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800 EAST 28TH STREET

MINNEAPOLIS, MN 55407

PATIENT RIGHTS: PERSONAL PRIVACY

Tag No.: A0143

Based on interview and document review the hospital failed to ensure a patient's right to personal privacy for 1 of 10 patients reviewed, Patient #1 (P-1), when a staff member, Nursing Assistant E (NA-E) asked (P-1) for her personal phone number and attempted to contact P-1 several times after she was discharged. Findings include:

Medical record review revealed P-1 was admitted to the hospital's emergency department (ED) on 3/23/2014 for suicidal intent. Nursing notes dated 3/23/2014 were reviewed and revealed P-1 was placed on 1 to 1 supervision for safety.

P-1 was interviewed on 4/30/2014 at 2:15 p.m. and stated a nursing assistant matching NA-E's first name and physical description was providing 1:1 supervision for her in the hospital's ED. P-1 stated NA-E asked for her phone number and to use her phone to call his phone, so he could be sure she had the right phone number. She did not feel she could give him the wrong number. P-1 stated he said he wanted to "hook-up" with her after she was discharged from the hospital, because she was beautiful and he wanted to be with someone beautiful. P-1 stated NA-E made her feel uncomfortable and she did not feel safe. P-1 stated NA-E called her and sent messages after she was discharged, so she changed her phone number.NA-E was interviewed on 4/29/2014 at 3:05 p.m. and stated he was the 1:1 staff to supervise P-1 on 3/23/2014. NA-E stated he felt bad for P-1 because she had cuts on her arm. NA-E initially stated he did not ask P-1 for her phone number, but gave her his number and he never spoke with P-1 after she was discharged. Later in the interview NA-E admitted he did get P-1's phone number and after she left the hospital he sent her a text message. NA-E stated he contacted P-1 because he wanted to refer P-1 to his pastor. NA-E stated he was aware he should not contact patients after they leave the hospital, but chose to call P-1 because she was suicidal and he wanted to help her.

The Abbott Northwestern patient rights document dated 05/13 was reviewed and revealed the following: (c) (1) The patient has the right to personal privacy.

PATIENT RIGHTS: RESTRAINT OR SECLUSION

Tag No.: A0168

Based on interview and document review the hospital failed to ensure the use if restraints was in accordance with the order of a physician or licensed independent practitioner (LIP) for 2 of 6 patients reviewed who utilized restraints, Patient #6 and Patient #10 (P-6, and P-10), when the hospital failed to obtain an order for the restraint until several hours after the restraint was being utilized. Findings include:

Medical record review revealed P-6 was admitted to the hospital's intensive care unit on 4/24/2014 with hallucinations. Flow sheet data for P-1 dated 4/24/2014 were reviewed and revealed bilateral soft wrist restraints were initiated for P-6 on 4/24/2014 at 6:48 p.m. Physicians orders for P-1 were reviewed and revealed there was no physician's or LIP's order for the restraints until 11:00 p.m., more than 5 hours after the restraints were initiated.

Medical record review revealed P-10 was admitted to the hospital's intensive care unit on 4/18/2014 with a head ache and history of subarachnoid hemorrhage. Flow sheet data for P-10 dated 4/26/2014 was reviewed and revealed bilateral soft wrist restraints were initiated on P-10 at 6:00 p.m. Physician's orders for P-10 were reviewed and revealed there was no physician's or LIP's order for the restraints until 12:07 a.m., more than 6 hours after the restraints were initiated.

Registered Nurse-F, (RN-F) was interviewed on 4/30/2014 at 10:30 a.m. and stated it is hospital policy that orders would be obtained as soon as possible after restraints are initiated for a patient.

Hospital Policy titled Restraints-Non-Violent Behavior, Effective Date: August 2013 and provided by the hospital was reviewed. Under the section titled Ordering: 2) the following was observed: In an emergency, the RN may apply restraints, but then must notify and obtain an order from the LIP immediately after the restraint(s) have been applied and patient safety ensured.