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Based on observation, interview, and record review the facility failed to ensure that one of 30 sampled patients (Patient 16) was not physically and verbally abused by staff during his stay in the Outpatient Behavioral Health Center (OBHC).

This deficient practice infringed (break or limit) on the patient's right to humane treatment which could affect the psychosocial well-being of the patient.

Findings:

During a tour of the OBHC, on 2/24/2021 at 2:00 p.m., surveyors were greeted by security staff at the entrance which was locked. To the right, after entering the facility, there were two rooms with locked doors. One room was designated as the Consultation Room which is used to gather information after patients are admitted, the other room was designated as the treatment room. In the back of the facility were 12 beds for patient separated approximately 10 feet apart. There was storage for patients' personal belongings in lockers along the walls; there were locked rooms for food, linen, and supplies. Surveyors were met by the Outpatient Behavioral Health Director at that time. The Outpatient Behavioral Health Director explained that all personnel working at the OBHC were recently hired after the incident involving Patient 16 and had no direct knowledge of this event.

During an interview, on 2/24/2021 at 1:20 p.m., the Risk Manager recounted the events that led to the alleged abuse of Patient 16. Patient 16 was admitted to the OBHC on 9/22/2020. Patient 16 was met by security personnel at the entrance; Patient 16 was escorted to the Consultation Room where he was assessed for his needs. According to the Risk Manager, Patient 16 became verbally abusive with the LVN and a verbal argument started between the Patient 16 and the LVN. Juice was brought to Patient 16 whereupon the LVN swatted it out of Patient 16's hand; the patient was subsequently given another juice. After the assessment, Patient 16 was brought into another room; as he was leaving the Consultation Room, the Security Officer pushed Patient 16 into the other room. According to the Risk Manager, after the patient was pushed into the room there was verbal arguing between Patient 16 and the Security Officer. An order for medication for sedating medication was placed, the Security Officer hit Patient 16 with his knee, the patient was restrained, and medication was given.

A review of the document titled 'Risk and Integrity Services Investigation Report' supplied by the Risk Manager on 2/24/2021 indicated that all the staff members involved with Patient 16, during the incident in the Outpatient Behavioral Care Center on 9/24/2021 (RN 8, LVN, Security Officer, LVN 2, RN 9, LVN 3, Public Safety Officer) violated the facility's 'Code of Conduct'. Additionally, this report indicated that Security Officer violated the facility's 'Use of Force' policy during this event. A review of 'Notice of Discharge' verified that these eight staff members were relieved of employment at this facility.

A review of the policy titled, "PSJH-RIS-753 Use of Force," with a last revised date of 3/2020 indicated that the use of force is governed by U.S. Supreme Court case Graham v. Connor, 490 U.S. 386 (1989) which established reasonableness of the use of force. According to this case, the factors for determining reasonableness were: severity of the crime, whether the subject was an immediate threat to others, how the subject was resisting arrest, how the subject was attempting to evade arrest. Furthermore, the document details the 5 levels of use of force to be implemented in a given situation (Presence, Soft Techniques, Hard Techniques, Less-lethal Force, Lethal Force); Level 5, Lethal Force, was reserved for instances where there was imminent danger of serious injury or death; The use of firearms, strikes to sensitive areas were examples of lethal force in the document.

A review of the policy titled, 'Outpatient Behavioral Health Center (OBHC) Patient Rights,' with a last revised date of 8/2017 indicated the following: Patients with mental illness have the same legal rights and responsibilities that are granted all other persons under Federal and State law/regulation. Specifically, these documents stated that persons cannot be denied the right to be free of abuse or neglect.

A review of the, 'Education Plan for OBHC and Security Caregivers' reported that education was given to staff of the OBHC after the incident on 9/22/2020. Two days, 10/5/2020 and 10/6/2020, were set aside to educate15 staff members about seclusion (isolation of patients from others for the purpose of managing violent or self-destructive behavior), restraint assessment, de-escalation (process used to decrease the emotional, behavioral, and mental intensity of a situation), face-to-face interviewing of patient, roles of staff in the facility. There were guest speakers and a posttest were taken by attendees.

Based on observation, interview, and record review the facility failed to secure private information of six of seven patients (Patient 32, Patient 33, Patient 34, Patient 35, Patient 36, Patient 37) while they were treated in the Emergency Department (ED, designated unit of the hospital where patients with injuries needing immediate attention are treated). This failure had the potential for unauthorized access to protected helath information of these patients.

Findings:

During a tour of (ED), on 2/24/2021 at 10:10 a.m., there was a monitor mounted on the wall at the nursing station. The nursing station in the ED was surrounded on 3 of the 4 sides by glass panels; the remaining side was open so that physicians and other staff could enter. At the far end of the nursing station there was a monitor mounted high on the wall. The monitor displayed the status of patients currently in the ED. The complete names, ages, legal sex and their complaints for their emergency room visit were shown on the monitor. These information were visible when standing close to the glass sides of the nursing station.

During an interview, on 2/24/2020 at 10:15 a.m., the ED Director stated that she could not see the names from outside the glass enclosed nursing station. When she walked closer to the glass enclosed nursing station, she acknowledged that she could see full names and chief complaints of the patients. She verified that personal information should not be available to those who are not directly treatment patients even though there were no visitors allowed in the ED.

A review of the facility's document titled, 'PSJH-RIS-850 General Privacy Policy,' with last reviewed date of 4/2020, indicated the following: the facility will protect all individually identifiable health information that is transmitted directly or through a third party (entity with which the facility contracts for services). This includes all forms of electronic, written, or written information relating to the patient's present, past, or future state of physical or mental health.

A review of the Facility's document titled, 'PSJH-RIS-801 Information Security Management,' with last reviewed date of 4/2020 indicated that all authorized users with access to PSJH confidential and internal use information and information systems are responsible for understanding and adhering to safe practices to secure these critical assets.