HospitalInspections.org

Based on policy review, record review, and interview, the hospital failed to ensure that staff followed hospital policy and procedure in obtaining and completing the patient consent and treatment agreement for 2 of 9 (Patient 7 and 9) sampled patients. This deficient practice places any patient at risk of not understanding their individual rights.

Findings Include:

Review of a hospital policy titled "Patient Rights and Responsibilities," dated 04/05/2025, showed that every patient has the right to receive information necessary to give informed consent prior to the start of any procedure or treatment and the right to refuse care, treatment, and services.

Review of a hospital policy titled, "Consents-Admission and Informed," dated 12/28/23, showed that if a patient cannot make or share decisions, a health care agent (a person legally designated by a patient to consent) or a court appointed guardian may give consent for treatment. If the patient lacks a health care agent or guardian, a patient family member or other adult that is involved and knowledgeable about the patient, may "assent" for treatment. The assent of the family member or other individual should be documented in the chart, along with an explanation that the patient is not competent, and that no health care agent, guardian or health care directive is available. A witness to the signed consent must be an associate that saw the patient or other individual or listened to the conversation to give consent.

Patient 7

Review of Patient 7's current medical record showed an 81-year-old admitted on 08/17/25 at 9:32 PM for altered mental status (confusion). Further review of the medical record showed past medical history that included advanced dementia (general term for loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life), and stroke.

Review of Patient 7's consent for treatment form showed that it was signed on 08/17/25 at 10:16 PM by an individual other than Patient 7. Further review of the form failed to identify the individual's relationship to the patient, failed to identify the justification for the signature (patient unable/unwilling to sign), and failed to provide a hospital staff member as a witness to the signature as required per hospital policy.

Patient 9

Review of Patient 9's current medical record showed a 37-year-old admitted on 08/18/25 at 2:00 PM with a diagnosis of Bipolar affective disorder (extreme mood swings, including emotional highs and lows).

Review of an undated document titled, "Letters of Guardianship and Conservatorship," showed that Patient 9 had a guardian and conservator.

During an interview on 08/26/25 at 9:45 AM, Staff A, Regulatory Manager, verified that Patient 9 had a guardian prior to the admission on 08/18/25 at 2:00 PM.

Review of Patient 9's, "Treatment and Consent Agreement," showed the form was not signed until approximately 24 hours after admission. Further review of the consent showed the hospital allowed the patient to sign the consent. The hospital failed to ensure the consent was signed by the guardian as required per hospital policy.

During an interview on 08/21/25 at 11:36 AM, Staff E3, Consumer Access Representative, stated that consents should be obtained on every patient visit.

During an interview on 08/21/25 at 1:59 PM, Staff S2, Consumer Access Supervisor, stated that if a patient arrives with an altered mental status or is unable to sign a new consent, the system will automatically fill in a consent form using the patient's signature, provided that the patient has visited this hospital system within the past calendar year.

During an interview on 08/21/25 at 1:59 PM, Staff V2, Manager of Consumer Access, stated that if a caregiver or someone else with portal access is involved in a patient's care, they may be able to sign the consent forms on behalf of the patient. In certain situations, especially for patients who do not have the capacity to consent, staff would need to review the emergency contacts to identify the legal guardian or decision-maker.

Based on observation, record review, and interview, the hospital failed to ensure the patient's right to personal privacy and failed to notify patients and/or patient representatives that video monitoring/surveillance and recording was taking place for 7 of 7 unidentified patients while in the hospital behavioral health area of the Emergency Department (ED). This deficient practice places any patient receiving care in the behavioral health area of the ED at risk for personal privacy violations.

Findings Include:

Review of a hospital policy titled, "Patient Rights and Responsibilities," dated 04/05/2025, showed that patients have the right to be informed of policies and practices that relate to patient care and treatment responsibilities and the right to confidentiality, privacy, and security as well as an environment that preserves dignity and contributes to a positive self-image. Further review of the policy failed to show that patients would be notified if they required video monitoring/surveillance or that such monitoring may be recorded.

An observation on 08/18/25 at 11:29 AM, showed that video monitoring of the behavioral health area of the ED was not protected in such a way as to prevent unauthorized persons from being able to view the occupied patient care areas. Observation also failed to show any type of notice, such as signage, that video monitoring and recording is in process.

An observation on 08/21/25, at 11:40 AM, showed the BHAC area of the ED had seven patients present. During this observation, multiple visitors walked past the monitoring screens and had the potential to view the occupied patient care areas.

During an interview on 08/14/25 at 4:19 PM, Staff Y, Security Manager, stated that cameras located in the Behavioral Health Assessment Center (BHAC) of the Emergency Department (ED) record and save video footage of patients in their personal care area.

During observations from 08/18/25 at 11:30 AM through 08/21/25 at 12:20 PM, multiple patient care units were noted to have large monitors that were located at the main nursing station area that displayed patient identifying information. This information included the patient's room number, initials, age, gender, attending physicians, and expected discharge date. The displayed health information was easily viewable by anyone walking past the nursing station areas.

Based on interview, record review, and facility policy review, the hospital failed to ensure that the use of restraints was in accordance with regulation and hospital policy when it utilized the use of four bed rails and/or lap belts as restraints to reduce the ability of a patient to move freely for 2 of 9 (Patient 8 and 12) sampled patients. This deficient practice violated the patient right to be free of restraint and places any patient receiving services at this hospital at risk of unauthorized use of restraints that may lead to serious injury and harm.

Findings Include:

Review of a hospital policy titled, "Patient Rights and Responsibilities," reviewed 04/05/27, showed that patients have the right to be free from mental and physical abuse.

Review of a hospital policy titled, "Restraints," dated 05/01/25, defined a physical restraint as " ...any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely ..." The purpose of the policy was stated as, "To protect the patient from physical and psychological harm, loss of dignity, violation of individual patient rights and even death ..." Additionally, the policy stated that restraint my never be used for the convenience of the caregiver or as a substitution for supervision, coercion, discipline, retaliation, or as punishment.

Patient 8

Review of Patient 8's current medical record showed a 68-year-old admitted on 08/15/25 at 1:36 PM with the diagnosis of psychosis (mental state that causes loss of reality) and schizophrenia (chronic mental condition that can result in hallucinations, confusion, delusions, and paranoia).

An observation on 08/21/25 at 11:40 AM, showed Patient 8 in an Emergency Department (ED) psychiatric room bed with four bed rails up. Patient 8 was resting peacefully and showed no indication of behavior that would require the use of restraints.

Review of Patient 8's medical record failed to show documented evidence of an order for the use of restraints.

During an interview on 08/21/25 at 11:45 AM, Staff D3, Safety Attendant, stated that the use of four bed rails would be considered restraint use and should not be utilized.

Patient 12

Review of Patient 12's current medical record showed an 87-year-old who was admitted on 08/18/25 at 9:53 PM with a diagnosis of hematuria (blood in urine). The past medical history included anxiety, depression, hypertension (high blood pressure), and dementia.

An observation on 08/19/25 at 4:15 PM, showed Patient 12 sitting in a chair with a belt alarm around the waist. Patient 12 was unable to remove the belt and was observed leaning forward in a pulling motion, yelling out to the staff. An unidentified staff member explained that the use of the belt was to help keep the patient in the chair due to the patient's increased confusion.

Review of Patient 8's medical record failed to show documented evidence of an order for the use of restraints.

During an interview on 08/21/25 at 11:57 AM, Staff C3, Registered Nurse (RN), stated that a lap belt had been utilized on Patient 12. Staff C3 stated that Patient 12 had dementia and was unable to release the lap belt independently. Staff C3 acknowledged that because of Patient 12's physical and mental status, the use of the lap belt was considered an inappropriate use of a restraint.

Based on document review, review of the hospital organizational chart, and interview, the hospital failed to ensure that it had only one nursing service under the direction of only one Registered Nurse (RN). This deficient practice poses a potential risk for inconsistency in the application of services and oversight of staff.

Findings Include:

Review the Hospital's Database Worksheet, dated 08/11/25, showed another hospital (Hospital 2) providing inpatient services under the same Certification Number (CCN).

During an interview on 08/11/25 at 11:30 AM, Staff D, Administrative Director, stated that another 96-bed hospital, Hospital 2 (H2), was opened under the same Certification Number (CCN) on 07/15/25.

Review of the hospital's organizational chart dated 07/25/25, showed that the hospital employed a different Chief Nursing Officer (CNO) for Hospital 2 (H2).

During an interview on 08/19/25 at 12:48 PM, Staff A, Manager Regulatory Accreditation, confirmed the failure to have only one nursing service under the direction of a single CNO and acknowledged the employment of two CNOs, one at each hospital location.

Based on observation, policy review, and interview, the hospital failed to ensure nursing staff were responsible in securing a medication room that contained medications, biologicals, and supplies in a manner to prevent access by unauthorized individuals. This deficient practice has the potential for adverse outcomes that could negatively impact the health and well-being of any patient receiving services at this hospital.

Findings Include:

Review of a hospital policy titled, "Medication Administration," effective 04/05/25, showed that medications must be kept in a secure area or taken immediately to the patient.

An observation of the 5th floor on 08/20/25 at 3:40 PM showed that a medication room containing medication and medication supplies was not closed and locked securely to prevent access from unauthorized persons.

An observation of the 5th floor on 08/20/25 at 3:40 PM and again on 08/21/25 at 12:01 PM, showed that an unlocked clean utility room that contained medication (normal saline used for IV administration) and medication supplies was not closed and locked securely to prevent access from unauthorized persons.

During an interview on 08/20/25 at 3:45, an unidentified Registered Nurse (RN), stated that he/she was unaware that the medication room was open and confirmed that the medication room should not be accessible to unauthorized persons.