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Based on a review of patient rights documentation, medical records, and observation on the behavioral health unit it was determined that the hospital was out of compliance with the Condition of Patient Rights. The hospital failed to protect the privacy of patients on the behavioral health unit by continually monitoring them in their rooms, failed to use and release restraints within regulatory parameters, failed to train staff who apply restraints in how to recognize distress, and failed to protect the rights of a patient in the emergency department who was catheterized by a nurse without a physician/LIP order, without the patient's consent, and apparently without asking the patient to urinate independently.

Based on a review of hospital policy, 10 open and 5 closed patient records, it was determined that the hospital failed to assess whether patient #1 lacked decision making capacity or certify an incapacity prior to obtaining multiple consents by patient # 1's surrogate decision maker.

Per hospital policy titled, "Informed Consent" (10/17/17) section 18 b. "Incapacity should be determined by the attending physician and a second physician, one of whom shall have examined the patient within 2 hours of the determination of incapacity and shall certify in writing that the patient is incapable of making an informed decision regarding treatment. The certification shall be based on personal examination of the patient. If a patient is unconscious or unable to communicate by any means, the certification of a second physician is not required."
Patient #1 was an 80+ year old patient who was admitted to the hospital for anemia and respiratory distress. Patient #1 was on a ventilator and non-verbal. Per physician progress notes, patient #1 was able to squeeze the providers hand when asked. Review of patient #1's record revealed six consents that included anesthesia, push enteroscopy, arteriogram, esophagogastroduodenoscopy and capsule endoscopy obtained from the patient's spouse.

There was no mention in the record that patient #1 was unable to make their own decision or a certification of an incapacity prior to obtaining multiple consents from a surrogate. Based on this the hospital failed to honor the patients right to make informed decisions about their care.

Based on observations of care on the behavioral health unit, interviews and review of behavioral health rights information, and policies including "Rights and Responsibilities of Patients (eff. 10/2016) it was determined that the hospital failed to provide privacy to 24 of 24 behavioral health unit patients when it, 1) video monitored all patients in their bedrooms with no clinical justification; and 2) made no provision for patient consent or a right to privacy notification.

Interview with the unit manager on August 7, 2018 at approximately 1100 revealed the unit had a total of 24 beds with a current census of 24 patients. The manager stated that all bedrooms are video monitored at all times. This fact was verified by observation of rooms and the central monitor present in the nurse's station. Query to the clinical director of the behavioral health unit and emergency department as to why patient bedrooms were monitored returned a response that there had been incidents of patient attacks on staff who had entered patient rooms alone. Further query as to how remote monitoring of bedrooms over in-person patient assessments and other precautions such as the supplied panic buttons would prevent such attacks failed to elicit a definitive response.

Tour of the nursing station revealed a large video monitor with feeds from each patient bedroom. While multiple staff were present in the nursing station, no single assigned staff person was observed actually monitoring the video feeds. The nurse's station monitor revealed the interiors of multiple bedrooms, many of which were occupied by patients. In one room, a patient was observed in the process of changing clothes. It was also noted that multiple diverse hospital staff occupied the nursing station, which made it possible for any clinical or non-clinical staff to view the bedroom of any patient at any time.

Review of the behavioral health patient admission booklet and other unit rights documents revealed no notification that patients had a right to privacy. However, the patient admission booklet stated that "Every patient has the right to: ...Be treated in a humane fashion ...Receive appropriate assessment. These rights were not honored where personal privacy was continuously violated, and where no credible assessment parameter was met by viewing patients on a screen.

Review of the hospital "Rights and Responsibilities of Patients (eff. 10/2016), revealed in part, Privacy and Confidentiality: Patients have the right to personal and informational privacy including: .... Patients should be interviewed and examined in surroundings designed to assure reasonable visual and auditory privacy." The hospital failed to protect this right by routine video monitoring of every patient bedroom.

Additionally, a unit policy entitled "Inpatient Responsibility Levels" (reviewed 10/2017) revealed in part, "All patients will be minimally observed every 30 minutes." Based on assessment, patients could also be observed every 15 minutes, have Day hall restriction, or Constant Observation which implied that the patient "will be within eyesight at all times including bathroom, shower and at bedtime. Camera monitors will not be utilized for this level of observation unless constant observation is part of the Day area restriction." This policy had not been updated following recent construction on the behavioral health unit, during which the cameras were added to each patient room. The hospital could provide no current policy delineating the reasons for continuous monitoring, who was to monitor, what types of behaviors would be reported to the RN or charge nurse, and if, or when, cameras would be turned off.

This policy stratified observation levels based on assessed patient acuity which progressively, and for clinical reasons resulted in reduced privacy for individual patients. However, the hospital had already and without clinical rationale, taken all rights to privacy from patients by monitoring their bedrooms regardless of clinical status or assessment of observed behaviors. Further, staff interviews confirmed that the unit had no policy for, nor practice of, asking for or documenting patient consent to such intrusive video monitoring. Only laminated signs, non-specific to the video-monitoring in bedrooms suggested to patients that video monitoring was occurring on the unit.

In summary, the hospital had the expertise, policies, and resources to make appropriate, in-person assessments of patients and then manage and monitor patients found to have dangerous behaviors. However, the hospital chose to violate the rights of behavioral health patients when, on an ongoing basis, they failed to give notice of, receive consent for, or promote the personal privacy of 24 patients who were continuously video monitored in their bedrooms. In doing so, the hospital demonstrated a gross and stigmatizing lack of respect for behavioral health patients whose rights to privacy were violated without consent or clinical rationale. In addition, it was difficult to determine how the mere presence of cameras, the output of which was not monitored in real-time, met the stated goal of keeping staff safer.

Based on interview, a review of the hospital Use of Force policy along with training content for various levels of security personnel, and record review for patient #4, it was determined that 1) the hospital Use of Force policy had no provision for clinical oversight during the use of force on patients; and 2) that the hospital employs Emergency Room Police Officers (ERPO) who may be called upon to utilize manual restraint, but do not receive hospital approved restraint training subject to clinical oversight. In addition, a hospital RN performed an invasive urinary catheterization of restrained patient (#15) without a physician's order to do so.

Review of the hospital Use of Force policy (revised 2/17) revealed in part, "Hospital police and security officers and all staff members may only used (sic) approved patient restraint techniques and devices that have been authorized for patient care activities." The policy also stated that use of force could span a range of activity from officer presence to deadly force. There was nothing in the policy indicating how to differentiate patients from non-patients, nor how or when to obtain clinical oversight when the use of force was applied to a patient.

In an interview on 8/7/18 at approximately 1000 a security manager stated that the hospital employs ERPOs who may have occasion to conduct manual restraint. Further review revealed that the hospital failed to train ERPOs in hospital approved restraint methods to which clinicians can give oversight. The lack of hospital direction and restraint training allowed any ERPO to restrain at the ERPO's discretion, using any restraint method, without any oversight by clinicians.

Patient #15 presented by self to the emergency department in July 2018. Patient #15 became a danger to self and other and was placed in 4-point restraints from 2012 through 0246 of the following day.

An RN entry at 2200 under "Behavior While Restrained, Violent," noted patient #15 to be "Abusive-physical, Agitated, Threatening." Documentation at 2215 under "Violent Restraint Hygiene/Elimination" noted, "Other: pt straight-cathed @ 2200." Review of orders revealed no order for urinary catheterization. A "Toxicology Screen Urine" order of 1817 revealed no direction to catheterize, though urine toxicology results were noted shortly after the catheterization at 2209.

No evidence was found that the RN asked restrained patient #15 regarding his elimination needs, asked for a urine specimen, or offered patient a urinal. Instead, without consent or physician order, and at risk of infection/injury, the RN invasively catheterized agitated patient #15.

In summary, the hospital failed to make a provision for clinical oversight within the Use of Force policy, failed to train ERPO's in safe restraint techniques under clinical oversight, and allowed nursing to perform a catheterization on restrained patient #15 without orders to do so.

Based on a review of patient #7's restraint, it was determined that patient #7 was not released at the earliest possible time.

Patient #7 was an adult who was admitted involuntarily in July 2018 to the behavioral health unit following threats of harm to self in the community. On day one of admission, a telephone order for seclusion was obtained at 0121 due to manic behaviors manifested as pacing the halls and then going into the rooms of sleeping patients. When staff attempted to redirect, patient #7 became hypersexual with female staff, making interventions ineffective. Consequently, patient #7 became a severe disruption to the milieu.

Behavioral documentation between the time of seclusion initiation and 0915 revealed improving behaviors from initially "banging on door/walls" to "Agitated, unable/refusal to follow directions" and at times "Nonsensical" to "Cooperative, Pacing, Restless" at 0915. Documentation revealed that patient #7 was "Walked to the bathroom," but was not released from seclusion.

An RN narrative note of 0947 revealed "Patient remains restless, pacing in the seclusion room. Expressing tangential and delusional thoughts about magical items in empty styrofoam cup. Able to comply with instructions after repeated prompts. Used restroom. Vital signs taken. Able to eat breakfast. patient did not expose himself or present further inappropriate of hyper-sexual behaviors at this time. Will continue to observe, process with patient and evaluate with team to consider seclusion termination."

Based on the RN note, patient #7 demonstrated behaviors which were no longer dangerous and did not justify continued seclusion. The documented restlessness, pacing, and expressing tangential thoughts did not indicate dangerous or imminently dangerous behavior yet patient #7 was kept in seclusion.

At the initiation of seclusion, the RN documented that patient #7 was told the criterion for release, though no actual content of that criterion was documented. However, an RN note of 1002 stated in part, "Staff approached patient to review conditions that must be met in order for seclusion to be discontinued." The conditions for release included being respectful to others, no sexually inappropriate behavior, and following redirection. While staff reviewed the conditions with patient, he kept talking about various other topics. He showed poor concentration, but expressed a willingness to work with staff. The RN then documented "Unfortunately, he became unexpectedly angry during interaction and would bang intermittently on door. Pt is not safe to discontinue from seclusion at this time."

Notwithstanding the banging on the door, patient #7 had already met behavioral criterion for release due to no longer being an imminent danger to self or other. The documented criterion of being respectful of others was not specific to behavior, was subjective and was not a criterion for secluding any patient. The criterion of being able to "follow redirection" also failed to specify which refusal of direction would cause harm to self or other, and as stated did not honor the right of patients to say "No." None of the criterion as stated was sufficient reason to seclude a patient or to keep a patient in seclusion. Patient #7 was not released from seclusion until after 1400.

Based on a review of patient restraint records, it was revealed that the face to face assessments for patient #7 was not conducted within one hour, and; 2) for patient #7 and #15, face to face assessments variously failed to address all regulatory elements.

Patient #7 was an adult who was admitted involuntarily in July 2018 to the behavioral health unit following threats of harm to self in the community. Patient #7 was secluded at 0115 due to wandering into a patient room. Review of the restraint documentation revealed no face to face until 0330 when the order to continue seclusion was written.

Review of the paper face to face form used on the behavioral health unit revealed three headings for current patient behavior, physical assessment, and reason for seclusion/restraint. The form failed to note all four regulatory elements of the face to face inclusive of the patient response to the intervention and the need to continue or terminate the restraint or seclusion.

One rationale listed current patient behavior was "Psychomotor restlessness, agitation or combative behavior that interferes with medical plan" Neither psychomotor restlessness nor agitation justify a seclusion/restraint. Another element was written as, "Sedation does not permit assessment of patient's response to situation or stimulation and therefore the patient is considered at risk of harm to self or other given recent events necessitating seclusion or restraint." This statement failed to justify continuing seclusion/restraint where the sedation is the response and causes absence of imminently dangerous behaviors.

The electronic record of the emergency department did have a face to face section that included all four regulatory elements. However, the same check boxes for the "psychomotor restlessness ..." and "the sedation does not permit assessment ..." were found under the heading of "Current Situation."

Patient #15 presented by self to the emergency department in July 2018. Patient #15 became a danger to self and others and was restrained. An electronic face to face form was filled in for the Immediate Situation and the Patient Reaction, but was missing indications of the patient's medical/behavioral condition and whether patient #15 could be released from the intervention.

In summary, the hospital failed to complete a face to face within one hour of the intervention for one patient. The hospital also used two different forms, both with various elements which do not justify seclusion/restraint, and the hospital failed to complete a face to face for patient #15.

Based on a review of restraint training, it was determined that the hospital had no training enabling staff to identify when a restrained patient was in psychological or physical distress. Review of all educational materials related to seclusion/restraint failed to demonstrate education materials specific to determining when a patient was in distress.