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Based on record reviews and interview, the hospital failed to implement its grievance policy as evidenced by failure to identify a patient's complaint of alleged sexual abuse as a grievance for 1 (#1) of 1 allegation of sexual abuse reviewed from a sample of 5 patients.
Findings:

Review of the "Complaint/Grievance Log" for September 2018 presented by S2DON revealed no documented evidence of a complaint/grievance submitted by Patient #1.

Review of the policy titled "Grievance, Complaints, and Appeals", presented as a current policy by S5HRD, revealed it is the responsibility of the Administrator to implement the policy and the responsibility of the Administrator and Patient Advocate to disseminate information to employees. The hospital's governing body has delegated the responsibility of the grievance process to the patient advocate, risk manager, and administrator. Further review revealed if any complaint/grievance could possibly be considered as abuse and/or neglect and/or a violation of patient rights, an incident report is immediately filed, and the Patient Advocate is notified immediately. The incident is investigated, and the Patient Advocate will meet with the grievant to discuss the results of the investigation and provide a written response.

Review of the "Hospital Abuse/Neglect Initial Report" documented by S2DON on 09/07/18 described the alleged incident as Patient #1 alleged that Patient #2 entered her room naked, touched her shoulder, looked at her "vagina", and had to be removed by the MHT.

Review of information presented by S2DON revealed an investigation was conducted, and the allegation was not substantiated.

In an interview on 10/09/18 at 2:10 p.m., S2DON indicated they did an incident report on Patient #1's allegation of sexual abuse but did not handle it as a grievance in accordance with hospital policy.

Based on record reviews and interview, the hospital failed to ensure it provided the patient with written notice of its decision in its resolution of the grievance that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion as evidenced by failure to have identified an allegation of sexual abuse as a grievance and to provide the patient with written notice of the decision following an investigation for 1 (#1) of 1 patient allegation of sexual abuse reviewed from a sample of 5 patients.
Findings:


Review of the "Complaint/Grievance Log" for September 2018 presented by S2DON revealed no documented evidence of a complaint/grievance submitted by Patient #1.

Review of the policy titled "Grievance, Complaints, and Appeals", presented as a current policy by S5HRD, revealed it is the responsibility of the Administrator to implement the policy and the responsibility of the Administrator and Patient Advocate to disseminate information to employees. The hospital's governing body has delegated the responsibility of the grievance process to the patient advocate, risk manager, and administrator. Further review revealed if any complaint/grievance could possibly be considered as abuse and/or neglect and/or a violation of patient rights, an incident report is immediately filed, and the Patient Advocate is notified immediately. The incident is investigated, and the Patient Advocate will meet with the grievant to discuss the results of the investigation and provide a written response.

Review of the "Hospital Abuse/Neglect Initial Report" documented by S2DON on 09/07/18 described the alleged incident as Patient #1 alleged that Patient #2 entered her room naked, touched her shoulder, looked at her "vagina", and had to be removed by the MHT.

Review of information presented by S2DON revealed an investigation was conducted, and the allegation was not substantiated. There was no documented evidence Patient #1 was sent a written notice of the decision following the investigation of the grievance.

In an interview on 10/09/18 at 2:10 p.m., S2DON indicated they did an incident report on Patient #1's allegation of sexual abuse but did not handle it as a grievance in accordance with hospital policy. She confirmed a written decision was not sent to Patient #1 once the investigation was completed.

Based on observations, record reviews, and interviews, the hospital failed to ensure patients had the right to privacy as evidenced by failure to develop policies and procedures for the use of a hospital closed circuit system that allowed video recording of patients inside 6 patient rooms with the video monitor placed in the nursing station that was visible to any staff walking through the nursing station. Patient #1 was video recorded while partially/fully naked in her room (Room "c") on 09/06/18 from 7:59 a.m. to 8:20 a.m. There was no documented evidence that patients were informed that they were being video-monitored inside their room for 6 (#1, #2, #3, #4, #5, R1) of 6 patient records reviewed for personal privacy from a sample of 5 patients and 4 random patients.
Findings:

Observation on 10/08/18 at 10:55 a.m. in the nursing station revealed a video monitor that had visibility inside patient rooms "a", "b", "c", "d", "e", and "f."

Observation during a tour of the hospital with S3MHT present on 10/08/18 at 11:05 a.m. revealed a camera was mounted on the ceiling in each patient room except in Room "g."

Observation of a hospital-provided video recording on 10/09/18 at 10:55 a.m. with S5HRD present and then replaced by S2DON of Room "c" on 09/06/18 from 7:29 a.m. to 11:30 a.m. revealed at 7:58 a.m. Patient #1 exited the bathroom in her room with no pants on. At 7:59 a.m. she was observed bending over with her back to the camera, and her buttocks were visible. At 8:00 a.m. she exited the bathroom with only her bra on, walked and opened the bedroom door more, and peeked in the hall. She then shut her room door and had her bathroom door open which blocked the view from the hall into the room. At 8:02 a.m. until 8:07 a.m. Patient #1 walked about her room naked. At 8:07 a.m. she wrapped herself with a towel, opened the door and stood in the door opening facing the hall. At 8:10 a.m. she remained at the door with the towel wrapped around her and walked in the hall. She returned to the bathroom and at 8:11 a.m. came out the bathroom with a towel draped in front of her with her buttocks exposed. At 8:12 a.m. Patient #1 walked in the room naked, sat on the bed, and put her pants on. She then put her shoes on. At 8:15 a.m. she entered the bathroom while putting her shirt on. Patient #1 exited her bathroom at 8:20 a.m. fully dressed and walked out her room.

Review of the policy titled "Patient Rights", provided as a current policy by S5HRD, revealed patients had the right to individualized treatment to include the assurance and protection of each patient's personal privacy within the constraints of the individual treatment plan.

Review of the "Hospital Closed Circuit System" signed by all patients admitted to the hospital revealed "I have been notified of the presence of a hospital closed circuit system for providing the monitoring of safety and security to the patients, staff and the environment of care. I have been notified that cameras are in all areas of the hospital unit. All recordings will remain the property of Seaside Behavioral Center. This permission is granted voluntarily." Further review revealed there was a section of the form that had a box to be checked when the patient refused to sign or was unable to sign the form. There was no documented evidence that the form included that the closed circuit system monitored patients inside the patient rooms.

There was no policy presented by S1CEO that was developed to address the use of a closed circuit system that video recorded inside patient rooms that addressed how it would be determined which patients required video recording inside their rooms.

Patient #1
Review of Patient #1's medical record revealed she was PEC'd on 09/05/18 at 8:18 p.m. when she made threats to take medication to end her life. Further review revealed she took Benzodiazepines and went to sleep in the woods in a suicide attempt. Her mental condition was documented as flat affect, slow speech, and no hallucinations or delusions. She was assessed as suicidal and dangerous to herself.

Review of Patient #1's "Admit Orders" revealed she was admitted on 09/06/18 at 1:53 a.m. with a diagnosis of Depression with suicide attempt. She was admitted to Room "c" which was video-monitored with a camera inside the room. Review of her nursing assessment documented by S6RN on 09/06/18 at 2:32 a.m. revealed Patient #1 was oriented times 3, was verbal, and her recent and remote memory were intact.

Review of Patient #1's "Hospital Closed Circuit System" form revealed she signed the form on 09/06/18, and S7MHT signed as the witness.

Patient #2
Review of Patient #2's medical record revealed he was PEC's on 09/05/18 at 9:30 a.m. when he was brought to the emergency department for evaluation for bizarre behavior and positively endorsed suicidal ideation. His mental condition was documented as refusing to answer any questions and bizarre behavior, and his physical exam revealed he was alert, followed commands, ambulatory, moved all extremities, and was aggressive. Patient #2 was assessed as suicidal, dangerous to self, and dangerous to others.

Review of Patient #2's Nursing Admission Assessment documented by S8RN on 09/06/18 at 9:45 a.m. revealed he was admitted on 09/05/18 at 6:30 p.m. Review of S8RN's assessment on 09/05/18 at 6:30 p.m. revealed Patient #2 was sedated.

Review of Patient #2's "Hospital Closed Circuit System" form revealed it was signed by Patient #2 on 09/10/18 with notation on 09/05/18 at 6:50 p.m. of "unable to complete due to sedation." Patient #2 was admitted to Room "a" which was video-monitored with a camera inside the room without having Patient #2 signing his acknowledgement of being video-monitored inside his room.

Patient #3
Review of Patient #3's medical record revealed he was PEC'd on 10/07/18 at 2:01 p.m. when he presented with depression and anxiety with suicidal ideations with no plan. He was assessed as suicidal, dangerous to self, and gravely disabled.

Review of Patient #3's "Hospital Closed Circuit System" form revealed it was signed by Patient #3 on 10/07/18.

Review of Patient #3's admit orders revealed an admitting diagnosis of Depression with anxiety. He was admitted to Room "d" which was video-monitored with a camera inside the room.

Patient #4
Review of Patient #4's medical record revealed he was PEC'd on 09/27/18 at 9:50 p.m. with paranoid delusions, psychosis, and a history of Schizoaffective Disorder.

Review of Patient #4's physician admit orders dated 09/28/18 at 12:07 a.m. revealed a diagnosis of Psychosis and Paranoid Delusions. He was admitted to Room "b" which was video-monitored with a camera inside the room.

Review of Patient #4's Nursing Admission Assessment documented by S6RN on 09/28/18 at 1:13 a.m. revealed Patient #4's mental status was psychotic, delusional, and paranoid, and his behavior was cooperative.

Review of Patient #4's "Hospital Closed Circuit System" form revealed it was signed by Patient #4 on 09/28/18.

Patient #5
Review of Patient #5's medical record revealed she was PEC'd on 10/04/18 at 4:23 p.m. when she presented as an angry woman who stated she needed to be back on her psychiatric medication, seemed psychotic but was difficult to assess. Her mental condition was documented as bizarre, angry, uncooperative, and psychotic. She was assessed as currently violent and gravely disabled.

Review of Patient #5's "Nursing Admission Assessment" documented on 10/05/18 at 4:20 p.m. revealed Patient #5 refused a skin and nursing assessment.
Review of Patient #5's "Hospital Closed Circuit System" form on 10/09/18 (4 days after admit) revealed no documented evidence the form had been signed by Patient #5. Further review revealed "refuse" was written on the bottom of the form. She was admitted to Room "c" which was video-monitored with a camera inside the room without having documented evidence of acknowledgement of being notified she was being video-monitored inside her room.

Patient R1
Review of Patient R1's medical record revealed she was PEC'd on 10/05/18 at 11:00 p.m. with a history of polysubstance abuse, a diagnosis of Schizoaffective versus Bipolar, and presenting with suicidal ideations, auditory/visual hallucination, and wanting rehab. Her mental condition was documented as oriented times 3, drowsy, goal-directed, non-bizarre, and endorsing auditory/visual hallucinations. She was assessed as suicidal and dangerous to self.

Review of Patient R1's nursing admit assessment documented on 10/06/18 at 9:00 p.m. revealed she was sedated with slurred speech. She was admitted to Room "c" which was video-monitored with a camera inside the room.

Review of Patient R1's "Hospital Closed Circuit System" form revealed Patient R1 signed the form on 10/07/18 (the day after admit). There was no documented evidence Patient R1 signed acknowledgement of being notified she was being video-monitored inside her room at the time she was admitted to Room "c" which had a camera inside the room.

Review of the list of current inpatients presented by S5HRD on 10/08/18 at 11:50 a.m. revealed Patient R2 was admitted on 10/02/18 to Room "h", Patient R3 was admitted on 10/03/18 to Room "i", and Patient R4 was admitted on 10/05/18 to Room "j". Rooms "h", "i", and "j" did not have functioning video cameras in these patient rooms. Patients R2, R3, and R4 each had a diagnosis of MDD with suicidal ideations.

In an interview on 10/09/18 at 10:22 a.m., S4MD indicated it was standard in psychiatric facilities to have video cameras in patient rooms. He further indicated he understands the consideration of privacy but it's like being a "Monday morning quarterback." He indicated everyone has their right to personal privacy, but it is the standard of care to have the ability to oversee a patient who has threatened suicide. He indicated he thinks facilities should have procedures to provide for video recording, 1-to-1 observation, or observation every 15 minutes as necessary. S4MD indicated he feels it is more intimidating to have staff walking behind you for a patient with a history of paranoia, and video recording can be less invasive.

In an interview on 10/09/18 at 1:00 p.m., Patient R1 indicated she was admitted on Saturday (10/06/18). She indicated she wasn't informed she was being monitored by a video camera in her room. She then asked "then I have to change in the bathroom?" When the surveyor asked if it bothered her to be watched on a video monitor while she was in her room, she answered "yes."

In an interview on 10/09/18 at 1:05 p.m., Patient #5 indicated she was "woozy" when she was admitted, so she doesn't remember if she was informed at admit that there is a video monitor in her room. However, she indicated she knew, because she had been a patient here before. When asked by the surveyor if it bothered her to be video-monitored in her room, she indicated it depended who was watching her. She further indicated she wouldn't want a male to watch her undressing.

In an interview on 10/09/18 at 2:10 p.m., S2DON confirmed the consent doesn't specifically say the cameras are in patient rooms. When asked how they determine which patients go into rooms with video surveillance, she indicated it's up to the nurse admitting the patient to decide to which room the patient will be admitted. She indicated they don't have a policy regarding how patient rooms are determined. S2DON confirmed Patients R2, R3, and R4 were admitted to Rooms "h", "i", and "j" respectively which did not have video monitoring inside the room, and each patient had a diagnosis of MDD with suicidal ideations.

Based on record reviews and interview, the hospital failed to ensure the nursing staff developed, and kept current, a nursing care plan for each patient as evidenced by failing to address the use of a hospital closed circuit system that video recorded patients inside their room for 3 (#1, #3, #5) of 3 patient records reviewed for nursing care plans from a sample of 5 patients.
Findings:

Review of the policy titled "Multidisciplinary Treatment Plans", presented as a current policy by S2DON, revealed the nurse will begin the Treatment Plan within 24 hours of the patient's admission to the unit. Interventions are specific treatment actions being provided including interdisciplinary approaches and treatment modalities based on assessment which certain staff or discipline are assigned to carry out to assist the patient in achieving specified objectives.

Review of the medical records of Patients #1, #3, and #5 revealed each patient was admitted to a room that was monitored by a video recorder inside the patient room.

Review of the "Master Treatment Plan" for Patients #1, #3, and #5 revealed no documented evidence that the plan addressed that the patients were being monitored by video cameras placed in their room as an intervention being used.

In an interview on 10/09/18 at 2:10 p.m., S2DON confirmed the treatment plans for Patients #1, #3, and #5 did not address the use of video monitoring in the patient room as an intervention.