HospitalInspections.org

Based on observation, review of medical records, and staff interview, it has been determined that the hospital failed to meet the Condition of Participation §482.13 related to the failure to ensure Patient Rights are afforded to Patient ID #1, who was made to remove his/her clothing in a common area on the hospital unit by a hospital staff member who was missing his cell phone.

Findings are as follows:

1. The hospital failed to ensure that the patients' rights requirements were met, relative to failure to follow their policy regarding providing considerate and respectful care for 1 of 1 patient, Patient ID #1. (Refer to A 129).

2. The hospital failed to ensure a patient's right to personal privacy for 1 of 1 patient who was physically searched in a common area for a missing cell phone, Patient ID #1. (Refer to A 143).

3. The hospital failed to ensure that the patient's right to receive care in a safe setting for 1 of 1 patient who was intimidated by staff, patient ID #1. (Refer to A 144).

4. The hospital failed to protect 1 of 4 patients from abuse, Patient ID #1 related to incident of staff to patient abuse. (Refer to A145).

Based on record review, review of video surveillance, and staff interviews it was determined that the hospital failed to follow the hospital's policy for "Rights and Responsibilities of Patients" and ensure that the patients' rights requirements were met relative to providing a patient with considerate and respectful care for 1 of 1 patient, Patient ID #1.

Findings are as follows:

Review of the hospital's policy "Rights and Responsibilities of Patients" states in part.

Section V. Procedure
" OLFH is committed to providing excellent patient care. Accordingly, it is the policy of OLFH to respect, protect and promote each patient's individuality and dignity, while assuring proper medical care ..."
"A. Rights of Patients" ...
1. The patient shall be afforded considerate and respectful care.
B. Additional Rights of Patients:
5. Treat a patient in a dignified and respectful manner."

Review of the record for patient ID #1, reveals, he/she was re-admitted to the long-term psychiatric unit in December of 2021 due to aggressive behaviors.

The patient's diagnoses include major neurocognitive disorder, aphasic (comprehension and communication reading, speaking, or writing disorder resulting from damage or injury to the specific area in the brain).

Surveyor review of the hospital's video surveillance dated 9/21/2022, revealed Patient ID #1, sitting in the TV room, near the door, that is open to the hallway. Staff A, Mental Health Worker (MHW) accompanied by Staff B, MHW are observed coming into the room while putting on gloves and pushing a cart which contained the patient safety check logbook located on the top of the cart. Staff A is noted to speak to the patient, although no audio is available, and points up to the camera, the patient stands up, appears fearful/unsure and removes his/her sweatshirt and places it on the table, then removes the 2 hospital gowns which were underneath the sweatshirt and lets them fall to the floor. The patient proceeds to pull down their pants which fall to his/her ankles leaving the patient exposed except for the brief the patient was wearing. Staff A then walks around behind the patient and standing directly behind the patients appears to check the brief the patient has on, and then picks up the sweatshirt and pat/feel the sweatshirt that is lying on the table for his missing phone. Staff A is then observed to walk back around to the front of the patient and he and Staff B take the cart and leave the room with the patient standing naked near the door which remained open. Patient ID # 1 is observed picking up his/her clothing and putting it on without any assistance. Throughout the video, Staff B, who followed Staff A into the room is observed to observe the patient remove their clothing except for the brief, standing naked while Staff A checked the patient for his phone. Staff B did not intervene in any way.

During an interview with the Nurse Manager on 9/27/2022 at approximately 2:30 PM, she reported that she and the Risk Manager went to interview patient ID # 1, the following day on 9/22/2022. She stated that the patient has aphasia and only says yes or no, however understands what is being said and has a good memory. She said she asked the patient if they recalled a phone being missing and the patient shook his/her head yes. The patient was asked if he/she remembered the two staff coming into the TV room, the patient shook her head yes. According to the Nurse Manager, the patient became anxious and upset when that question was asked, at that point the patient began pointing to herself and making sounds. When the patient was asked if the staff who came into the room was Staff A, the patient nodded her head yes. The Nurse Manager said she then asked the patient if Staff A, told her to take his/her clothes off and the patient nodded her head vigorously yes.

On 9/27/2022 at approximately 2:50 PM, the surveyor, accompanied by the Nurse Manager and the Risk Manager, went to the unit to meet with Patient ID #1. The patient was sitting in the TV room, where according to the Nurse Manager she/he usually sits. When approached, the surveyor said hello, and the patient nodded. The Nurse Manager asked her if she recalled a missing phone, and she said yes and began to look anxious. She then asked her if she remembered Staff A coming to the TV room where he/she was sitting, the patient shook his/her head yes. The patient also shook his/her head yes when asked if Staff A told him/her to take off his/her clothes.

During a subsequent Surveyor interview with the Nurse Manager on 9/27/2022, after viewing the video, she stated that upon identification of this incident, Staff A & B were suspended and referred to human resources.

Based on record review, surveillance video review, staff and patient interviews it was determined that the hospital failed to ensure a patient the right to personal privacy for 1 of 1 patient who was accused of taking a staff members cell phone, patient ID #1.

Findings are as follows:

Review of a hospital reported incident, dated 9/22/2022, revealed that a male Mental Health Worker (MHW) had reported to the hospitals security that he lost his cell phone while working on the behavioral health unit. Security reviewed the surveillance video and determined that Patient ID #1 had picked up the phone in the common area TV room. Security informed the MHW of the findings.

1. Review of the hospital policy "Patient, Packages, Room and Unit Search Policy" dated 2/1/1987, reviewed on 2/28/2018 states in part:

POLICY STATEMENT "It is the policy ... of Division of Behavioral Health to promote a safe and therapeutic environment for all patients and staff by preventing contraband, harmful material, and illicit substances on the Behavioral Health units".

DEFINITIONS "A search is a process by which designated staff look for contraband, harmful material, and illicit substances that could affect patient and staff safety.

PROCEDURES
1. "Patient Search Indications: A patient search is performed and documented by two people in the following circumstances:
~ A patient admitted to the unit and or returning from a pass
~ Any patient who demonstrates symptoms which suggest the use of contraband drugs
~ Any patient who demonstrates symptoms which suggest that the patient may have a potential weapon on his/her person

2. Patient Search Procedure:
~ A physician order is obtained for the search
~ A physician order is obtained for a physical hold if required
~ The patient is requested to go to his/her room with two staff members. There should be two staff members present, one of each gender, unless clinically contraindicated" ....

Surveyor observation of the hospital's video surveillance video dated 9/21/2022, revealed Patient ID #1, sitting in the common area TV room, near the door, that is open to the hallway. Staff A, a Mental health Worker (MHW) and Staff B, MHW, are observed entering the room, Staff A, while putting gloves on. Staff A is observed in the video to say something to the patient (there is no audio) and points up to the camera, the patient stands up appears fearful/unsure and removes his/her sweatshirt and places it on the table, he/she removes the 2 hospital gowns which were underneath the sweatshirt, lets them fall to the floor, then proceeds to pull down his/her pants which fall around his/her ankles leaving the patient exposed except for the brief the patient was wearing. Staff A then walks around behind the patient and standing directly behind the patients appears to check the brief the patient has on, and then picks up the sweatshirt and pants/ feels the sweatshirt that is lying on the table for his missing phone.

Staff A, then walks back around to the front of the patient, he and Staff B leave the room with the patient still standing near the door which remained open. Patient ID # 1 is observed picking up his/her clothing and putting it on without any assistance. During this time a member of the housekeeping staff, is observed walking into the TV, and wipes off a tabletop and leaves, while Patient ID #1 is trying to get dressed. Throughout the video, Staff B, who accompanied Staff A into the room, observed the patient to remove their clothing except for the brief, while Staff A checked the patient and for his cell phone, Staff B failed to intervene in any way.

During an interview with the Nurse Manager on 9/29/2022 at approximately 2:15 PM, she acknowledged that the MHW's did not follow the hospital policy and should have notified the nurse who was on the unit prior to approaching the patient, because a physician's order is necessary prior to a patient search. Additionally, staff should have searched the room prior to searching the patient. She also acknowledged that the patient should have been returned to his/her room for personal privacy prior to any search process. The manager was unable to produce evidence that the patients right to personal privacy was protected.

Based on observation of the hospital's video surveillance, record review and staff interviews, it has been determined that the hospital failed to provide care in a safe setting for 1 of 4 sample patients, Patient ID #1 and 3.

Findings are as follows:

Review of a hospital incident report dated 9/22/2022 revealed that on 9/21/2022, a Mental Health Worker (MHW) Staff A, reported his cell phone missing to the hospital security. The Security Officer (SO) reviewed video surveillance and determined that Patient ID #1, had taken the employees cell phone. The SO then informed the MHW of this observation.

Review of the record for Patient ID #1, reveals, he/she was re-admitted to the long-term psychiatric unit in December of 2021. The patient's diagnoses include major neurocognitive disorder, aphasia (a comprehension and communication, reading, speaking, or writing, disorder resulting from damage or injury to the specific area in the brain). The patient can respond to yes or no questions and according to the Nurse Manager, she indicated the patient has a good memory.

Review of the hospital's policy" Rights and Responsibilities of Patients" states in part:
" ...Section V. Procedure
B. Additional Rights of Patients ...
3. Treat a patient in a caring and polite way and ensure that a patient is free from all forms of mental, physical, sexual and verbal abuse, neglect, harassment, exploitation and corporal punishment.
4. Provide a patient with care in a safe setting ..."

Review of the hospital's video surveillance dated 9/21/2022, revealed Patient ID #1, sitting in the TV room.
Staff A was observed to enter the room and noted speaking to Patient ID #1, (no audio available), then pointed up to the camera located on the unit. The patient then stood up, and appeared fearful/unsure, removed his/her sweatshirt, placing it on the table, then proceeded to remove 2 hospital gowns which were underneath the sweatshirt and let them fall to the floor. The patient then pulled down his/her pants which fell around their ankles, leaving the patient wearing only a brief. Staff A then walks around behind the patient, and standing directly behind the patient appears to check the brief the patient has on, and then picks up the sweatshirt and pats/ feels the sweatshirt that is lying on the table for his missing phone

Staff A walked back around to the front of the patient and he and Staff B took the cart, and both left the room. Patient ID #1 was left standing near the door which remained open. Throughout the video, MHW Staff B, who had accompanied Staff A into the TV room was observed watching the patient remove their clothing except for the brief, standing naked, while Staff A checked the patient and for his phone. Staff B failed to intervene.

On 9/27/2022 at approximately 2:50 PM, the surveyor, accompanied by the Nurse Manager and the Risk Manager, went to the unit to see Patient ID #1. The patient was sitting in the common area TV room. When approached, the patient got up from the chair and when the surveyor said hello, she nodded. The Nurse Manager asked her if she recalled a missing phone, and she said yes and appeared anxious. She then asked her if he/she remembered Staff A coming to the TV room where he/she was sitting and the patient raised his/her eyes, shook his/her head yes. The patient also shook his/her head yes when asked if Staff A told him/her to take off their clothes. The patient appeared upset and kept shaking their head yes.

During an interview with the Nurse Manager on 9/27/2022 at approximately 1:30 PM, she acknowledged that the patient was not provided care in an environment that would be safe, appropriate care. Additionally, she acknowledged that Staff B, should have intervened.

Based on record review, staff interview and surveyor observation of the hospital's video surveillance it has been determined that the hospital failed to protect 1 of 4 sample patients from abuse (Patient ID # 1).

Findings are as follows:

Review of an incident report dated 9/22/2022 revealed on 9/21/2022, a Mental Health Worker (MHW) Staff A, reported his cell phone missing to the hospital security. Security reviewed video surveillance and determined that patient ID #1, had taken the phone and informed the MHW of this information.

Review of the medical record for Patient ID #I, reveals, he/she was re- admitted to the long-term psychiatric unit in December of 2021 after being discharged the prior day to a nursing home. The patient was readmitted due to aggressive behaviors.

The patient's diagnoses include major neurocognitive disorder, Alzheimer type, aphasia post stroke, seizures, hypertension, history of deep vein thrombosis, low back pain and osteoarthritis.

The record reveals the patient has aphasia, however, can answer yes or no to questions and according to the Nurse Manager has a good memory.

Review of the hospital's policy Titled, "Mandatory Reporting of Patient Abuse & Patient to Patient Abuse" states in part:

"Definitions"

"Abuse: Any conduct which harms or is likely to physical harm the patient ... ... Intentionally engaging in a pattern of harassing conduct which causes or is likely to cause emotional or psychological harm to the patient ...."

"Assault: Intentional act designed to make the victim fearful, and it produces reasonable fear of harm".

Surveyor review of the hospital's video surveillance dated 9/21/2022, revealed Patient ID #1, sitting in the common area TV room, near the door, that is open to the hallway. Staff A, Mental health Worker (MHW) and Staff B MHW are observed coming into the room, Staff A putting on gloves. Staff A is observed to speak to the patient (no audio is available) and points up to the camera, the patient stands up, appears fearful/unsure and removes his/her sweatshirt and places it on the table, then proceeds to remove the 2 hospital gowns which were underneath the sweatshirt and lets them fall to the floor, pulls down his/her pants which fall around their ankles leaving the patient exposed except for the brief. Staff A then walks around behind the patient and standing directly behind the patients appears to check the brief the patient has on, and then picks up the sweatshirt and pats/ feels the sweatshirt that is lying on the table for his missing phone. Staff A, then walks back around to the front of the patient and he and Staff B take the cart and leave the room with the patient still standing naked near the door which remained open. Patient ID # 1, who appears fearful and confused is observed picking up his/her clothing and putting it on without any assistance.

Throughout the video, Staff B, who followed Staff A into the room is observed watching the patient remove their clothing except for the brief, standing naked while Staff A checked the patient for his missing phone. Staff B failed to intervene in any way.

The Surveyor interviewed the Nurse Manager on 9/27/2022, at approximately 2:30 PM, who stated that after learning that Staff A had lost his phone, she asked security to view the video as Staff A has been seen with his phone in patient areas in the past. She stated that she viewed the video at 3:20 PM and after seeing the video she notified the Risk Manager.

The Nurse Manager stated that she and the Risk Manager went to interview Patient ID #1, the following day (9/22/2022). She stated that the patient has aphasia and only says yes or no, however understands what is being said and has a good memory. She said she asked the patient if she/he recalled a phone being missing and the patient shook his/her head yes. She said she then asked the patient if she/he remembers the two staff coming into the common area TV room, and she/he answered yes. She stated that the patient became anxious and upset when that question was asked. She told the surveyor that at that point the patient began pointing to him/ herself and making sounds. When asked if the staff who came into the room was Staff A, the patient nodded her head yes. The Nurse Manager said she then asked the patient if Staff A, told her to take off his/her clothes and the patient nodded his/her head vigorously and said yes.

On 9/27/2022 at approximately 2:50 PM, the surveyor, accompanied by the Nurse Manager and the Risk Manager, went to the unit to see Patient ID #1. The patient was sitting in the common area TV room. When approached, the patient got up from the chair and when the surveyor said hello, she nodded. The Nurse Manager asked her if she recalled a missing phone, and she said yes and appeared anxious. She then asked her if he/she remembered Staff A coming to the TV room where he/she was sitting and the patient raised his/her eyes, shook his/her head yes. The patient also shook his/her head yes when asked if Staff A told him/her to take off their clothes. The patient appeared upset and kept shaking their head yes.

During an interview with the Risk Manager on 9/28/2022 at approximately 11:00 AM, she acknowledged that telling a patient remove their clothes in the TV room, to look for a missing phone, is abusive and agreed that an assault occurred based on the hospital's policy definition which states (an intentional act designed to make the victim fearful, and it produces reasonable fear of harm) did occur.