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Based on policy review, medical record review and interview, the facility failed to ensure patient respect, dignity, and privacy were maintained for 1 of 3 (Patient #9) sampled patients reviewed for patients rights.

The findings included:

1. Review of the facility's policy titled "Patient Rights and Responsibilities," dated 10/2024, revealed "...respects the dignity and pride of each individual we serve...To be treated with consideration, respect and recognition of their individuality, including the need for privacy in treatment..."

Review of the facility's policy titled "Information Protection," dated December 23, 2024, revealed, "...the purpose of this Policy is to establish general requirements for the patient privacy program and provide pertinent definitions and provide guidance for some aspects of the Health Insurance Portability and Accountability Act (HIPAA)...To establish the requirements for each Company-affiliated facility to protect patients' privacy rights and their individually identifiable Health Information as required by the HIPAA Privacy Standards..."

2. Review of the closed medical record revealed Patient #9 was admitted on 9/17/2024 with diagnoses of Post Traumatic Stress Disorder, Bipolar Disorder, and Suicidal Ideation.

Review of the History of Present Illness (HPI) dated 9/17/2024, revealed "...Patient presents to the ER [Emergency Room] with mental health concerns. Patient reports a history of bipolar disorder...He [she] presents to the ER today reporting suicidal ideation. She will not disclose to me any particular stressors or other reason why she has suicidal ideation today. She does report compliance with current medication..."

Review of the "UNLOCKED PROGRESS NOTE," dated 9/17/2024, revealed "...Crisis Narrative...location...[hall bed]...C [Client] reported endorsing SI [Suicidal Ideation] with plan to "slit wrist" using a razor blade...reported having 7/10 intent to follow through with this plan...reported struggling with SI "on and off of years," however this episode has been consistent for two weeks...reported engaging in SIB [Suicidal Ideation Behavior] via cutting on 9/15/2024...reported major stressor is mom moving back...meets criteria for IP [In-patient] due to SI with plan, access, and intent...Consent was given from Dad...[Named Family Member #2]..."

3. During a telephone interview on 12/2/2024 at 11:16 AM, Family Member #1 was asked to tell me about Patient #9's ER visit. Family Member #1 stated "...Seen in the Emergency Department [ED] for suicide risk...she had been to therapy and revealed to the therapist she had a plan...my 21-year-old son took her to the appointment...then he took her to the hospital...to the ER...once her father and I got there...she was just on a gurney in the hallway...at no time did put her in a room...the crisis person came, they talked to her in the hallway around other patients...there was no privacy for her what so ever...they were so busy and did not have a room to take her to...everything they did it was in the hallway...there was a patient across from her...2 other patients out in the hallway as well..."

During an interview on 12/4/2024 at 10:14 AM, the ED Director was asked if the patient was provided privacy in the hallway beds. The ED Director stated, "...It's not conducive. We try to respect their privacy. We pull the screen so the other patients cannot see on the other side." The ED Director was asked if the other patients in the hallway could hear other conversation. The ED Director confirmed the patients could be heard by other patients in the hallway. The ED Director confirmed Patient #9 was positioned in the hallway bed.

Based on facility policy, record review, facility document review, facility email review, and interview, the facility failed to ensure that privacy was protected for 1 of 3 (Patient #31) sampled patients reviewed for Health Insurance Portability and Accountability Act (HIPAA) privacy.

The findings included:

1. Review of the facility's policy titled "Information Protection," dated December 23, 2024, revealed, "...the purpose of this Policy is to establish general requirements for the patient privacy program and provide pertinent definitions and provide guidance for some aspects of the Health Insurance Portability and Accountability Act (HIPAA)...To establish the requirements for each Company-affiliated facility to protect patients' privacy rights and their individually identifiable Health Information as required by the HIPAA Privacy Standards..."

2. Review of the "Patient Information Form," revealed Patient #31's name, room number, social security number, date of birth, next of kin information, and insurance information.

3. Review of the "Text Message," dated 12/3/2024 at 9:03 AM, revealed Patient #31's Patient Information Forms which contained personal information. The text of Patient #31's Patient Information Forms was provided by Patient #22's Family Member #3.

4. Review of the "Complaint Form," dated 11/4/2023, revealed "...I [Patient #22] also received someone else's case paperwork when being dismissed. I [Patient #22] had the lady [Patient #31] in room [Named room number] personal information (emergency number, her address, phone, [Named Insurance] ID [identification], social security number)..."

5. Review of the email dated 11/11/2023, revealed "...The below action still needs to occur...were you able to determine the identity of the lady [Patient #31] in [Named room number]...Can provide the name of the nurse who provided the discharge instructions to [Named Patient #22]..."

6. During a telephone interview on 12/2/2024 at 3:33 PM, Family Member #3 [for Patient #22] was asked to tell me about the incorrect information she received at discharge from the hospital. Family Member #3 stated, "...right before we got ready to leave the hospital...they brought me all these papers, and I saw it had some other lady's stuff [Patient #31]...I kept that too...it had the lady's social security number, telephone number and all her insurance information..."

During a telephone interview on 12/30/2024 at 4:13 PM, the Vice President of Quality stated the hospital was unable to to identify the person whose records were compromised.

The hospital failed to ensure the HIPAA privacy of Patient #31's personal information. The hospital failed to identify and inform Patient #31 that her personal information was disclosed to Patient #22 and her family.

Based on medical record review and interview, the nursing staff members failed to ensure the patients were observed and monitored during seclusion and after medication administration for 2 of 3 (Patient #1 and #23) sampled patients reviewed for behavioral management.

The findings included:

1. Review of the facility policy titled "Patient Restraint/Seclusion," dated 11/2024, revealed "...This policy/procedure applies to health care professionals operating within... Healthcare facilities that have responsibility for ordering, assessing... monitoring... Patient in... seclusion... must have an individual performing and documenting real time... This can be evidenced through a monitoring log or form or electronic means to determine these checks were performed..."

2. Review of the medical record revealed Patient #1 was admitted on 11/11/2024 with diagnoses of Paranoid Schizophrenia, Bipolar Disorder, Borderline Personality and Homelessness.

Review of the "Physician's Orders," dated 11/11/2024, revealed, "...Suicide precautions... Observation time... Line of sight... Midazolam [Versed - medication used to produce sleepiness or drowsiness and to relieve anxiety] Inj [injection]...Dose...5 MG [milligrams]...IM [intramuscular]..."

Review of the "Physician's Orders," dated 11/13/2024 revealed "...Midazolam Inj... Dose... 10 MG... IM... Ziprasidone [Geodon - psychotropic medication used to treat symptoms of schizophrenia and acute manic or mixed episodes associated with bipolar disorder] Inj (Geodon Inj)... Dose... 20 MG...IM...RESTRAINTS...Violent restraint device...Seclusion...4 hours..."

Review of the "Current Hospital Medication," revealed "...11/11/2024...10:23 PM ...Midazolam... (VERSED)... 5 MG... X1ED...IM..."

Review of the "ADMINISTRATION PERIOD," dated 11/11/2024, revealed "...VERSED 5 MG/1 ML [milliliter]...IM...Right Upper Arm 22:22 [10:22 PM] GAVE 5 MG..."

Review of Emergency Note dated 11/12/2024 revealed "...PT [patient] CONTINUALLY COMING OUT OF TREATMENT ROOM, COMING TO NURSES STATION DEMANDING TO LEAVE. PT PROCEEDS TO BANG ON WINDOW OF NURSES STATION AND SCREAMING IN THE HALLWAY...PT ALSO SEEN PEEKING INTO OTHER PT TREATMENT ROOMS. SECURITY CALLED TO ASSIST GETTING THE PT BACK TO TREATMENT ROOM. BEHAVIORAL HEALTH NURSE RESPONDED AND ATTEMPTED TO DEESCULATE [De-escalate] PT. PT PROCEEDED TO SCREAM AND BANG ON WALLS/DOORS. SECURITY ARRIVED AND SUCCESSFULLY GOT PT BACK INTO TREATMENT ROOM. PT IS NOW ON SECLUSION ORDERS..."

Review of the "ADMINISTRATION PERIOD," dated 11/13/2024, revealed "...VERSED 5 MG/1 ML...IM...Left Hip 11:41 [11:41 AM] GAVE 10 MG..."

Review of the "ADMINISTRATION PERIOD," dated 11/13/2024, revealed "...GEODON...20 MG IM...Left Hip 11:41 [11:41 AM] GAVE 20 MG..."

Review of the "Follow-up Note," dated 11/13/2024 revealed "...Today the patient had to be sedated due to inappropriate behavior..."

Review of the Follow up Note dated 11/14/2024 revealed "...Today the patient is up walking around peering in [named patient]'s window...During follow up we asked the patient about the encounter she had with the pt in [patient's room number]. She began to laugh and states "women are mystical creatures we have the power of the gods, but only when we know we have the goods we can control men and get them to do what we want from them." The patient presents in a manic state she believes that she can control men with her sexual allure. Her speech is rapid she has been presenting with hypersexual behavior with an elevated confidence accompanied by being provocative, attention seeking, removing her own clothes and exposing herself to the men in the POD [psychiatric unit in the Emergency Department]..."

There was no documentation provided that Patient #1 was monitored during seclusion and following the administration of medications for behavioral management.

3. Review of the medical record revealed Patient #23 was admitted on 11/12/2024 with diagnoses of Restlessness and Agitation, Psychosis, Anxiety Disorder, Insomnia, and Homelessness.

Review of the "ADMINISTRATION PERIOD," dated 11/12/2024, revealed "...HALDOL [antipsychotic medication used to treat mental/mood disorder]... 5 MG IM... Right Outer Thigh 22:41 [10:41 PM] GAVE... 5 MG... ATIVAN [medication used to treat anxiety disorders]... 2 MG IM... Right Outer Thigh 22:41 [10:41 PM] GAVE... 2 MG... BENADRYL [antihistamine which can cause drowsiness]... 50 MG IM... Right Outer Thigh 22:41 [10:41 PM] GAVE... 50 MG..."

Review of the "ADMINISTRATION PERIOD." dated 11/13/2024, revealed "...ATIVAN... 2 MG IM EVERY 6 HOURS AS NEEDED... Both Hips 10:39 [10:30 AM] GAVE... 2 MG..."

Review of the "ADMINISTRATION PERIOD," dated 11/14/2024, revealed "...GEODON... 40 MG PO [By mouth] TWICE DAILY... 23:11 [11:11 PM] GAVE 40 MG..."

Review of the Psychiatric Consultation Noted dated 11/14/2024, revealed "...Psych [Psychiatric] Consult HPI [History of Present Illness]... Pt is a 30yo [30-year-old]... with a past psych hx [history] of schizophrenia who presents for capacity eval [evaluation]. Pt is in the hospital for reported being disorganized and erratic... In hospital, Pt has been manic, hyper-verbal, restless, easily agitated, appears to be responding to internal stimuli. Pt also has grandiose delusions..."

Review of the Follow UP dated 11/14/2024, revealed "...This writer asked patient about an incident that happen today with another female patient in the pod. I asked patient if had any sexual activity with female patient. Pt said, "that's over, I know we can't do anything here". I asked patient to tell me about the incident, and patient described that female patient kept following him around, taking her clothes off, standing at his door. Pt said they were flirting with eachother [each other]..."

4. During an interview on 12/6/2024 at 8:44 AM, the management staff was asked to describe the process for monitoring of patients in seclusion and receiving medication considered as a form of restraint. The Regulatory Manager stated, "...The process is we are not fully electronic charting the component of the 15-minute checks are on paper...we don't have them scanned in the system... the break down is... documents are put in a basket and are picked up and scan into the legal records... we don't know where they are..."

During an interview on 12/6/2024 at 9:47 AM, the Regulatory Manager confirmed the facility was unable to provide documentation of the observation monitoring for Patient #1 and Patient #23.

The facility failed to monitor patient in seclusion and following the administration of medications used for behavioral management.