HospitalInspections.org

Based on observation, interviews and document review, the facility failed to protect the confidentiality of patient clinical records in accordance with facility policy and regulatory requirements for a census of 112 patients.

This failure violated patients' rights to confidentiality of their protected health information (PHI) in an acute psychiatric hospital setting.

Findings:

According to the U.S. Department of Health and Human Services (www.hhs.gov), the 1996 HIPAA (Health Insurance Portability and Accountability Act) Privacy Rule defines "[PHI] as individually identifiable health information, including demographic data, that relates to the individual's past, present or future physical or mental health or condition [and] the provision of health care to the individual".

During an initial tour of the facility with the Chief Nursing Officer (CNO), the Assistant Nursing Officer (ANO) and the Chief Operations Officer (COO) on 4/22/25 at 10:30 a.m., unattended patient clinical records and provider notes were observed on the table in the 2nd floor lounge between patient units 2 West and 2 East (common area that included reclined chairs, a coffee table, lockers and elevators). Further observation revealed PHI including, but not limited to, patient names, medical record numbers, provider notes, assessments and psychiatric diagnoses.

During a concurrent observation and interview on 4/22/25 at 10:35 a.m., it was observed Nurse Practitioner (NP) exited patient unit 2 East and returned to the clinical records on the table. NP stated the papers included her provider notes and patient information.

During an interview on 4/22/25 at 10:40 a.m., the CNO stated staff and patients walk through the lounge on their way to other areas of the hospital.

During an observation on 4/22/25 at 10:40 a.m., a housekeeper was observed cleaning the lounge.

Review of a facility policy titled, "Patient's Rights and Responsibilities, RI17", dated 10/24, indicated, "The patient has the right, within the law, to personal and informational privacy".

Review of the facility February 2019 Medical Staff Bylaws, and Rules and Regulations indicated that "Membership on the medical staff of [hospital name] or exercise of Temporary Privileges is a privilege that shall be granted to and continued with only professionally qualified and currently competent Members who...(e) comply with the facility's HIPAA policies".

Based on observation, interview, and record review, staff failed to follow policies and procedures (P&P) for three of 33 sampled patients (Patient 1, Patient 17, and Patient 18) when:

1. A Mental Health Technician (MHT) found Patient 1 unresponsive on a bathroom floor, and it took two minutes to start CRP (Cardiopulmonary Resuscitation - an emergency lifesaving procedure performed when the heart stops beating), five minutes to call 911 (to get paramedics to bring Patient 1 to general acute care hospital), and 12 minutes to bring the emergency equipment cart (a wheeled container carrying medicine and equipment for use in medical emergencies) into Patient 1's room.

2. Nursing staff failed to complete fall risk assessments after Patient 17 fell three times.

3. Nursing staff failed to complete a fall risk re-assessment after Patient 18 had a fall.

These failures results in an uncoordinated and delayed response to Patient 1's medical emergency, which may have potentially contributed in Patient 1's death, and may have increased the risk of Patient 17 having two additional falls resulting in a fracture of his lower back, and may have increased the risk for Patient 18 to have additional falls with injuries.

Findings:

1. During a record review of Patient 1's "Progress Note (PN)", dated [3]/8/25, the PN indicated, "It was 5:50 am when my MHT called me telling me that there is an emergency...911 was here or arrived at 6:00. EMTS (Emergency Medical Technicians - a medical professional that provides emergency medical services) continued CPR 20 minutes but patient expired...Patient pronounced dead at 6:23 am."

During an interview on 4/22/25 at 11:24 a.m., with Registered Nurse (RN) 5, RN 5 stated that staff training included Code Blue and Code 100 (Code to alert staff of minor emergencies). RN 5 stated, "RNs will be the leader of the code and will be the one who initiate it. The leader is normally the charge nurse". RN 5 added the charge nurse would assign staff tasks during a code, which included getting the emergency equipment cart, calling 911, and notifying the supervisors. RN 5 stated, when staff hear a Code Blue alert, "We rush immediately after we hear the overhead announcement. The expectation is to rush, assess, and help on the situation."

During an interview on 4/23/25 at 9:43 a.m., with the Chief Nursing Officer (CNO), the CNO stated nurses could have approached Patient 1's medical emergency on 3/8/25 differently, such as delegating tasks to the MHTs to immediately retrieve the emergency equipment cart when the charge nurse returned to the patient. Additionally, the CNO confirmed the nursing staff's handling of Patient 1's Code Blue did not align with the hospital's P&P or meet the hospital's expectations. The CNO added, "Staff could have done a more effective job at handling the code."

During an interview on 4/24/25 at 9:36 a.m., with the Chief Executive Officer (CEO), the CEO stated Patient 1's Code Blue Form (a structured format for documenting medical interventions during emergencies) was not completed due to the termination of the nursing staff on the same day as the incident. Furthermore, the CEO was unable to confirm whether the nursing staff involved had initiated a hospital wide Code Blue alert, and stated the nursing staff should have promptly initiated a Code Blue alert when Patient 1 was found unconscious on the bathroom floor and utilized the tools and knowledge gained from their training.

During a concurrent video surveillance review of the incident which involved Patient 1 and interview with the Director of Risk Management (DRM) on 4/24/25 at 8:30 a.m., the DRM stated the nursing staff's management of the Code Blue and their response failed to meet the hospital's established standards and expectations. Furthermore, the DRM added the nursing staff involved in the Code Blue were subsequently terminated. The DRM also confirmed the video indicated :

1. At 5:44 a.m. - MHT 2 discovered Patient 1 on the bathroom floor
2. At 5:45 a.m. - MHT 2 notified RN 2 at the nursing station
3. At 5:46 a.m. - RN 2 and MHT 2 went back to Patient 1's room, CPR initiated by RN 2.
4. At 5:47 a.m. - MHT 2 called RN 1 from the nursing station.
5. At 5:48 a.m. - MHT 2 obtained the vital signs (records blood pressure, heart rate, respiratory rate, and blood oxygen level) machine from unit 3W and brought it to Patient 1's room on unit 3E.
6. At 5:49 a.m. - RN 1 arrived and assigned MHT 2 to call 911.
7. At 5:56 a.m. - MHT 2 and MHT 3 brought the emergency equipment cart to Patient 1's room.
8. At 6:01 a.m. - EMTs arrived and continued CPR on Patient 1.
9. At 6:23 a.m. - Patient 1 expired.

During an interview on 4/25/25 at 9:45 a.m., with the DRM, the DRM stated the significance of staff adhering to the hospital's P&P for Code Blue was, "To ensure the safety of all patients within our care and aid in their recovery for stabilization."

During a review of a facility document titled "[Name of Hospital] Position Desription" for Mental Health Technician, dated 7/19, the document indicated, "Qualifications...Additional Requirements: Incumbent must maintain a current, valid certificate in Cardiopulmonary Resuscitation (CPR)...Knowledge, Skills, and Abilities...1. Knowledge of all code procedures."

During review of a document titled, "[Name of Hospital] Position Desription" for Staff Nurse (R.N.), dated 7/19, the document indicated, "Qualifications...Additional Requirements: CPR certification...Knowledge, Skills, and Abilities...2. Knowledge of all code procedures."

During a review of the hospital P&P titled, "Code Blue" revised 5/23, the P&P indicated, "In the event that a person is found in cardiac/respiratory arrest [heart or lungs stop working] or any medical emergency: 1. Staff member will clearly announce, "Code Blue", and give precise location ...over facility paging system ...2. Nursing Staff on the unit will respond to the location of the Code Blue, as assigned on the Nursing Assignment Sheet, and will bring the designated emergency equipment cart...4. Staff member trained...will begin providing CPR...The Code Blue Leader will direct other members of the team to complete the following: a. call 911 ...1. RN will document in Code Blue/Code 100 Form."

During a review of the hospital P&P titled, "Code 100", dated 10/24, the P&P indicated "...where the patient no longer has a pulse and/or is not breathing, a Code Blue is to be initiated and announced over the facility paging system ...9. The code blue record is to be completed during the code ..."

2. Review of Patient 17's clinical record titled, "Face sheet", indicated Patient 17 was admitted to the hospital on 12/4/24 at 4:16 p.m. and discharged on 12/21/24 at 11:18 p.m.

Review of Patient 17's clinical record titled, "Pre-Admission High Risk Notification Form [HRN]", dated 12/4/24 at 4:50 p.m., indicated Patient 17 had a history of falls and continued to have a high-risk factor for falls. The HRN indicated Patient 17 used a front wheel walker [FWW] and had a history of stroke causing mild left sided weakness.

During a concurrent interview and record review on 4/24/25, at 11:15 a.m., with Performance Improvement Consultant (PRC), of Patient 17's medical record and an untitled document of Patient 17's falls while at the hospital from 12/4/24 through 12/20/24 were reviewed. The PRC confirmed the incidences of falls and associated documentation indicated the following:

A. On 12/5/24 at 2:12 a.m., Patient 17 had an unobserved fall on 12/4/24 at 11:55 p.m. in patient room with no injury. There was no documented evidence of a fall risk re-assessment in Patient 17's chart.

B. On 12/8/24 at 4:46 p.m., Patient 17 had an observed fall on 12/8/24 at 4:46 p.m. in common area. Patient 17 had moderate pain at the back of her head post fall. There was no documented evidence of a fall risk re-assessment in Patient 17's chart.

C. On 12/12/24 at 1:40 p.m., Patient 17 had an observed fall on 12/12/24 at 1:40 p.m., in group room with no injury. There was no documented evidence of a fall risk re-assessment in Patient 17's chart.

D. On 12/13/24 at 9:11 p.m., Patient 17 had an observed fall on 12/13/24 at 4:30 p.m., in patient room with no injury.

E. On 12/20/24 at 5:50 a.m., Patient 17 had a fall on 12/20/24 at 4:30 a.m. in patient room. Patient 17 was admitted to the acute care hospital with diagnosis of fractured lumbar spine (break in bones of lower back)."

During a concurrent interview and record reviews on 4/23/25, at 12:09 p.m., with Chief Operations Officer (COO), Patient 17's clinical record titled "HRN" dated 12/4/24 at 4:50 p.m. was reviewed. COO confirmed the "HRN" was not signed by the nurse admitting the patient on the unit. COO stated, "The nurses use this paper, pre-admission high risk notification form to paint the picture of the needs of the patient, this will tell what precautions to put in place and then will do their own assessment on admission ...Pre-Admission high risk notification form needs to be signed by the admitting nurse on the floor asap and it was not done."

During an interview on 4/24/25, at 2:40 p.m. with Charge Nurse (RN 6), RN 6 stated, "When the patient comes to us on the floor, patient comes in with high risk notification form, we know their risk factors and we start the interventions right away ...we have to complete the forms within 2 hours of patient coming to the unit ...If a patient falls in spite of all interventions in place, we do fall re-assessment, to manage risk factors for falls and avoid injuries."

3. Review of Patient 18's clinical record titled,"Face sheet", indicated that Patient 18 was admitted to the hospital on 11/20/24 at 12:50 p.m. and discharged on 11/27/24 at 5:18 p.m.

Review of Patient 18's clinical record titled," HRN", dated 11/20/24 at 1:10 p.m., indicated Patient 18 had history of falls and was also currently high-risk for falls. Patient 18 used a cane and was agreeable to use a FWW.

Review of Patient 18's incident report documentation, dated 11/20/24 at 11:18 p.m., indicated Patient 18 had a witnessed fall in the hallway on 11/20/24 at 9:50 p.m. The incident report further indicated that around 9:50 p.m. Patient 18 was attempting to get on to the chair to reach the patient phone in the hallway when she lost her balance and fell on her tail bone. Patient 18 complained of pain, bruises were noticed on the back and was sent to hospital for further evaluation. Patient 18 returned from the hospital with a diagnosis of pelvic fracture.

During an interview on 4/24/25, at 10 a.m. with COO, COO confirmed a fall risk re-assessment was not completed after Patient 18's fall on 11/20/24.

A review of the hospital's P&P titled, "Fall Assessment/Precautions", last revised 1/25, indicated, "[Hospital] has established guidelines to assess it's patients' risk for falls, develop action plans to reduce the risk of falling and fall related injuries and to maintain a safe and therapeutic environment of care ... Assessments For Adult patients- A Registered Nurse will complete an Edmonson Psychiatric Fall Risk Assessment upon admission as part of the Admission Nursing Assessment and reassess if a patient's medical condition changes or if a patient falls ...Upon Fall Risk Assessment, if the patient scores 70 or greater, a Fall risk Treatment Plan and Fall Precautions will be initiated. Patients can also be deemed a fall risk based on referral information. The A & R [Assessment and Referral] department can place a patient on fall precautions with the physician's order identified on the Admission Order. Reassessments are completed daily and documented on the fall-risk re-assessment form, treatment plan, weekly update form, and/or in the 24 hour nursing note."

A review of the hospital's P&P titled, "Precautions", last revised 1/2025, indicated, " It is the policy of the [Hospital] to provide a therapeutic environment to meet the treatment needs of a patient presenting with high risk behavior(s) and appropriate interventions to decrease risk to the patient, peers, staff and visitors ...When a patient is placed on precautions at admission, his/her "Pre-Admission High Risk Notification Form [HRN]" ...will be completed to reflect the precaution(s) ordered."