HospitalInspections.org

Based on medical record review and interview, the facility failed to ensure privacy for one patient (#1) of five patients reviewed.

The findings included:

Patient #1 (named patient) was admitted to the Senior Behavioral Health Unit (SBH) from the Emergency Department (ED) on January 18, 2011, with the Chief Complaint of 2 weeks duration of increased Depression with thought of cutting wrist but no current suicidal thoughts.

Medical record review of the ED Physician's note, dated January 18, 2011, at 3:20 p.m., revealed "...Suicidal thoughts, depressed, paranoid...past history of suicide attempts...admitted..."

Medical record review of the Physician's Order, dated January 18, 2011, at 4:00 p.m., revealed "...fall and suicide precautions (monitor every 15 minutes)..."

Medical record review of the Care Plan, dated January 18, 2011, no time noted, revealed "...Hopelessness...Q 15 minute checks for safety and observation...Assess for specific plan for self harm..."

Medical record review of the q (every) 12 hr (hour) Nursing Care Flowsheet, dated January 18, 2011, at 5:00 p.m., revealed "...admitted from home due to depression with suicidal ideation of cutting wrist. Has had sev (several) attempt in the past. Contracted for safety..." Continued review revealed the patient was placed on q 15 min (minute) suicide and fall precautions per physician's order. Continued review of the daily Nursing Flow sheets revealed documentation the patient was monitored q 15 min from admission through discharge.

Review of the Nursing Flowsheet, dated January 21, 2011, at 2:00 p.m., revealed "...told OT (Occupational Therapy) that she had tried to cut her wrists this morning with a plastic knife. Patient has small red marks on wrists...states she was not trying to kill herself, but she just wanted to know to see what it felt like. Patient was told she would need to be within staff eye sight at all times, and patient was put in a geri-chair in front of the nurse's station. Continued review revealed at 7:30 p.m., the patient "...went back in her room lying in bed...Advised patient she would have to come back out in front of nurses station for observation because of suicide observation...patient and bed brought out in front of nurse's station..." Continued review revealed at 9:30 p.m., the patient was "...awake, lying in bed in front of nurse's station..." Continued review revealed at 12:00 a.m., the patient was "...resting quietly in bed with eyes closed. Continued review revealed on January 22, 2011, at 5:00 a.m., the patient "...remained in front of nurse's station for close observation...resting quietly with eyes closed..." Continued review revealed at 9:15 a.m., the patient "...in sight of staff...denied any suicidal ideation ..."

Medical record review of the physician's note, dated January 22, 2011, at 1:32 p.m., revealed "...constant observation for using plastic knife on wrists...denies suicidal ideation..."

Interview, in the conference room on October 27, 2011, at 11:00 a.m., with the Chief Nursing Officer and the Nurse Manager of the Senior Behavioral Health Unit, confirmed the patient's privacy was not ensured during the time the patient was made to be in front of the nurse's station during the day and into the night of January 21, at 2:00 p.m. until January 22, at 1:32 p.m., 2011.

C/O #27590

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