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Based on interview and document review, the governing body failed to have systems that were effectively established and implemented to ensure patient rights were upheld, including the right to personal privacy in the emergency department (ED). This deficient practice had the potential to affect all patient who met the psychiatric status to be placed in one of the three monitored rooms.

Findings include:

The hospital was found not to be in compliance with the Condition of Participation of Patient Rights at 42 CFR 482.13 when the hospital failed to protect patient rights in the ED. The hospital intituted practices for video taping patients in 3 examination rooms used for patients presenting with behavioral issues.

On 7/26/18, at 12:12 p.m. the Vice President of Patient Care Services (VPC) for the facility and the Regional Quality Director (RQD), verified video monitoring affected three patient rooms in the ED which were used routinely used for patients with mental health/behavioral health concerns until they were assessed for possible inpatient admission. The VPC verified there were a total of eight rooms in behavioral unit of the ED with video capability however, only three of them were used routinely for triage of patients coming in to be evaluated for behavioral health and would have been subject to video recording without the patient's knowledge. This had the potential for affect all patients admitted to one of the three designated behavior examination rooms located in the emergency department.

Based on observation, interview and document review, the hospital failed to protect patient rights to privacy related to the use of video taping equipment, without patient consent, in the emergency department (ED). 1 of 2 patients (P33) reviewed in regards to a complaint (H0078047) verified the hospital had video taped them in an ED exam room without verbal or documented consent. It was further learned the video taping of behavioral patients who present to the emergency department was a routine practice which had the potential to affect other patients who arrived at the hospital for care. As a result of these findings, the hospital was found not to be in substantial compliance with the Condition of Participation of Patient Rights at 42 CFR 482.13. The cumulative effect of this system failure resulted in the hospital's inability to ensure care was provided in an effective manner and in accordance with patient rights.

Findings include:

The hospital failed to promote P33's right to not have video taping conducted without consent after she presented to the emergency department for a psychiatric assessment requested by the city police.

On 7/26/18, at 12:12 p.m. the Vice President of Patient Care Services (VPC) for the facility and the Regional Quality Director (RQD), verified video monitoring affected three patient rooms in the ED which were used routinely used for patients with mental health/behavioral health concerns until they were assessed for possible inpatient admission. The VPC verified there were a total of eight rooms in behavioral unit of the ED with video capability however, only three of them were used routinely for triage of patients coming in to be evaluated for behavioral health and would have been subject to video recording without the patient's knowledge. This had the potential for affect all patients admitted to one of the three designated behavior examination rooms located in the emergency department.

Refer to A143 for additional information.

Based on interview, document review and video tape review, the hospital failed to promote visual privacy for 1 of 2 patients (P33) reviewed when the patient presented to the emergency department (ED) for psychiatric evaluation and was videotaped without her knowledge or consent. This lack of verbal knowledge or consent violated P33's right to personal privacy. This investigation was in response to complaint H0078047.

Findings include:

P33 was brought to the ED on 5/25/18 at 10:14 p.m. via a police transport hold for welfare check which required a psychiatric/medical evaluation after C1 had made repeated phone calls to 911.

On 7/25/18 at 12:15 p.m. an archived video tape of P33 while in the emergency department examination room was reviewed with the provider and surveyors for content. During the review, the provider answered surveyor questions regarding content. The tape and comments from the hospital staff started with P33's arrival in the ED on 5/25/17, at 10:14 p.m. At the time of her presentation to the ED, P33 declined to sign a consent for treatment form, and declined to sign the hospital's declination form. P33 was then moved to the emergency department examination room, P33 was requested to change into behavioral scrubs. P33 initially refused to change into scrubs, then after a long conversation with the 5 staff members in the room (which included two security guards), P33 agreed to change her clothing. Before changing her clothes the five hospital staff left the room. P33 then removed her blouse and pants, and put the scrub top on. She threw the pants across the room. When P33 changed her cloths her upper back and shoulders were visible on the tape. No other bare body parts were observed on the tape. After changing her clothes, P33 was observed to sit on the bed and pulled a folded bath blanket over her lap momentarily, then pushed that aside and paced the room wearing the scrub top. At 11:04 p.m. the ED physician entered the room to assess P33. At 11:44 p.m. the ED physician returned to the room by request of P33, who requested her belongings and stated she wanted to go home. Towards the end of the tape P33 was given her belongings back, changed into her own clothing, again facing away from the camera, with only her upper back and shoulders exposed. P33 then signed the discharge form and wrote "illegally detained." At 12:46 a.m. P33 was given discharge paperwork and exited the ED room. The tape recording stopped at that time.

During interview on 7/25/18, at 12:25 p.m. the emergency room director (ERD) stated the purpose of video monitoring patients in the ED rooms was to evaluate and treat patients who may be a danger to themselves or others was for safety reasons because the hospital had experienced an increase in violent patients in the previous year. The ERD stated P33's behavior had been "erratic and she was threatening to sue the hospital" during her ED course. ERD stated the video monitoring footage was only visible at the ED nursing station, which was centrally located within a pod of patient rooms and was not visible to the public. The ERD stated the video monitoring could be turned off at the nursing station, however, the usual nursing practice was to leave the video screen up and activated on the monitor at all times. The hospital's director of security (DS), who was also present during the interview, stated on 5/30/17, the video footage had been archived because P33 had lodged a complaint with the hospital. The DS stated absent a complaint the video footage would have been taped over within 30 days.

On 9/29/17, A United States District Court for the District of Minnesota ordered the facility to turn over "All video and audio recordings, and all other documents and files, electronic files and other items related to P33's care on 5/25-26/2017.

On 7/25/18, at 10:30 a.m. P33 was called and interviewed regarding the complaint filed with CMS (Center for Medicare/Medicaid Support) with three surveyors who introduced themselves to P33 before the interview began. During the phone interview P33 encouraged the surveyors to view the video tape that had been recorded during her stay in the emergency department on 5/25/18, in the late p.m. (afternoon). P33 stated, "I was really shocked that they videotaped me the whole time I was there." P33 stated the video tape "was horrifying to her" and there were no markings in the room to tell her she was being recorded. P33 stated she learned she was being video recorded after requesting tapes of her entering and leaving the ED for a federal court case she had filed related to the ED visit and her treatment by the police. P33 was surprised to see video footage of her while in the exam room of the ED versus just leaving and entering the hospital as she would have expected to be captured by the security cameras at the ED entrances. P33 stated she had refused to sign consent for treatment at the hospital rather, annotated the consent form indicating she was "illegally detained." P33 stated she declined the consent because she did not feel the police needed to take her to the ED because she did not agree she was a danger to herself or others, and did not feel she required the mental health evaluation.

On 7/25/18, during a follow-up tour of the physical environment of the ED area, it was noted that there was no signage from the Sally Port into the behavioral area to notify patients video recording was used, nor was their signage in the patient rooms. A television screen for patient room monitoring with split screens for several patient rooms was visible from behind the nursing desk in the central nursing station, and was accessible and visible to patient care staff working on the unit.

The hospital consent for treatment form dated 2/3/17: indicated Photos/video: Care teams may take photos or videos for medical or teaching purposes. If the photos or videos are used for teaching, my name or other information that would identify me will not be shown. It was later learned that P33 had declined to sign the consent for treatment form and declined to sign the declination form on and during the ED stay.

On 7/26/18, at 12:12 p.m. the Vice President of Patient Care Services (VPC) for the facility and the Regional Quality Director (RQD), verified that because P33 had not signed the consent for services form, and had no other way of knowing that a video recording was in progress, there was no signage posted in the ED hallways approaching the behavioral rooms, and no signage in the exam room itself. The VPC further stated that the hospital's policy needed to be "revisited", and the intent of the video monitoring was to provide a lower level of supervision for those patients who were not assessed to require a 1:1 sitter for safety, however, still required additional monitoring to ensure safety. The VPD stated the video monitoring affected three patient rooms in the ED which were used routinely used for patients with mental health/behavioral health concerns until they were assessed for possible inpatient admission. There were a total of eight rooms in behavioral unit of the ED with video capability, however, only three of them were used routinely for triage of patients coming in to be evaluated for behavioral health and would have been subject to video recording without the patient's knowledge. The video monitoring did not occur in the other ED units used to room patients with other medical concerns. The RQD stated that the video monitoring policy was an issue that needed a "bigger fix."

The hospital's policy entitled, Photography and other Recording Devices, Use of, printed 6/25/18, indicated that video recording of a patient for treatment purposes was allowed when the patient signed the consent form on admission to the hospital. Types of recording devices included, but were not limited to video cameras.

Based on interview, document review and video tape review, the hospital failed to ensure a process for quality assessment and performance improvement activities that promoted patient rights regarding video taping without consent or knowledge of being video taped when presented at the emergency department to be assessed for behavioral concerns and examined in a designated behavioral exam room which had a camera taping the entire stay in the room. The hospital failed to identify rights violation regarding no consent was given to the patient or concern with privacy when undressing/dressing as an opportunity for quality improvement related to patient rights for visual privacy for 1 of 2 patients (P33). This had the potential to affect all patients who receive emergency department treatments and were placed in one of the three designated behavior rooms which contained a camera. This was in response to complaint H0078047.

Findings include:

P33 was brought to the ED on 5/25/17, at 10:14 p.m. via a police transport hold after a welfare check which required a psychiatric/medical evaluation in regards to repeated phone calls to 911 were made by P33.

On 7/25/18, at 12:15 p.m. an archived video tape of P33 while in the emergency department (ED) examination room had been provided by the hospital regarding P33's emergency room visit on 5/25/17 at 10:14 p.m. This tape was viewed by the provider and surveyors for content. The provider answered surveyor questions as the tape was screened for content. The tape started with P33 entering the examination room accompanied by hospital security personal and licensed staff. After P33 had entered the examination room she was requested to change into behavioral scrubs. P33 initially refused to change into the scrubs until security personal talked to her. The hospital and security staff left the room, then P33 was seen taking her clothing off and put on the scrub top and threw the bottoms across the room. P33 left her underwear on. During the time she was undressing/dressing the location of the camera allowed only her upper shoulders and head could be seen. After changing into the scrub top P33 sat on bed, then wandered around the room. At 11:04 p.m. the ED physician entered the room and examined/assessed P33 while providing visual privacy the entire time. After completing his assessment/examination her left the room leaving P33 alone. At 11:44 p.m. the ED physician returned to the room by request of P33, who requested her belongings and to go home which were provided by staff. Before leaving the exam room P33 had been asked to sign a discharge form and P33 wrote, "illegally detained." At 12:46 a.m. P33 was given discharge paperwork and exited the ED room.

It was later learned that P33 was not informed of the continuous video taping of her stay while in the designated behavior examination room, and she refused to sign the consent for treatment form or to sign the declination form.

On 7/26/17, at 12:12 p.m. the Regional Director of Quality (RDQ) and the Vice President of Patient Care Services (VP-PC) stated that the Director of Patient Satisfaction makes a report to the quality committee about grievances. However this specific incident had not been reviewed in quality.

The video monitoring policy had been revised by practice council effective 2/16, and revised 2/2018. The Policy had been reviewed by system Nursing Practice Council, and has to go through the system Emergency Department Leadership.

Based on observation, interview and documentation review, the hospital was found to be out of compliance with Life Safety Code (LSC) requirements. These findings had the potential to affect all patients in the hospital.

Findings include:

Refer to Life Safety Code deficiencies at K351 and K920.

Based on interview and document review, the facility failed to implement policy to ensure timely notification of death to the organ procurement organization for evaluation of potential organ, tissue and eye donation for 2 of 5 patients (P2 and P4) who died in the hospital.

Findings include:

On 7/26/18, at 9:10 a.m., a review of the facility's death records was conducted with intensive care nurse manager (ICNM)-H the hospital's organ procurement coordinator, registered nurse educator (RNE)-I and nursing director (RN)-J present. The review revealed the following:

P2 had presented to the emergency room on 8/6/17, with alerted mental status, weakness, low blood sugar and emesis. P2's condition rapidly deteriorated and died at 3:30 p.m. P2's Record of Death form identified P2's time of death as 8/6/18 at 3:30 p.m., however, the form lacked documentation of the time the Donor Referral line had been notified. There was no further documentation in P2's medical record of the time the Donor Referral line had been notified of P2's death.

P4 had presented to the emergency room on 2/10/18, with cardiac arrest. P4 was declared dead at 9:02 a.m., and family was notified of P4's death at 10:40 a.m. However, P4's Record of Death form identified the Donor Referral line had been notified at 11:00 a.m., 1 hour and 58 minutes after P4 had been declared dead. There was no further documentation of the time of notification of death in P4's medical record.

On 7/26/18, at 9:20 a.m., ICNM-H stated the facility had a contract with Lifesource for organ, tissue procurement and the Minnesota Lions organization for eye procurement. She stated when a patient met the criteria for imminent death or brain death, the RN taking care of the patient was responsible to notify Lifesource within 60 minutes of the patients death. NM-H stated every patient death was to be reported to Lifesource for potential harvesting of organs, tissue or eyes. She stated the Lifesource or Minnesota Lions representatives approached the patient's family for potential donation after the notification of death. At 10:48 a.m., ICNM-H confirmed the current hospital policy and confirmed the above findings.

The hospital utilized a Record of Death form, revised 2/1/18, to record pertinent information regarding each patient's death which included the date and time of death. The form identified an Organ/Tissue/Eye Donor Assessment was to be completed on all patients within one hour of meeting clinical triggers(for patients on a ventilator, call when brain death in imminent OR before life sustaining therapies are withdrawn) or one hour of cardiac death. The Record of Death form also listed all patient deaths (20 weeks gestation or older) must be referred to Donor Referral line, with listed telephone number, to evaluate donation options, NO EXCEPTIONS. Further, the form included an area to document the time the donor referral line had been notified.

On 7/26/18, at 9:48 a.m., RNE-I stated nurses were required to report "every" patient death to Lifesource. She stated nurses were not required to document when Lifesource had been notified in the progress notes, however, they were required to document the time of notification on the patient's Record of Death form.

Review of the hospital's policy titled Donation/Procurement: Organ, Tissue and Eye, approved 2/21/18, listed all cardiac deaths and imminent brain deaths (20 weeks gestation and older) were referred to the organ procurement agency through the donation hotline. The policy listed the time of referral was ideally within 60 minutes of cardiac death or imminent brain death.

Review of the hospital's policy titled Donation after Circulatory Death, revised 6/17, identified timely notification to Lifesource shall occur within one hour of determining that the patient meets the criteria for circulatory death. Notification to Lifesource shall be made prior to the withdrawal of any life-sustaining support.

Based on interview and document review, the Acute Care Hospital failed to insure daily defibrillator checks were conducted for 1 of 3 defibrillator units located in the main post anesthesia care unit (PACU).

Findings include:

During review of the process for monitoring of defibrillators located on the 3 Crash Carts in the PACU area it was noted that Crash Cart #2, located in the main PACU pod (with the potential for 12 patients following surgical procedures) had not been tested daily per protocol. The Professional Practice Leader/OR Educator (PPL) and the Lead CRNA were in attendance and confirmed there were four days between July 1 and July 23, 2018, on which the procedure for the day shift charge nurse testing the defibrillator units and the evening charge nurse verified the check was completed by initialing the log the testing had not been completed. This PACU unit is in use 24 hours/day as needed for recovery.

Review of the surgical log for the dates of 7/1/18, 7/4/18, 7/14/18, and 7/15/18, included:

7/1/18- there were 8 surgical cases recovered in this PACU
7/4/18- there were 3 surgical cases recovered in this PACU
7/14/18- there were 11 surgical cases recovered in this PACU
7/15/18- there were 10 surgical cases recovered in this PACU

The nurse manager (NM)-F for the PACU was interviewed on 7/26/2018, at 11:30 a.m. confirmed surgical cases were performed and patients recovered on the dates on which the defibrillator function was not tested according to facility policy. NM-F verified that the cart and defibrillator #2 in the main PACU would have been utilized if the need had occurred. In addition to the failure to monitor the defibrillator, the log indicated changes in the lock tab which maintained integrity of the contents. In a subsequent interview the NM-F , and PPL indicated they were not aware of the gap in performance expectation. Both NM-F and PPL indicated the charge nurses were responsible to ensue that the crash cart checks were completed each shift and that the failure to follow this policy had placed all patients in that area at risk. NM-F indicated the normal practice was to collect these sheets at the beginning of the month and the missing checks would have been discovered at that time.

The facility policy: Code Blue Cart Security/Maintenance with revision date of February 2017, included: Maintenance and quality checks are required to assure the equipment and supplies are ready for immediate use. A staff member at each cart location is assigned to conduct cart inspections every day the unit provides patient care services.