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Based on observation, interview, and documentation in 1 of 4 Behavioral Health Unit (BHU) medical records reviewed (Patient #1) it was determined that the hospital failed to ensure patient privacy during a "body search" conducted during the patient's admission to the BHU, and further failed to ensure that video monitoring and surveillance related practices were conducted in accordance with clear and complete policies and procedures. Findings include:

1. Documentation in the medical record of Patient #1 reflected that he/she was admitted to room 578 on the BHU on 6/22/2010 at 0243 as a result of "worsening depression and suicidal thoughts and attempts". Documentation recorded in electronic notes dated 6/22/2010 at 0559 reflected "Search completed on admit." There was no other documentation in the record related to this "search". A subsequent entry in the electronic notes dated 6/23/2010 at 1450 reflected that the patient had "a grievance about [his/her] admission process." The nature of the grievance was not described.

2. A tour of the BHU on 9/2/2010 was conducted with the Director of the BHU and other hospital representatives. Rooms numbered 534, 541, 545, and 578 were entered. Video camera equipment was observed to be installed in each of those rooms, positioned to record all areas of the room. The bathrooms in each of those rooms were observed to not have video cameras.

Each of those rooms were observed to include a large window which allowed a view of a hospital parking structure located across a hospital campus street from the building in which the BHU was located.

During the tour monitor screens were observed at the unit's two nurses stations displaying images of areas and rooms under video surveillance. The Director verified that all patient rooms are under video surveillance at all times. The Director pointed out that BHU staff could retrieve and view previously recorded images for up to thirty days at one of the computer monitors located at the Main Tower nurses station. The Director identified that he, as well as the BHU Supervisor, could also retrieve and view previously recorded images on their computers.

3. The hospital's Inpatient Psychiatric Unit Policy and Procedure titled "Searches of Patient, Belongings, and Environment", dated as last revised "6/03", was reviewed. That policy included a definition for "Body Search" as "A visual inspection of the patient's body surface for presence of contraband, and evidence of acute bodily injury". The policy included the following statements: "A patient's right to privacy will be respected to the greatest extent possible...All patients must have a body search and belongings search on admission and upon return from pass...Results of all searches will be documented in the patient's medical record...Two healthcare providers (or one healthcare provider and one security staff person, if indicated) will be in attendance during any search...Identify and document the scope of the search: body, body orifice...Document the rationale for conducting the search, and the results of the search, in the interdisciplinary progress note...". This policy included no provisions to ensure patient privacy during body searches in patient rooms or other areas under video surveillance.

The Inpatient Psychiatric Unit Policy and Procedure titled "Patient Admission and Nursing Assessment/Initial Intake for Behavioral Health Units", dated as last revised "11/09", was reviewed. The policy described the admission process and included the following: "Escort patient to exam room or assigned patient room (if private). Provide overview of the admission process, including purpose and need to conduct body search. Have patient change into scrubs. Body/safety search is to be conducted by staff member of the same sex...". The policy also stated that during orientation to the unit "Special emphasis is to be placed on review of patient rights, including...use of video monitoring for safety." This policy included no provisions to ensure patient privacy during body searches in patient rooms or other areas under video surveillance.

The "Adult Informed Consent For Voluntary Admission Behavioral Health Services" form, dated "3/08", included a statement which read "I understand that videotaping may be conducted for the safety and security of all patients as part of our program." The language on this consent, "...may be conducted..." was not accurate as observations and interviews described above confirmed that video monitoring and surveillance was conducted at all times in all patients' rooms.

The hospital Department of Security Services policy and procedure titled "Use and Disclosure of Data", dated as last revised "November 2009", was reviewed. It reflected that audio, visual, and other electronic data was collected as part of the department's security operations and "All data collected by this technology is property of Providence Health & Services and managed by Security Administration." The policy stated that "Captured data will only be queried, viewed, copied, disclosed or disseminated for a legitimate business need and when pre-approved." It further revealed that "Electronic copies of data will be protected in a computerized file that will not be accessible by unauthorized individuals." This policy had not been followed as observations and interviews described above reflected that any BHU staff member could retrieve and view previously recorded images on a computer monitor at a BHU nurses station.

The Inpatient Psychiatric Unit policy and Procedure titled "Closed Circuit Television on Inpatient Behavioral Health Units", was also dated as revised "11/09". It reflected that "Only members of the BH Leadership shall view playback and/or download digitally recorded images from the [Closed Circuit Television] system. It also indicated that "The BH Consent for Voluntary Admission shall service as patient formal notice of [Closed Circuit Television] system and patient's approval." This policy had not been followed as observations and interviews described above reflected that any BHU staff member could retrieve and view previously recorded images on a computer monitor at a BHU nurses station. Further the BHU consent form did not inform the patient that they were being video monitored and recorded in their patient room at all times.

There were no policies which reflected procedures for obtaining a patient's express consent to be video monitored and recorded during body or orifice searches described in policies and procedures above.

4. During an interview in the afternoon on 9/2/2010 the grievance documented in the record of Patient #1 was discussed with the Director of the BHU and other hospital representatives. According to those individuals the patient had voiced concerns related to the lack of privacy provided during the body search on admission to the BHU. It was confirmed during the interview that an admission body search of Patient #1, which included disrobing and changing into hospital scrubs, was conducted in the patient's room in view of the video cameras installed in the patient's room, the window coverings in the patient's room were not closed at the time of the search, and the search was conducted by one RN who did the search alone in violation of policy.

During the interview the hospital representatives confirmed that the video monitoring and surveillance occurred in hallways, patient rooms, and common areas on the unit. There was no video monitoring in patient bathrooms. The recordings were digital with an "auto-rewrite" every six to eight weeks. It was revealed that the hospital media staff and security team were the only parties outside of the BHU with access to those digital recordings.

During the interview the Director of the BHU provided a copy of the admission packet that all patients receive upon admission to the unit. A document titled "Welcome to Providence Adult Inpatient Behavioral Health", dated "3/10", was reviewed. On page 4 of that document it describes that "...all items brought on to the unit by you or your visitor will need to be checked for safety." On page 6 it indicated that patients had a right to "Be shown consideration for your personal privacy." On page 10 if reflected that "For the protection of everyone on the unit, staff will inventory your belongings upon admission...To keep dangerous objects off the unit, staff may search the unit, which may include patients' rooms. All of the rooms on the unit are monitored by a video camera. For your privacy you may want to dress in your bathroom." There was nothing in this document which informed patients that body searches would occur on admission, that body and orifice searches may occur at any other time during the hospitalization, and that informed them how their privacy would be assured during those processes.

Based on observation, interview, and documentation in 4 of 4 Behavioral Health Unit (BHU) medical records reviewed (Patient #s 1, 2, 3, and 4) it was determined that the hospital failed to ensure that its practices for conducting patient "searches" for patient safety purposes were carried out in accordance with BHU policies and procedures. Findings include:

1. The hospital's Inpatient Psychiatric Unit Policy and Procedure titled "Searches of Patient, Belongings, and Environment", dated as last revised "6/03", was reviewed. That policy included a definition for "Body Search" as "A visual inspection of the patient's body surface for presence of contraband, and evidence of acute bodily injury". The policy also defined other searches which included "Orifice Search", "Belongings Search", "Room Search", and "Discretionary Search". The policy included the following statements: "Searches are conducted for the purpose of identifying the presence of and securing any illegal or dangerous substances, objects or weapons...in order to protect the health, safety and security of all patients, staff and visitors...All patients must have a body search and belongings search on admission and upon return from pass...Results of all searches will be documented in the patient's medical record...Two healthcare providers (or one healthcare provider and one security staff person, if indicated) will be in attendance during any search...Identify and document the scope of the search: body, body orifice, patient room, and patient belongings...Document the rationale for conducting the search, and the results of the search, in the interdisciplinary progress note."

The Inpatient Psychiatric Unit Policy and Procedure titled "Patient Admission and Nursing Assessment/Initial Intake for Behavioral Health Units", dated as last revised "11/09", was reviewed. The policy described the admission process and included the following: "Escort patient to exam room or assigned patient room (if private). Provide overview of the admission process, including purpose and need to conduct body search. Have patient change into scrubs. Body/safety search is to be conducted by staff member of the same sex...".

2. Documentation in the medical record of Patient #1 reflected that he/she was admitted to the BHU on 6/22/2010 at 0243 as a result of "worsening depression and suicidal thoughts and attempts". Documentation on a "Close Observation for Suicide/Behavior" form reflected that the patient was being supervised with checks every 15 minutes. Those checks reflected that the patient was with an RN until 0400. That documentation then reflected that the patient was "reading in bed" at 0415 and 0430, was "rest" at 0445, and "eyes closed" at 0500. There was no documentation as to where the patient was on those checks at 0515, 0530, and 0545. Documentation recorded in electronic notes reflected that the "Search completed on admit" did not occur until 6/22/2010 at 0559, one hour and 45 minutes after the patient had been released to his/her room. There was no other documentation in the record related to this "search".

A subsequent entry in the electronic notes dated 6/23/2010 at 1450 reflected that the patient had "a grievance about [his/her] admission process." The nature of the grievance was not described.

During an interview in the afternoon on 9/2/2010 the grievance documented in the record of Patient #1 was discussed with the Director of the BHU and other hospital representatives. According to those individuals the patient had voiced concerns related to the lack of privacy provided during the body search on admission to the BHU. It was confirmed during the interview that an admission body search of Patient #1, which included disrobing and changing into hospital scrubs, was conducted in the patient's room in view of the video cameras installed in the patient's room, the window coverings in the patient's room were not closed at the time of the search, and the search was conducted by one RN who did the search alone in violation of policy.

3. Documentation in the medical record of Patient #2 reflected that he/she was admitted to the BHU on 6/22/2010 at 1418 and was identified as having "potential for violence towards self". There was no documentation of an admission search.

Electronic notes dated 6/24/2010 at 2254 reflected that "Room searched and no contraband found." There was no other documentation in the record related to this "search".

4. Documentation in the medical record of Patient #3 reflected that he/she was admitted to the BHU on 7/3/2010 at 0104 as a result of depression and "suicidal statements". Electronic notes dated 7/3/2010 at 0113 reflected that the patient was being supervised with "every 15 minute checks". Documentation in electronic notes dated 7/23/2010 at 0327 reflected that "personal and body search completed...was falling asleep during admission intake...was permitted to sleep...is sleeping at this hour." It was not clear when the admission search had occurred and if it was before or after the patient had been released to the unit to sleep and was being supervised every 15 minutes.

Electronic notes dated 7/3/2010 at 1323 reflected "Room search complete, no contraband found".

There was no other documentation in the record related to these "searches".

5. Documentation in the medical record of Patient #4 reflected that he/she was admitted to the BHU on 7/19/2010 at 1209 as a result of "potential for violence toward self...toward others". There was no documentation of an admission search or any other searches.

6. The documentation in the records of Patient #s 1, 2, 3, and 4 did not reflect the practice and documentation requirements identified in the policy and procedure described above. During a telephone interview with the Director of the BHU on 9/3/2010 at approximately 1145 it was confirmed that there was no additional documentation in the records of Patient #s 1, 2, 3, and 4 related to searches.

Based on interview and documentation in 1 of 8 Emergency Department (ED) records reviewed (Patient #6), it was determined that the hospital failed to ensure that the medical record was complete and contained sufficient information to reflect the patient's course through the ED and justification for the lack of diagnostic testing to further evaluate the cause of the patient's symptoms. Findings include:

1. Documentation on the Triage and Nursing Care Plan report in the ED record of Patient #6 reflected that the patient walked into the ED, accompanied by another individual, on 6/21/2010 at 2241 with a chief complaint of a fever which had reached 103 degrees Farenheit (F). The record reflected that the patient was triaged at 2250 and his/her temperature at that time was 38.4 degrees Celsius (C) or 101.12 F.

During the course of the ED visit the patient was observed to be lethargic and experienced vomiting. He/she was given medications by mouth to reduce fever and nausea. An intravenous line was started through which the patient received fluids and additional medications.

Documentation on the dictated Emergency Room Report by the practitioner who evaluated and treated the patient included a history and physical examination. In that report the practitioner documented that the patient had reported that he/she had recently traveled from New York. There was no documentation to reflect that bloodwork or other diagnostic testing had been conducted. The "Clinical Impression" was documented as "Viral syndrome versus influenza. Fever." The report indicated that "The patient was discharged home in good condition".

The Triage and Nursing Care Plan form reflected that at 0110 on 6/22/2010 the patient was discharged, accompanied by "friends", with written instructions and medications for pain, fever, and nausea.

2. The practitioner who evaluated and treated the patient (Staff #1), and the RN assigned to the patient in the ED (Staff #2) were interviewed on 9/16/2010 at approximately 1400. The practitioner recalled this patient because of the patient's concern about being able to fly back to New York on the day following the ED visit. During the interview Staff #1 and #2 recollected that the patient had reported traveling from New York. Both of these individuals denied that the patient had reported traveling to or from any other location. The practitioner stated that he/she had discussed with the patient the need to do bloodwork to further evaluate the cause of the symptoms. The practitioner reported that the patient's response was to defer any additional work-up at that time and wait to start that process until he/she arrived back home in New York the following day.

During the interview the practitioner (Staff #1) acknowledged that he/she had not documented this information in the record of Patient #6 and stated "I didn't dictate completely."

Based on interview and documentation in 1 of 1 ED record reviewed (Patient #8) of a patient who was discharged alone from the ED, it was determined that the hospital failed to ensure that its practices for discharging patients from the ED, who were unaccompanied by other individuals, were carried out in accordance with ED policies and procedures. Findings include:

1. The hospital's Emergency Services policy and procedure titled "Discharge Plan of Care and Education", dated as "Effective 10/2008", was reviewed. The "Goal" was "Patient's are discharged according to individualized need...". It included the following requirements for the "Discharging RN": "Complete discharge nursing assessment, including the patients' condition ...Consider the safety needs for those patients who are unable to carry out their usual activities and/or who are unable to protect themselves, such as but not limited to:...Patients who have had sedation and others at risk should be accompanied by a designated responsible adult...Coordinate discharge...".

2. Documentation on the Triage and Nursing Care Plan report in the ED record of Patient #8 reflected that the patient arrived in the ED by wheelchair on 7/3/2010 at 1750. No one was identified as accompanying the patient. The patient reported that he/she had tripped and fallen and had landed on his/her face and head. The patient denied that he/she has lost consciousness. The ED record reflected that the patient had abrasions on his/her head and face, and had a "deformed" finger.

Documentation on the dictated Emergency Room Report by the practitioner who evaluated and treated the patient reflected that the patient had abrasions over his/her nose and top lip which were cleaned. The left hand had: "2 lacerations on the palmar surface with bone protruding; the fingers are angulated backwards at the PIP joints bilaterally." The patient's hand was numbed with Lidocaine, the dislocations were reduced, and the lacerations were sutured. The record reflected that the patient received narcotic pain medication, antibiotics, and anti-nausea medication intravenously. The report indicated that "The patient was discharged home in good condition and told to return for worsening concerns."

The Triage and Nursing Care Plan form reflected that at 2036 on 7/3/2010 the patient was "given bus pass" and discharged by "self".

There was no documentation in the record which reflected how the patient got to the ED and whether he/she was accompanied by others. The space for that information on the ED record was blank.

In accordance with the policy and procedure identified above, at discharge there was no documentation to reflect that the patient's individualized needs had been evaluated and assessed to ensure that releasing him/her from the ED with a "bus pass", unaccompanied by another individual, did not place the patient at risk.

3. During an interview in the afternoon on 9/2/2010 the case of Patient #8 was discussed with the ED Associate Nurse Manger and other hospital representatives. They shared that the patient had been driven to the ED by friends who left the hospital before the patient was discharged. When the patient was ready for discharge he/she was unable to recall or find phone numbers for those individuals. The patient did not have a wallet or phone with him/her when brought to the ED and the patient was wearing paper scrubs that staff had provided as his/her shirt had been stained with blood. According to the hospital representatives the patient was given a bus pass by ED staff, was directed to the security desk by other ED staff for assistance with transportation, and security staff transported the patient on a hospital shuttle to a local public transit station where the patient was left.

During the interview the hospital representatives indicated that they had later learned that the patient had taken a public transit train going in the opposite direction of his/her home and had ended up in the wrong town, where he/she eventually was assisted by police to get home.

Hospital representatives stated that corrective actions, including staff teaching, had been identified and taken as a result of this incident.