple attempts to locate Patient 22 within the vicinity were attempted but unsuccessful.

Review of Patient 22's second EDT notes dated 9/24/24 at 7:22 A.M. indicated, Patient 22 was still having SI.

A concurrent interview and record review were conducted with RN 21 on 10/23/24 at 10:17 A.M. RN 21 stated per review of Patient 22's EDT notes, Patient 22 and her partner should have not been in the waiting area but should have been placed in a room for continuous psychological monitoring with a hospital staff to prevent Patient 22 from eloping.

An interview was conducted with the Clinical Nurse Manager (CNM) on 10/24/24 at 1:45 P.M. The CNM stated Patient 22 should have been placed inside a room and should have been assigned a hospital staff to conduct safety checks. The CNM further stated there was no documentation Patient 22 was assigned a hospital staff for safety checks.

Review of the hospital's policy titled, Emergency Department revised, 04/2023, indicated, "2. Appropriate steps shall be taken to attempt to prevent at risk patients from leaving the ED without authorization..2 Identifiers for patients at risk for elopement: ...confusion or change in mental status. e.request clothing and/or personal belongings, f. active 5150 hold ...3. Patient determined to be missing: ...Attempts shall be made to locate the patient. Hospital security or law enforcement shall be notified as appropriate."