HospitalInspections.org

Based on document review, observation, and interview, it was determined that for 4 of 4 patients (Pt #5, Pt #11, Pt #12, Pt #13) observed on closed circuit video monitoring, the Hospital failed to adhere to measures to ensure that patient's personal privacy was maintained.

Findings include:

1. The Hospital's policy titled, "AAH [Hospital] Patient Rights and Responsibilities" (dated 12/12/2019), was reviewed, and required, "...Confidentiality & Privacy: Patients will be given reasonable visual and auditory privacy and may request a transfer to another room when such accommodations are available...Additionally, patients have a right to personal privacy which includes at a minimum that patients have privacy accommodations depending on safety risks during personal hygiene activities..."

2. The Hospital's policy titled, "IMMC [Hospital] Supplemental Protocols for Management of Suicidal/Homicidal Patients" (3/24/2023), was reviewed, and required, "Purpose: To provide guidelines for the management of the suicidal patient admitted to non-psychiatric units that will reduce the likelihood of self-inflicted harm...Closed Circuit Video Monitoring: In real-time a staff member monitors patients visually in a centralized location using the unit's video monitoring equipment in order to alert other staff members on the unit to respond immediately for any safety alerts...Admitting RN [registered nurse] and/or RN assigned for the shift: Placement of cameras in the room are positioned so that the patient privacy curtain cam be utilized by caregivers as appropriate for bathing, exams, procedures, etc...The RN will document a nursing progress note when video monitoring is initiated." On 5/17/2023 at 10:15 AM, the Inpatient Unit Director (E #8) stated that although this policy is titled for suicidal/homicidal patients, it also covers non- suicidal/homicidal patients that may require video monitoring.

3. On 5/15/2023 at 10:15 AM, an observational tour of the 5341 (Medical Unit) was conducted. During the tour, it was noted that a video monitoring system is set-up and in use at the nurse's station right off the hallway corridor. There were 4 patients (Pt #5, Pt #11, Pt #12, Pt #13), being monitored via video per a RN sitting at the nurse's station.

4. On 5/16/2023 at 10:30 AM, an additional tour of the 5341 (Medical Unit) was conducted. The rooms in which Pt #5, Pt #11, Pt #12, and Pt #13 were in on 5/15/2023, did not have the capability to draw the privacy curtain in front of the video care when personal care is being provided. In Pt #13's room, wound care was being performed and was visible on the camera, as the camera was not suspended during that time.

5. On 5/16/2023, the clinical records for Pt #5, Pt #11, Pt #12, and Pt #13 were reviewed and lacked RN clinical documentation/progress note from when the video monitoring was intiated, per policy.

6. On 5/16/2023 at 10:40 AM, an interview was conducted with E #8. E #8 confirmed that the privacy curtains were installed in the way that they cannot be drawn in front of the camera since these rooms are in an older constructed building. E #8 stated that since the curtains can't be drawn in front of the camera, the cameras should be suspended when personal care is being provided to the patient. E #8 acknowledged that the 4 clinical records lacked nursing documentation on video monitoring.

Based on document review, observation, and interview, it was determined that for 1 of 1 Behavioral Health Unit observed for safety measures implemented, the Hospital failed to ensure that patients received care in a safe setting, by not removing a potentially hazardous device from patient's access, including patients on assault precautions.

Findings include:

1. The Hospital's policy titled, "AAH [System Hospital] Patient Rights and Responsibilities" (dated 12/12/2019), was reviewed on 5/16/2023, and required, "The purpose of this Policy is to delineate the rights and responsibilities of patients and their representatives...Patient safety: Team members will follow current standards of practice and existing policies and procedures from patient environmental safety...and will protect vulnerable patients..."

2. The Hospital's policy titled, "'IMMC [Hospital] Assault Precautions (Behavioral Health Department) (dated 1/11/2022), was reviewed on 5/16/2023, and required, "...The staff will do a search of the patient's belongings, clothing and room for potentially dangerous objects. Items that are not considered contraband but could be weaponized (e.g., thrown) may be removed..."

3. On 5/15/2023 at 2:15 PM, an observational tour of the Behavioral Health Unit (631) was conducted. During the tour, in Pt #7's room, a medical device (walker) was at the patient's bedside, with no staff present and accessible to other ambulatory patients. According to the Charge Nurse (E #4), Pt #7 used to be on 1:1 (sitter precautions), but no longer is as of 5/3/2023 (12 days prior).

4. The Behavior Health's Unit Precautions list was reviewed. Pt #7 was not on assault precautions (when a patient demonstrates a potential for acting out aggressively). However, 13 of the 16 patients on the unit were on assault precautions.

5. On 5/15/2023 at 2:30 PM, an interview was conducted with the Director of Behavioral Health (E #5). E #5 stated that she sees the potential risk of having Pt #7's walker unattended. E #5 stated that the walker could be potentially used as a weapon and since Pt #7 was off 1:1 precaution, the walker should have been kept behind the nurse's station for safety reasons.

Based on interview and document review it was determined that for 2 of 4 (Pt. #1 and Pt. #2) clinical records reviewed regarding use of restraints, the Hospital failed to ensure that a physician's order was obtained.

Findings include:

1. On 5/16/2023 at approximately 9:45 AM, an interview was conducted with a Registered Nurse (RN/E#1). E #1 stated that (Pt. #1) had to be restrained on 4/2/23, with soft wrist restraints during E #1's shift, due to the patient thrashing around while needing lab draws. E #1 stated that E #1 did not get a physician's order, E #1 assumed that the Charge Nurse (E #3) would get the physician's order.

2. On 5/16/2023, at approximately 12:00 PM, an interview was conducted with Attending Internal Medicine Hospitalist (MD#1). MD #1 stated that he recalled patient with no recollection of being contacted regarding Pt. #1 being placed in restraints. MD #1 stated that restraints can be placed in emergent situations, but a physician must be notified after any placement of restraints.

3. On 5/16/2023, the Hospital's policy titled, "Restraint and Seclusion" (revised 3/2023) was reviewed and included, "... III. b. A restraint is any manual hold, 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 ... Holding a patient with the intent to restrict their movement against their will, regardless of the duration of the hold ... (patients do have the right to refuse treatment) ...IV. E. A physician or APC (Advanced Practice Clinician) order must be obtained...Restraint Order Renewal: Each restraint order may be renewed based on the following limits for up to a total of 24 hours except when the IL Mental Health Code applies."

4. On 5/15/2023, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital's Medical Surgical unit on 3/29/2023 with a diagnosis of biliary obstruction (digestive tract blockage). The clinical record did not include a physician's order regarding use of non-violent restraints.

5. On 5/16/2023, the clinical record of Pt #2 was reviewed, Pt #2 was admitted to the Hospital's Medical unit on 3/9/2023 with a diagnosis of CVA (stroke). Pt #2's nursing restraint flowsheets indicated that the patient was in non-violent (medical) restraints on 3/10, 3/11, 3/12, 3/13, 3/16, 3/17, 3/28, 3/30, 3/31, 4/1, 4/2, 4/3, 4/4, 4/5, 4/6, 4/7, 4/8, 4/9. and 4/10/2023. Pt #2's clinical record lacked physician's orders for the use of restraints on 3/12, 4/1, 4/7, and 4/9/2023.