HospitalInspections.org

Based on policy review, record review, and interview, the hospital failed to ensure the right to patient privacy and failed to obtain written consent for treatment in advance of furnishing or discontinuing patient care for 1 of 5 sampled patients (Patient 1). This deficient practice places any patient at risk of not understanding their individual rights.

Findings Include:

Review of a hospital policy titled, "Patient Rights and Responsibilities," approved on 09/19/23 showed, " ...We respect and value our patient's role in making decisions about their health care, and we are committed to protecting their rights as a patient ...The patient has the following rights regarding information about their care:...To accept or refuse any procedure, drug or treatment and to be informed of the consequences of any such refusal ...To be informed of any hospital policies, procedures, rules or regulations that apply to their care ... The patient has the following rights regarding privacy surrounding their care: ...To personal privacy. Discussions about their care, consultations, exams and treatments will be conducted as discreetly as possible and on a need to know basis ..."

Patient 1

Review of Patient 1's medical record showed a 25-year-old admitted on 04/05/25 at 1:25 AM with a diagnosis alcohol intoxication. No past medical history.

Review of Patient 1's medical record failed to show a signed consent for treatment or Notice of Patient Privacy Practices prior to Patient 1 discharging home on 04/05/2025 at 11:18 AM.

During an interview on 04/08/2025 at 9:07 AM, Staff B, Director of Organizational Outcomes, verified Patient 1 did not have a signed consent to treat or Notice of Patient Privacy Practices in the medical record.

Based on observation, record review and interview, the hospital failed to protect patient privacy rights by failing to notify the patient/patient's representative of video monitoring for 2 of 2 sampled patients (Patient 4 and 5) and failed to post signage that video monitoring in progress as required per hospital policy. This deficient practice places patients and visitors receiving services at this hospital at risk for having their rights to personal privacy violated.

Findings Include:

Review of a hospital policy titled, "Patient Rights and Responsibilities," approved on 09/19/23 showed, " ...We respect and value our patient's role in making decisions about their health care, and we are committed to protecting their rights as a patient ...The patient has the following rights regarding privacy surrounding their care: ...To personal privacy. Discussions about their care, consultations, exams and treatments will be conducted as discreetly as possible and on a need to know basis ..."

Review of a hospital policy titled, "Med Sitter," approved on 12/19/23 showed, " ...Policy:
Mobile video monitoring may be initiated for at-risk patients who meet inclusion criteria, after other safety interventions have been trialed and have not been successful ...The patient and/or legally authorized representative will be notified of the monitoring. Cameras will provide 24/7 live feed of the patients being monitored ... Signage inside and outside the patient's room will serve to notify families, nursing and ancillary departments that the patient is being monitored ... RN: Notify the patient and/or legally authorized representative that mobile video monitoring has been implemented for safety. Provide patient/family with education document, and orient patient/family to mobile video monitoring rationale/procedure. Amend patient's plan of care (Injury Prevention Plan) to reflect use of mobile video monitoring for safety ..."

Patient 4

During an observation on 04/07/25 at 10:48 AM, the video monitoring room showed that Patient 4 was being monitored by Mobile Video Monitoring (a portable video monitor screen with camera and microphone abilities that allows one-way and/or two way video and audio communication.).

During an observation on 04/07/25 at 10:56 AM of Patient 4's room, no signage was posted that video monitoring was in progress as required per policy.

During an observation on 04/08/25 at 9:23 AM, the video monitoring room showed three unidentified patients being monitored by Mobile Video Monitoring.

During an interview on 04/08/25 at 9:23 AM, Staff D, Emergency Department (ED) Technician, identified the patient in room 208 as Patient 4.

During an observation on 04/08/25 at 9:59 AM of Patient 4's room, no signage was posted that video monitoring was in progress as required per policy.

Review of Patient 4's live electronic medical record on 04/08/25 at 3:49 PM with Staff A, Chief Nursing Officer (CNO) and Staff B, Director of Organizational Outcomes, showed Patient 4 was admitted on 03/31/25 to the medical surgical floor.

Further review of the medical record failed to show documented evidence that Patient 4 or Patient 4's representative was notified of video monitoring in progress.

During an interview on 04/08/25 at 3:49 PM, Staff A, CNO and Staff B, Director of Organizational Outcomes, stated that the hospital did not follow policy when they failed to document notification to the patient and/or patient representative of video monitoring and failed to update the care plan for Patient 4 to include the use of video monitoring.

During an interview on 04/08/25 at 3:49 PM, Staff A, CNO, stated that there was no signage posted outside the patient room notifying any staff or visitor that video monitoring was in progress as required per hospital policy.

Patient 5

During an observation on 04/07/25 at 10:48 AM, the video monitoring room showed that Patient 5 was being monitored by Mobile Video Monitoring.

During an observation on 04/07/25 at 10:56 AM of Patient 5's room, no signage was posted that video monitoring was in progress as required per policy.

During an interview on 04/08/25 at 9:23 AM, Staff D, Emergency Department (ED) Technician identified the patient in room 207 as Patient 5.

Review of Patient 5's live medical record showed Patient 5 did not have a durable power of attorney (DPOA) on file.

Review of Patient 5's live electronic medical record on 04/08/25 at 3:49 PM with Staff A, Chief Nursing Officer (CNO) and Staff B, Director of Organizational Outcomes, showed Patient 5 was admitted on 03/10/25 to the medical surgical floor.

Further review of Patient 5's medical record failed to show documented evidence that Patient 5 or Patient 5's representative was notified of video monitoring in progress.

Further review of Patient 5's medical record failed to show documented evidence that the plan of care (Injury Prevention Plan) was updated to reflect the use of mobile video monitoring for safety as required per hospital policy.

During an interview on 04/08/25 at 3:49 PM Staff A, CNO and Staff B, Director of Organizational Outcomes, stated that the hospital did not follow policy when they failed to document notification to the patient and/or patient representative of video monitoring and failed to update the patients care plan for Patient 5.

During an interview on 04/08/25 at 3:49 PM, Staff A, CNO, stated that there was no signage posted outside Patient 5's room notifying any staff or visitor that video monitoring was in progress as required per hospital policy.

Based on interview, record review, and facility policy review, the hospital failed to ensure that the use of restraints was in accordance with regulation and hospital policy as evidenced by the use of four bed rails to prevent a patient from being able to freely exit his or her bed for 1 of 5 (Patient 4) sampled patients observed for restraints.

This deficient practice is a violation of patient rights and places any patient receiving services at this hospital at risk of unauthorized use of restraints that may lead to serious injury and harm.

Findings Include:

Review of a hospital policy titled, "Restraint Policy," approved 09/14/22, showed, " ...Physical restraint: Any manual method or physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. (CMS CoPs 482.13) This includes: a. The use of side rails to prevent a patient from exiting a bed ..."

Patient 4

An observation on 04/07/25 at 10:48 AM of the video monitoring room, showed a Patient in room 208 observed via video monitoring with four bed rails up.

An observation on 04/07/25 at 10:56 AM of the second floor, showed a patient in room 208 with four bed rails up.

An observation on 04/08/25 at 9:23 AM of the video monitoring room, showed a Patient in room 208 observed via video monitoring with four bed rails up.

During an interview on 04/08/25 at 9:23 AM, Staff D, Emergency Department (ED) Technician identified the patient in room 208 as Patient 4.

An observation on 04/08/25 at 9:59 AM of the second floor, showed Patient 4 with four bed rails up. An unidentified Registered Nurse (RN) verified that Patient 4 did not have an order for restraints.

Review of Patient 4's live electronic medical record on 04/08/25 at 3:49 PM with Staff A, Chief Nursing Officer (CNO) and Staff B, Director of Organizational Outcomes, showed Patient 4 was admitted on 03/31/25 to the medical surgical floor. During the record review, Staff A and Staff B confirmed that the medical record failed to show documented evidence that Patient 4 had an order for restraints.

Based on policy review, document review, and interview, the hospital failed to ensure restraints were used in accordance with an order from a physician or other licensed practitioner for 1 of 5 (Patient 4) sampled patients reviewed for restraints. This deficient practice violated patient rights and places any patient receiving services at this hospital at risk for serious injury and harm.

Findings Include:

Review of a hospital policy titled, "Restraint Policy," approved 09/14/22, showed, " ...1. Each episode of restraint use requires an order from the licensed independent practitioner (LIP) responsible for the patient's care.

Patient 4

An observation on 04/07/25 at 10:48 AM of the video monitoring room, showed four unidentified patients being monitored by Mobile Video Monitoring. Monitoring showed a patient in room 208 with all four bed rails up.

An observation on 04/07/25 at 10:56 AM of the second floor, showed a patient in room 208 with four bed rails up.

During an interview on 04/08/25 at 9:23 AM, Staff D, Emergency Department (ED) Technician identified the patient in room 208 as Patient 4.

An observation on 04/08/25 at 9:23 AM of the video monitoring room, showed Patient 4 in room 208 observed via video monitoring at this time with bed all four bed rails up.

An observation on 04/08/25 at 9:59 AM of the second floor ,showed Patient 4 with four bed rails up. At the time of observation an unidentified Registered Nurse (RN) verified that Patient 4 did not have an order for restraints.

Review of Patient 4's live electronic medical record on 04/08/25 at 3:49 PM with Staff A, Chief Nursing Officer (CNO) and Staff B, Director of Organizational Outcomes showed that Patient 4 was admitted on 03/31/25 to the medical surgical floor. During the record review Staff A and Staff B confirmed that the medical record failed to show documented evidence that Patient 4 had an order for restraints.