HospitalInspections.org

Based on policy and procedure review, patient medical record review and interview, the facility failed to ensure patients and/or their representatives, were informed of patient rights for 5 of 5 records reviewed (Pts. N1 through N5).

Findings:
1. t 12:25 PM on 12/17/10, review of the policy titled: "Patient Rights & Responsibilities" "Applicable To: All Departments and Medical Staff" "Policy/Procedure #: ADM 550" with a "Date Reviewed: 11/2003" and a "Date Revised: 12/2004", indicated:
a. this document has 22 items (pt. rights) listed on 3 pages

2. At 12:30 PM on 12/17/10, review of the policy titled: "Patient Rights" "Applicable To: Behavioral Health Services" "Policy #: BH 04.001" with a "Date Reviewed: 03/10" and a "Date Revised: 03/10", indicated:
a. this document has 18 policy statements (rights) listed under section 2.0, F. and the policy is 2 pages long

3. Beginning at 12:30 PM on 12/17/10, review of patient closed medical records indicated that patients or their representatives were given, and signed, a copy of "Patient's Legal and Human Rights" LHN Behavioral Health Form Number 1600-0001-39 with a Rev. date of 04/24/07, that does not match either policy listed in 1. and 2. above

4. Interview with staff members NA and NF at 3:30 PM on 12/17/10 indicated:
a. the patient rights policies (1. and 2. above) are the current patient rights documents
b. the policies in 1. and 2. above do not read the same
c. the patient rights document signed by patients or their representatives upon admission to the behavioral unit do not match either of the policies in 1. and 2. above (the document in the patient chart has 27 patient rights listed)
d. it cannot be determined that patients and/or their representatives received copies of their rights based on the document given versus those that were indicated as the current patient rights policies

Based on policy and procedure review, patient medical record review, other facility document review and interview, the behavioral unit failed to ensure the privacy of one of 5 patients (pt. N3).

Findings:
1. At 12:25 PM on 12/17/10, review of the policy titled: "Patient Rights & Responsibilities" "Applicable To: All Departments and Medical Staff" "Policy/Procedure #: ADM 550" with a "Date Reviewed: 11/2003" and a "Date Revised: 12/2004", indicated:
a. under "Procedure", number 11., "The patient has a right to privacy and confidentiality..."

2. Beginning at 12:30 PM on 12/17/10, review of closed patient medical records indicated that pt. N3:
a. had a form titled "Patient's Legal and Human Rights" that stated: "1. You have the right to be treated with dignity and respect...2. You have the right to privacy in your treatment, in your care, and in the fulfillment of your personal needs..."
b. had documentation on the "Patient Variance Record" form :
I. on 9/16/10 at 8:30 AM, that read: "...Stated 'They said I slept all NOC [night] but '[other pt]' continues to come into my room. I can't get to understand to stay out or go away. I took my Kleenex box et struck it against my knee. So I really didn't truly fall asleep until 1:00 AM'"
II. on 9/18/20 at 12:35 AM, that read: "addendum for 9/17/10 23:30. Pt heard asking for assistance and room mate ringing bell at 21:30. Staff responded immediately and discovered...peer holding onto bathroom door handle. Peer was assisted out of room. Tech went back to room to check on pt who reported...had been startled and frightened...by peer at bathroom door. Pt...reported...was okay, but frightened..."

3. At 11:40 AM on 12/17/10, review of the incident/event reports related to pt. N3 indicated:
a. on 9/17/10 at 9:30 PM in room 625 (bed 2), "Staff heard bell and call for assistance. Found [opposite sex] peer holding door handle to pt. bathroom. Peer assisted out of room. Pt. reassured by tech. Pt later reported back pain from twisting when startled by pt..."

4. At 11:00 AM on 12/17/10, interview with staff member NC indicated:
a. there is no facility policy related to wandering patients and how to maintain other patients' privacy and safety in regard to such wandering

5. Interview with staff member NF at 11:35 AM and 3:30 PM on 12/17/10 indicated:
a. this staff member was the "Administrator on call" the night of 9/17/10 and received a phone call from pt. N3's spouse in regard to another patient, of the opposite sex, having been in N3's hospital room and, and bathroom, and frightening them
b. pt. N3 had their rights to privacy violated when another patient entered their room on two separate, known, occasions (9/16/10 and 9/17/10)

Based on policy and procedure review, patient medial record review, other facility document review, tour of the gero psych unit and interview, the behavioral health unit failed to ensure that care was received in a safe setting for one of 5 patient records reviewed (pt. N3).

Findings:
1. At 12:25 PM on 12/17/10, review of the policy titled: "Patient Rights & Responsibilities" "Applicable To: All Departments and Medical Staff" "Policy/Procedure #: ADM 550" with a "Date Reviewed: 11/2003" and a "Date Revised: 12/2004", indicated:
a. under "Procedure", number 12., "The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned..."

2. Beginning at 12:30 PM on 12/17/10, review of closed patient medical records indicated that pt. N3:
a. had documentation on the "Patient Variance Record" form :
I. on 9/16/10 at 8:30 AM, that read: "...Stated 'They said I slept all NOC [night] but '[other pt]' continues to come into my room. I can't get to understand to stay out or go away. I took my Kleenex box et struck it against my knee. So I really didn't truly fall asleep until 1:00 AM'"
II. on 9/18/20 at 12:35 AM, that read: "addendum for 9/17/10 23:30. Pt heard asking for assistance and room mate ringing bell at 21:30. Staff responded immediately and discovered...peer holding onto bathroom door handle. Peer was assisted out of room. Tech went back to room to check on pt who reported...had been startled and frightened...by peer at bathroom door. Pt...reported...was okay, but frightened..."

3. At 11:40 AM on 12/17/10, review of the incident/event reports related to pt. N3 indicated:
a. on 9/17/10 at 9:30 PM in room 625 (bed 2), "Staff heard bell [dinner type bell, not bathroom call light] and call for assistance. Found [opposite sex] peer holding door handle to pt. bathroom. Peer assisted out of room. Pt. reassured by tech. Pt later reported back pain from twisting when startled by pt..."

4. At 11:00 AM on 12/17/10, interview with staff member NC indicated:
a. there is no facility policy related to wandering patients and how to maintain other patients' privacy and safety in regard to such wandering

5. Interview with staff member NF at 11:35 AM and 3:30 PM on 12/17/10 indicated:
a. this staff member was the "Administrator on call" the night of 9/17/10 and received a phone call from pt. N3's spouse in regard to another patient, of the opposite sex, having been in N3's hospital room and, and bathroom, and frightening them
b. wandering patients on a gero psych/dementia unit are "not unusual occurrences"
c. pt. N3 had their rights to feeling that care was being provided in a safe environment violated when another patient entered their room at night on two known occasions (9/16/10 and 9/17/10)

Based on patient medical record review and interview, the facility failed to ensure that documentation was accurate for one of 5 patient records reviewed (Pt. N3).

Findings:
1. Beginning at 12:30 PM on 12/17/10, review of closed patient medical records indicated that pt. N3:
a. had documentation on the "Special Observation Flowsheet" by the BHT (Behavioral Health Technician) that on 9/17/10, the patient was in "Patient Room" "Quiet" at 9:15 PM, 9:30 PM, and 9:45 PM with the patient having had "Position", "Pain" and "Bathroom" at 8:00 PM, 9:00 PM and 10:00 PM
b. had documentation on the "Special Observation Flowsheet" by the BHT (Behavioral Health Technician) on 9/17/10, at 10:15 PM, 10:30 PM and 10:45 PM that the patient was in the "Patient Room" "Sleeping"
c. had documentation by nursing on the "Patient Variance Record" form that read: "9/18/10 00:35 addendum for 9/17/10 23:30. Pt heard asking for assistance and room mate ringing bell at 21:30. Staff responded immediately...Pt. later came to nurses' station (22:00) and asked to use phone, left message for spouse..."

2. At 11:40 AM on 12/17/10, review of the incident/event reports related to pt. N3 indicated:
a. on 9/17/10 at 9:30 PM in room 625 (bed 2), "Staff heard bell [dinner type bell, not bathroom call light] and call for assistance. Found [opposite sex] peer holding door handle to pt. bathroom. Peer assisted out of room. Pt. reassured by tech. Pt later reported back pain from twisting when startled by pt..."

3. Interview with staff member NF at 3:30 PM indicated:
a. the hourly rounding consists of 3 P's: pain, positioning, and potty (bathroom) for patients on the unit
b. the documentation between the BHT and the RN (registered nurse) do not correspond as the patient was not in their room "quiet" between 9:30 PM and 9:45 PM when another patient had entered the room while pt. N3 was in the bathroom, blocked the doorway when pt. N3 attempted to leave the bathroom, and caused pt. N3 to twist their back in trying to get away from the intruder
c. the incident report generated by nurse P1, also indicates pt. N3 was not "quiet" in their room at 9:30 PM on 9/17/10
d. another discrepancy between the BHT charting and the nurse documentation is at 2200 hours when the nurse noted the patient was at the nurses' station calling a spouse due to the earlier episode and the trauma caused to the patient--the BHT charted the patient was checked for pain, position and bathroom and then at 10:15 was in their room and sleeping