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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.13 Patient Rights was out of compliance.

A-0144 The Patient has the right to receive care in a safe setting. Based on observations, interviews, and document reviews, the facility failed to ensure a safe patient care environment. Specifically, the facility failed to ensure items that posed a safety risk to patients or others, were not accessible to patients in three of three inpatient psychiatric units observed.

A-0147 The patient has the right to the confidentiality of his or her clinical records. Based on observations, interviews, and document reviews, the facility failed to ensure patient information was protected. Specifically, the facility failed to ensure computer screens with patient information visible were not accessible to patients in one of three inpatient psychiatric units observed.

Based on observations, interviews, and document review, the facility failed to ensure a safe patient care environment. Specifically, the facility failed to ensure items that posed a safety risk were not accessible to patients in three of three inpatient psychiatric units observed.

Findings include:

Facility policies:

According to the policy Identification and Removal of Unsafe Items (Contraband) on the units or teams, unsafe items include any items that can be used in an unsafe manner or as a ligature (an item used for tying or binding something tightly) such as drawstrings, belts (not including approved shortened Velcro belt loop options), shoelaces, long /calf-length socks, electronics with cords, neckties, and scarves; this is not an exhaustive list of all items. Staff are not allowed to alter patient clothing without written permission from the patient or the patient's guardian. If a patient declines to allow cords or ties to be removed from their clothing, the clothing will be sent home with family members or placed in long-term storage until the patient is discharged from the hospital.

According to the policy General Staff Responsibilities on Treatment Units and With Patients, staff shall be familiar with the Patient's Rights Pamphlet and ensure that patient rights are respected and protected. The doors of all vacant patient sleeping rooms and vacant seclusion rooms must be kept locked. The doors of any patient rooms that have a Medical Bed, shall be locked when the patient is not in their rooms. Staff members are responsible for milieu management, which includes but is not limited to, ensuring that the environment is safe, paying attention to patients, and limiting distractions. Staff is expected to monitor patients and the unit milieu closely, and to avoid any personal activities that may distract their attention away from monitoring patients. Staff may chart in the milieu but should have a reasonable plan for storing the patient chart and/or device in a secure place, should they be required to attend to a patient situation.

According to the policy Safeguarding Patient Valuables, Belongings, and External Food Items, the purpose of this policy is: to ensure a consistent method to identify, inventory, control, and dispose of patient belongings; to minimize potential risk to personal property including loss, misplaced, stolen, or damaged items, and; to state expectations regarding what patient belongings can be kept on the unit when there are storage issues. Upon admission, the patient and their belongings will be searched and inventoried. Items deemed appropriate for the unit will be given to the patient for their personal and private use or be stored in long-term storage. Personal belongings may include but are not limited to clothing, prosthetic devices, medications from home, and luggage. Dangerous items include but are not limited to illicit substances, weapons of any kind, sharp instruments, toiletries that contain glass, and steel-toe boots.

Reference:

According to the Patient Rights Handbook, to maintain a safe environment, shoelaces, cords, and strings will not be allowed on the unit. If you want an article of clothing that has cords or strings, these will need to be removed. Staff may not alter or remove strings or cords without your written permission. Unsafe items include strings and cords, such as shoelaces, electrical cords, clothing with cords, laces, or strings this could include headbands and jewelry, as well as other items staff deem to be a safety risk. Hygiene items that post safety issues will be kept in staff possession and given out for use at designated times under staff supervision.

1. The facility failed to ensure items that posed a safety or ligature risk, including sharpened pencils, shoe laces, bras, and detachable computer and telephone cords, were not accessible to patients in the inpatient psychiatric units. Additionally, workstations on wheels (WOWs, or laptop computers on mobile carts used for medical record documentation) were left unattended in patient care areas.

A. Observations conducted of inpatient psychiatric units on 10/3/23 revealed unsafe items were accessible to patients.

i. Observations conducted on 10/3/23 at 4:00 p.m. of Team One Unit revealed a sharp short pencil in room B163 and a sharp short pencil and shoelaces in room B184. Observations further revealed the doors to rooms B163 and B184 were open, which allowed patients access to the rooms. During the observation, registered nurse (RN) #1, who was assigned to provide care on the unit, stated she had never worked on a unit where it was okay to have shoelaces. RN #1 further stated having these items in the patient units was dangerous because patients could hurt themselves.

ii. Observations conducted on 10/3/23 at 4:35 p.m. of Team Two Unit revealed detachable computer cords and a telephone cord on the staff desk unattended. Observations also revealed a sharp small pencil and a bra with detachable straps and underwire in room 139. Additionally, the door to room 139 was open and accessible to patients walking around the unit. During the observation, chief quality officer (Officer) #6 stated bras with elastic removable straps and underwires were not allowed as they posed a risk to patient safety.

iii. Observations conducted on 10/3/23 at 5:10 p.m. of Team Three Unit revealed several sharp small pencils in multiple patient rooms whose doors were open and accessible to patients walking around the unit.

iv. Video footage reviewed on 10/4/23 at 12:52 p.m. of Team Two Unit revealed detachable computer cords and a telephone cord on the staff desk at 4:35 p.m. were unattended by staff for six minutes from 4:35 p.m. to 4:41 p.m. and for two minutes from 4:46 p.m. to 4:48 p.m. During both observations, three patients were seen standing at the staff desk.

The above observations were in contrast to the facility policy Identification and Removal of Unsafe Items which read, unsafe items included any items that could be used in an unsafe manner or as a ligature such as drawstrings, belts (not including approved shortened Velcro belt loop options), shoelaces, long /calf-length socks, electronics with cords, neckties, and scarves. The policy further read that this was not an exhaustive list of all items.

The above observations were also in contrast to the Patient Rights Handbook which read, to maintain a safe environment, shoelaces, cords, and strings will not be allowed on the unit.

These observations were also in contrast to the facility policy General Staff Responsibilities on Treatment Units and With Patients which read, doors to all vacant patient sleeping rooms and vacant seclusion rooms must be kept locked.

v. Observations conducted on 10/3/23 revealed four out of five units allowed hygiene products in patient's rooms. These items included plastic combs, brushes, and toothbrushes.

These observations were in contrast to the Patient Rights Handbook which read, hygiene items that posed safety issues would be kept in staff possession and given out for use at designated times under staff supervision.

B. A document review of the Observation Precaution List revealed patients on suicide precautions were on units that contained unsafe items.

i. Team Two Unit had one patient who was on suicide precautions.

ii. Team Three Unit had one patient on acute suicide precautions.

C. Interviews with staff revealed the facility failed to ensure the safety of patients from potential contraband items on the inpatient units.

i. On 10/5/23 at 9:51 a.m., an interview with mental health clinician (MHC) #3 was conducted. MHC #3 stated contraband was defined as anything that could cause harm to self or others such as cans, shoes with strings, plastic bags, gloves, DVDs, and cords. MHC #3 further stated computer cords and telephone cords were considered a ligature risk and patients could use them for self-harm or to harm others. MHC #3 further stated the cords could have been taken and used at a later time for self-harm or to harm others.

ii. On 10/4/23 at 3:01 p.m., an interview with RN #4 was conducted. RN #4 stated contraband was defined as anything considered a ligature risk, sharp objects, or anything that could be made into a weapon. RN #4 further stated small golf pencils were occasionally allowed for patient use but the staff kept track of them and patients were required to return them.

This interview was in contrast to the observations conducted in the patients' rooms which revealed several pencils unaccounted for and available to unsupervised patients.

iii. On 10/4/23 at 4:13 p.m., an interview with the quality manager (Manager) #5 was conducted. Manager #5 stated contraband was defined as anything unsafe that could cause harm to self or others, including damaged items that could have been turned into weapons. Manager #5 further explained patients could potentially swallow crayons, flexi-pens, or markers if they wanted to. Manager #5 also stated patient rooms were kept unlocked so patients could come and go unless there was a doctor's order to lock them in their room.

This was in contrast to the facility policy General Staff Responsibilities on Treatment Units and With Patients which read the doors of all vacant patient sleeping rooms and vacant seclusion rooms must be kept locked.

iv. On 10/4/23 at 11:52 a.m., an interview with Manager #2 on Team Two Unit was conducted. Manager #2 stated there was always staff seated at or watching the staff desk where computer cords and a telephone cord were present.

This was in contrast to the video observation of the staff desk completed on 10/3/23 at 4:35 p.m. which revealed no staff present for intervals of 2 minutes and 6 minutes while patients were present.

v. On 10/3/23 at 4:26 p.m., an interview with the chief quality officer (Officer) #6 was conducted. Officer #6 stated patients could have shoelaces for medical reasons if they had a physician's order.

This interview was in contrast to the Patient Rights Handbook which read, to maintain a safe environment, shoelaces, cords, and strings were not be allowed on the unit.

Based on observations, interviews, and document review, the facility failed to ensure patient information was protected from unauthorized access. Specifically, the facility failed to ensure computer screens with patient information visible were not accessible to patients in one of three inpatient psychiatric units observed.

Findings include:

Facility policy:

According to the policy General Staff Responsibilities on Treatment Units and With Patients, staff shall be familiar with the Patient's Rights Pamphlet and ensure that patient rights are respected and protected. Staff shall recognize that all medical record data is confidential and may only be released according to the Policy and Procedures 34.03, Release of Information to the News Media/Interviewing and/or Photographing patients. Confidential material shall be discussed only for work-related purposes, and out of the hearing of patients and visitors.

Reference:

According to the Patient Rights Handbook, the confidentiality of your treatment information is protected by law. Please do not share your peer's private information.

1. The facility failed to ensure patient information was protected from unauthorized access.

A. Observations of the facility revealed staff did not close the screen on patient electronic medical records to prevent unauthorized use.

i. Observations conducted on 10/3/23 at 4:35 p.m. of Team Two Unit revealed a laptop computer unsecured and unattended on the central milieu staff table which was open and showed information from two medical records visible on the screen. Observations also revealed three patients standing at the central milieu table, one with a clear view of the computer.

B. Interviews with staff revealed the facility failed to ensure the confidentiality of patient information on the inpatient unit.

i. On 10/5/23 at 9:51 a.m., an interview with mental health technician (MHC) #3 was conducted. MHC #3 stated annual training was required regarding computers being left open and unattended. MHC #3 further explained that leaving a computer open and unattended was a Health Insurance Portability and Accountability Act (HIPPA ) (A Federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge) risk because patients had access to the central milieu staff table.

ii. On 10/4/23 at 3:01 p.m., an interview with registered nurse (RN) #4 was conducted. RN #4 stated open and unattended computers were a risk to patient confidentiality if a patient's information was left on the screen. RN #4 further stated patients had access to all of the unit including the staff table and would have been able to view information on the screen. RN #4 stated yearly training on patient confidentiality was required.

iii. On 10/4/23 at 4:13 p.m., an interview with the quality and nurse manager (Manager) #5 was conducted. Manager #5 stated staff had exposed private patient information by having left a computer screen open and visible on Team Two Unit staff table. Manager #5 further explained training about patient privacy and closing accessible computers was mandatory to maintain patient confidentiality.