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Based on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, "Patient Rights and Responsibilities" for 8 of 32 sampled patients (Patient 21, Patient 22, Patient 2, Patient 9, Patient 11, Patient 12, Patient 13, and Patient 14) when staff could not provide documentation of Patient Rights and Responsibilities (PRR) or Notice of Privacy Practices (NOPP) being provided. This failure had the potential for patients and their representatives not to be informed of their rights and responsibilities or privacy practices.

Findings:

During a review of the form titled, "Document Signature Checklist (DSC)," dated 6/23, the DSC indicated checkboxes for "Notice of Privacy Practices (NOPP)" and "Patient Rights & Responsibilities." The DSC indicated by signing the form, the patient or legal representative had received or refused a copy of the documents checked.

During an interview on 12/2/24 at 3:07 p.m. with Revenue Cycle Manager (RCM), RCM stated when patients register, the patients' rights and responsibilities should be reviewed verbally with the patient by the Patient Access Representative. RCM stated the DSC must be checked off to indicate patient rights information was discussed with the patient. RCM stated there was a handout for Patient Rights and an area on the DSC indicating if the patient received or declined copies of the handout. RCM stated without the checkmark on the DSC beside "Patient Rights & Responsibilities" and "Notice of Privacy Practices" we don't know if the patient got the information.

During a concurrent interview and record review on 12/2/24 at 3:31 p.m. with RCM, Patient 21's DSC, dated 10/17/24 at 7:03 p.m., was reviewed. The DSC indicated nothing was checked off on the document signature list. DSC box indicated, "have been offered but declined copies of documents checked from the above list" was checked off. RCM stated the form was signed by Patient 21's mother but there was no evidence that patient rights were discussed or patient received a copy of the NOPP. RCM stated it should have documented and the top three on the document signature list (Conditions of Admissions, Notice of Privacy Practices, and Patient Rights & Responsibilities) should have been checked off.

During a concurrent interview and record review on 12/2/24 at 3:37 p.m. with RCM, Patient 22's DSL, dated 10/17/24 at 10:19 p.m., was reviewed. Patient 22's DSC indicated nothing was checked off on the document signature list. DSC box indicated, "have been offered but declined copies of documents checked from the above list" was checked off. RCM stated the DSC was signed by the mother. RCM stated a copy of the signed NOPP dated 10/17/24 was found in Patient 22's medical record. RCM stated there was no verification or validation patient rights and responsibilities was discussed.



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During a concurrent interview and record review on 12/2/24 at 2:27 p.m. with Director of Informatics (Registered Nurse [RN] 2), the facility's form titled, "Document Signature Checklist (DSC)" for Patient 2 was reviewed. The DSC had checkboxes for "Notice of Privacy Practices (NOPP)" and "Patient Rights & Responsibilities (PRR)." RN 2 stated the check boxes were to indicate what was provided to the patient. The DSC also had a section with check boxes and a signature line to indicate if the Patient or Patient Representative had received or declined a copy of the documents checked. Patient 2's DSC had one box checked, and it was not for NOPP or PRR. RN 2 stated "This is all they did. It's (Patient Rights) not checked."

During a concurrent interview and record review on 12/3/24 at 2:17 p.m. with RN 2, the DSC for Patient 9 was reviewed. There was no check mark for PRR being provided to Patient 9. RN 2 confirmed the finding.

During a concurrent interview and record review on 12/3/24 at 2:25 p.m. with RN 2, the DSC for Patient 11 was reviewed. There was no check mark for NOPP and PRR being provided to Patient 11. RN 2 confirmed the finding.

During a concurrent interview and record review on 12/3/24 at 2:30 p.m. with RN 2, the DSC for Patient 12 was reviewed. There was no check mark for PRR being provided to Patient 12. RN 2 stated "Patient rights isn't checked."

During a concurrent interview and record review on 12/3/24 at 2:35 p.m. with RN 2, the DSC for Patient 13 was reviewed. There was no check mark for NOPP and PRR being provided to Patient 13. RN 2 stated there was no Patient Rights provided.

During a concurrent interview and record review on 12/3/24 at 2:51 p.m. with RN 2, the DSC for Patient 14 was reviewed. There was no check mark for NOPP and PRR being provided to Patient 14. RN 2 stated there was no documentation for Patient Rights being provided.

During a review of the facility's P&P titled, "Patient Rights and Responsibilities," dated 4/22, the P&P indicated, "V. PROCEDURE: A. Notification of Patient: 1. Patients will receive a copy of the Rights and Responsibilities upon admission/registration to inpatient and outpatient settings at [hospital]. (See Addendum A.) B. Overview of Patient Rights and Responsibilities: . . . 2. Patients have the right to: . . . q) Confidential treatment of all communications and records pertaining to the patient's care and stay in the hospital. The patient will receive a separate Notice of Privacy Practices that explains the patient's privacy rights in detail and how [hospital] may use and disclose PHI [protected health information]."

Based on interview and record review, the facility failed to:

1. follow their policy and procedure (P&P) titled, "Patient Safety Observation" for monitoring one of seven sampled patients (Patient 21) presenting to the Emergency Department (ED) with suicidal ideation and at high risk for self-harm. This failure had the potential for suicidal patients to harm themselves while in the ED.

2. follow their policy and procedure for reporting an allegation of abuse for one of one sampled patients (Patient 2). This failure had the potential to place Patient 2 at risk for further abuse.

Findings:

During a review of Patient 21's "Patient Information (PI)," dated 10/17/24 at 6:58 p.m., the PI indicated Patient 21 was registered in the ED at 6:58 p.m.

During a review of Patient 21's "Visit History Viewer (VHV)," dated 11/17/24 from 7:01 p.m. to 10/18/24 at 11:48 a.m., the VHV indicated Patient 21 was in the ED waiting room from 7:01 p.m. until 10:11 p.m. then moved to the ED bed designated as "OF11."

During a concurrent interview and record review on 12/2/24 at 2:53 p.m. with Registered Nurse (RN) 1, Patient 21's Columbia Suicide Severity Rating Scale (C-SSRS- validated tool used to determine a patient's risk for suicide) was reviewed. RN 1 stated Patient 21 was brought to the ED via private vehicle with suicidal ideation. RN 1 stated Patient 21 scored a "10- high risk" on the C-SSRS done by the triage nurse.

During a concurrent interview and record review on 12/2/24 at 3:40 p.m. with RN 1, Patient 21's "Emergency Documentation (EDD)," dated 10/17/24 at 7:51 p.m. was reviewed. The EDD indicated, "Patients presents with mother for SI [suicidal ideation] with plan of overdosing on ibuprofen [pain medication] or cutting herself. Patient texted her friend and her sister discussing the plan. Denies HI [homicidal ideation] at this time."

During a review of Patient 21's "Observation Log (OL)," dated 10/17/24, the OL indicated Patient 21's line of sight observation started at 10:45 p.m. and documentation continued every 15 minutes until Patient 21 was discharged on 10/18/24 at 11:39 a.m.

During a review of Patient 21's "Violent and Self-Destructive Restraint Flow Sheet (RFS)," dated 10/18/24, the RFS indicated Patient 21 was placed in 4 limb restraints for being a danger to self and others.

During a review of Patient 21's "Restraint/Seclusion Nursing Notes (RNN)," dated 10/18/24 at 1:10 a.m., the RNN indicated Patient 21 had removed plastic fasteners from the stretcher bedrails and attempted to use them to cut her arms. RNN indicated Patient 21 was banging her head and arms on the wall and floor and knocked a hole in the wall with her right elbow. RNN indicated Patient 21 kicked a security guard and attempted to bite and assault staff. RNN indicated after Patient 21 was placed in restraints she attempted to tip the gurney over.

During an interview on 12/2/24 at 4:54 p.m. with Director of Emergency Services (DES), DES stated Patient 21 came into the ED at 6:58 p.m. and remained in the waiting room after triage. DES stated Patient 21's suicidal monitoring observations did not start until 10:45 p.m. DES stated, based on the policy for a patient who is high risk for suicide, Patient X required a one-to-one (1:1) observation with documentation every 15 minutes, which was not documented in Patient 21's medical record until 10:45 p.m. DES stated if no bed was available in the ED, Patient 21's should have been placed in a "law enforcement chair (chairs within direct site of the nurse's station used by patients brought in by law enforcement)." DES stated that had always been the policy but there have been deviations in practice on the night shift.

During a concurrent interview and record review on 12/2/24 at 5:23 p.m. with RN 1, Patient 21's Medical Record (MR) was reviewed. RN 1 stated there was no documentation in Patient 21's MR of observation in the ED waiting room every 15 minutes.

During an interview on 12/3/24 at 11:06 a.m. with DES, DES stated Patient 21's suicide risk assessment was a "10" which was high risk and any patient with a risk assessment over "6" should have been brought back to the main ED. DES stated Patient 21 should have been brought back right away and had line of site and 1:1 observation, but wasn't brought back until 10:11 p.m. DES stated RN 3 told her Patient 21 was with her mom, so she had someone to watch her and keep her safe. DES stated the policy was Patient 21 should have been taken to the law enforcement area if no beds were available and observation should have been started.

During a review of the facility's P&P titled, "Patient Safety Observation," dated 7/23, the P&P indicated, "I. PURPOSE: To establish guidelines for the use of patient safety observers, both in-person and virtual, to ensure the safety of patients at risk of harm to themselves or others. . . C. In-Person Observation 1. Line of Sight Observation a) This observation level is utilized for patients, who exhibit potential for self-harm or harm to others, but do not require immediate intervention. B) Patient behavior, activity and safety will be observed and documented at least every 15 minutes and upon behavior change on Associated Form, #3115, In-Person Observation Log . . . 3. One to One (1:1) Observation . . . c) Have been screened as high risk for suicide utilizing the Columbia Suicide Severity Rating Scale (CSSRS) d) A 1:1 patient safety observer will be deployed to the bedside and suicide precautions will be implemented."


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2. During a concurrent interview and record review on 12/2/24 at 2:30 p.m. with RN 7, Patient 2's "Progress Note (PG)" dated 11/18/24 at 10:42 a.m. was reviewed. The PG indicated, "On 11/17/24 around 16:30 (4:30 p.m.) received complaints from pt's (patients) that it smelled like cigarette smoke in the room. Security was called and items removed from pt. Per pt security held both her wrists. Assessed a bruise to left wrist. . ." RN 7 stated the progress note was documented by RN 4.

During a concurrent interview and record review on 12/2/24 at 2:48 p.m. with RN 4, Patient 2's "Electronic Medical Record (EMR)" was reviewed. RN 4 stated Patient 2 said security held her wrist. RN 4 stated she notified the charge nurse and assessed the patient. RN 4 stated "It was a new bruise inside her (Patient 2) wrist."

During an interview on 12/2/24 at 3:01 p.m. with RN 4, RN 4 stated she didn't recall having Abuse training. When asked if she knew what to report, or who to report to, RN 4 stated "No."

During a concurrent interview and record review on 12/2/24 at 3:02 p.m. with RN 5, RN 5 stated she was the Supervisor of the Unit (2 Center). RN 5 reviewed the PG documented by RN 4. RN 5 stated she wasn't aware of the allegation. RN 5 stated "She (RN 4) should've notified the Charge Nurse, myself, and the House Supervisor."

During a phone interview on 12/3/24 at 8:58 a.m. with Security Officer (SO), SO stated there were calls from staff and patients on 2 center regarding smoke smell in room. SO stated staff knew who it was, and wanted me to let her know she couldn't smoke, and we needed to confiscate the cigarettes. SO stated "She (Patient 2) had a coffee mug with ashes and cigarettes." SO stated initially Patient 2 denied she was smoking, and finally admitted. SO stated Patient 2 was told "No Smoking" and she (Patient 2) threatened to punch staff and frailing (moving wildly) her arms. SO stated "I intervened grabbed both wrist, and told her she couldn't threaten staff." Patient 2 handed over the cigarette and matches, and I gave them to the nurse. SO stated "Patient 2 said she was going to complain, but I never heard anything." SO stated he made a report of the incident.

During a concurrent interview and record review on 12/3/24 at 9:18 a.m. with RN 6, RN 6 reviewed the PG documented by RN 4. RN 6 stated she told staff to call security to control the situation, because we told Patient 2 there was no smoking. Patient 2 continued to smoke and say it's her right. RN 6 stated she wasn't in the room with security and didn't know what happened. RN 6 stated "I wasn't aware of the alleged assault. Had I known an occurrence report would have been made, and notified his (security officer) superior."

During an interview on 12/3/24 at 10:20 a.m. with Director of Staff Development (DSD), DSD stated "We send new hires a video training to complete prior to their start date."

During a concurrent interview and record review on 12/3/24 at 10:29 a.m. with Human Resources Business Partner (HRBP), RN 4's Learning Transcript (LT) was reviewed. The LT indicated RN 4 Date of Hire was 1/2/24. RN 4 completed "New Hire Orientation 12/28/23, Abuse/Mandatory Reporting Requirements 1/4/24, and [Hospital] -All Staff Review 3/12/24."

During a review of the facility document titled "New Hire Orientation (NHO)" undated, the NHO indicated "Standard - Abuse, Neglect & Exploitation, The hospital must: Educate staff on reporting possible abuse . . ."

During a review of the facility document titled "[Hospital name] All Staff Review (ASR)" undated, the ASR indicated "Abuse, Neglect and Exploitation- Mandated Reporters are licensed employees. . . Policy ADM -PI-120 Sentinel/Adverse Events- . . . All staff have an obligation to immediately report any incident and/or allegation of abuse of a patient while in the facility. Upon identifying an allegation and/or incident, the individual will: Notify their immediate Supervisor."

During a review of the facility policy and procedure (P&P) titled, "Mandated Reporting Requirements" dated July 2024, the P&P indicated "Procedure: 2.a) Any mandated reporter . . .has observed or has knowledge of an incident that reasonably appears to be abuse . . . shall complete a verbal and written report for each report of known or suspected instance of abuse . . ."

Based on interview and record review, the facility failed to have a careplan for restraint use for one of six sampled patients (Patient 5). This failure resulted in interventions, goals, and expected outcomes not being developed.

Findings:

During a concurrent interview and record review on 12/3/24 at 1:29 p.m. with Registered Nurse (RN) 2, Patient 5's Electronic Medical Record (EMR) was reviewed. Patient 5's "Restraint for Non-Violent Behavior (RNVB)" order dated 11/15/24 indicated "Side Rails x (times) 4 Bilateral Soft Wrist." RN 2 reviewed the order and stated the restraint use was from 11/15/24 at 2030 (8:30 p.m.) to 11/16/24 at 0600 (6 a.m.). RN 2 reviewed the careplans for Patient 5, and there was no restraint careplan. RN 2 stated "They should have one (careplan for restraints)."

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Plan of Care (IPOC) (Non-Psychiatric Patients),"
review date February 2024, the P&P indicated "III. POLICY STATEMENT: It is the policy of [Hospital name] that all inpatients will have an interdisciplinary plan of care (IPOC) to assist in setting priorities of care that promote health, wellbeing and healing . . . V. PROCEDURE: A. The POC will consist of the following: 1. Actual or potential problems 2. Outcome/goals . . .4. Interventions. . ."

Based on observation, interview, and record review, the facility failed to ensure restraint orders for one of six sampled patients (Patient 4) were followed. This failure resulted in Patient 4 being restrained inappropriately.

Findings:

During a concurrent observation and interview on 12/2/24 at 11:46 a.m. in Patient 4's room, Patient 4 was in bed with Sitter at the bedside. Sitter stated Patient 4 was previously in a 4 point restraint, and doctor ordered 2 point restraint.

During a concurrent interview and record review on 12/2/24 at 4:15 p.m. with Registered Nurse (RN) 7, Patient 4's "Electronic Medical Record (EMR") was reviewed. Patient 4 's order for Restraint For Non-Violent Behavior (RNVB) dated 11/28/24 at 0245 (2:445 a.m.) was reviewed. The RNVB indicated, "Side Rails x (times) 4." RN 7 stated Patient 4 was seen in the Emergency Department (ED), and the ED Doctor ordered the restraints.

During a review of Patient 4's "Emergency Documentation- ED Note Physician (EDNP)" dated 11/28/24 at 6:06 a.m., the EDNP indicated, "Assessment/Plan, Restraint For Non-Violent Behavior, 11/28/24 2:45:00 PST (Pacific Standard Time), Altered Mental Status, Side Rails x 4 . . ."

During a concurrent interview and record review on 12/3/24 at 11:20 a.m. with RN 2, RN 2 reviewed Patient 4's restraint order dated 11/28/24, and stated it was for Side Rails x 4. RN 2 reviewed Patient 4's "Restraint Monitoring (RM)" dated 11/28/24, and the RM indicated "Restraint Type/Location, Soft Wrist, Bilateral w (with)/ side rails x4, Soft Ankle, Bilateral w/side rails x4. Restraint applied properly . . ."

During an interview on 12/3/24 at 11:46 a.m. with RN 2, RN 2 stated "What was ordered is not what was applied." RN 2 stated the EMR indicated RN 8 as the nurse who applied and documented the restraints.

During an interview on 12/3/24 at 11:58 a.m. with Director Emergency Services (DES), DES stated "We only have two siderails (on the beds)." DES stated the nurse needs to clarify the order (for restraints).

During a concurrent interview and record review on 12/3/24 at 3:22 p.m. with RN 8, RN 8 reviewed the RNVB order for Patient 4 to have Side Rails x 4. RN 8 stated "The doctor put it in wrong . . .maybe." RN 8 stated "I'm assuming the doctor gave a verbal order." RN 8 was unable to find documentation of verbal order given. RN 8 stated the doctor is new, "I should have clarified the order."

During a review of the facility's policy and procedure (P&P) titled, "Physician Orders (PO)" dated October 2022, the PO indicated "V. PROCEDURE: 7. Orders that are unclear or that do not comply with hospital policy will be clarified and corrected prior to implementation. In the event there are concerns or questions regarding a physician order . . .will immediately contact the physician for clarification."

Based on interview and record review, the facility failed to ensure two of six sampled patients (Patient 16 and Patient 18) in restraints were monitored according to the physician order. This failure had the potential to result in circulatory, motor, and sensory deficits.

Findings:

During a concurrent interview and record review on 12/3/24 at 4:10 p.m. with Registered Nurse (RN) 2, the Electronic Medical Record (EMR) for Patient 16 was reviewed. Patient 16 was admitted on 11/25/24. The order for Restraint for Non-Violent Behavior (RNVB) dated 11/27/24 at 2052 (8:52 p.m.) was reviewed. RN 2 stated the order was for behavior. The RNVB indicated "Reason for Restraint: Behavior interfering with medical care. Side Rails x (times)4, Bilateral Soft Wrist." The RNVB indicated "Restraint Monitoring Non-Violent Behavior Q(every) 2 hr (hour), Duration 24 hr." The monitoring sheet indicated to monitor for Behavior, Active ROM (Range of Motion -the range of movement at a joint that occurs when muscles contract and relax without assistance), and Passive (assist in moving muscles) ROM.

During a concurrent interview and record review on 12/3/24 at 4:20 p.m. with RN 2, the Restraint Monitoring was reviewed for 12/1/24. There was no documentation of monitoring at 0600 (6 a.m.). RN 2 stated "There's no monitoring for 6 a.m."

During a concurrent interviw and record review on 12/3/24 at 4:32 p.m. with RN 2, Patient 18's EMR was reviewed. Patient 18 was admitted on 11/23/24. Patient 18's order for RNVB dated 11/23/24 at 2046 (8:46 p.m.) was reviewed. The RNVB indicated "Reason for Restraint: Altered Mental Status. Bilateral Soft Wrist." The RNVB indicated "Restraint Monitoring Non-Violent Behavior Q2hr Duration 24 hr." The restraint was applied at 2100 (9 p.m.), and there was no documentation of monitoring at 0000 (Midnight). RN 2 stated "It wasn't done."

During an interview on 12/4/24 at 11:30 a.m. with RN 1, a policy and procedure for restraint monitoring was requested. RN 1 stated "Order is for 2 hours to monitor. It's not in policy. It's an order."

During a review of the facility's policy and procedure (P&P) titled "Physician Orders (PO)" dated October 2022, the P&P indicated, "Purpose: To provide standards for prescribing and writing orders by physicians and advanced practice providers and for the initiation and administration of those orders by healthcare professionals."

Based on observation, interview, and record review, the facility failed to ensure a contracted Registered Nurse (CRN) providing dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) services to one of one sampled patient (Patient 11), performed hand hygiene after contact with equipment. This failure had the potential to spread infectious diseases to patients, staff, and visitors.

Findings:

During an observation on 12/2/24 at 11:32 a.m. of room 3227, Patient 11 was in bed with family at bedside. CRN was connecting tubing to the dialysis machine without wearing gloves. CRN finished the connections, and with no hand hygiene started documenting on a form.

During an interview on 12/2/24 at 11:35 a.m. with CRN, CRN stated the tubing isn't sterile. CRN stated "I should have done hand hygiene, but I don't see the problem."

During a concurrent interview and record review on 12/2/24 at 4:03 p.m. with Director of Licensing and Accreditation (DLA), DLA provided documentation of Education for CRN. The "Hospital Services HD (Hemodialysis) Annual Procedural Skills Verification Checklist (HSASVC) dated 5/22/24 for CRN was reviewed. The HSASVC indicated CRN was signed off as "Satisfactory performance of skill" on 5/22/24.

During a review of the "Hospital Services Agreement (HSA) signed April 17, 2024, the HSA indicated, "3.2 Policies and Procedures. (a) All Company Staff shall comply with the policies and procedures of Hospital in effect on the date hereof that relate to the provision of the Services. . ."

During a review of the facility policy and procedure (P&P) titled "Hand Hygiene" dated June 2022, the P&P indicated, "B. Indications for Hand Hygiene 3. Hand hygiene is practiced: b) After 4) Contact with inanimate objects (including medical equipment) in the immediate patient vicinity."