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

A-0143 - Standard: Patient Rights: Personal Privacy. The patient has the right to personal privacy. The facility failed to ensure the personal privacy of patients who received care while being monitored via camera in the emergency department.

A-0168 - Standard: Restraint or Seclusion: The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under §482.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law. The facility failed to ensure orders were obtained by a physician, or other Licensed Independent Practitioner (LIP), for 3 of 6 patients who were placed in restraints (Patients #1, #5 and #8).

A-0179 - Standard: Restraint or Seclusion: The patient must be seen face-to-face within 1 hour after the initiation of the intervention to evaluate -(A) The patient's immediate situation; (B) The patient's reaction to the intervention; (C) The patient's medical and behavioral condition; and (D) The need to continue or terminate the restraint or seclusion. The facility failed to evaluate physically restrained patients face to face within one hour, to include an evaluation of the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition and the need to continue or terminate the restraint or seclusion in 5 of 6 medical records involving restraint documentation reviewed (Patients #1, #5, #6, #8 and #10).

Based on observations and interviews, the facility failed to ensure the personal privacy of patients who received care in the Emergency Department (ED).

This failure created an instance in which a patient in the ED was able to be viewed by other individuals in the ED who were not associated with the care of the patient.

FINDINGS:

POLICY

According to Patient Rights and Responsibility, patients have the right to care or treatment that is respectful, recognizing the patient's dignity, and provides for personal privacy to the extent possible during the course of treatment.

According to Photographing-Videotaping and Other Imaging of Patients or Other Visitors, the facility strives to protect patients within reasonable limits, from invasion of privacy that might occur from the use of videotaping during healthcare activities.

REFERENCE

According to Patient Rights, Responsibilities and the Grievance Mechanism Plan, Patients have the right to consent or refuse to have filming or recording of their care. Patients have the right to care or treatment which is respectful, recognizes dignity and provides for personal privacy to the extent possible during the course of treatment.

1. The facility did not ensure the privacy of an ED patient being monitored via camera which was displayed on a monitor at the nursing station, in clear view of the public.

a) On 11/29/17 at 9:34 a.m., a tour of the ED was conducted. On arrival to the ED an observation of the nursing station was conducted. Mounted at the nursing station and in view of the public was a monitor. Displayed on the monitor was a fully undressed patient (Patient #2) in an exam room with a staff member inside the room and one staff member located just outside of the room.

Located at the nursing station, where the monitor was displayed, were several staff members including the ED charge nurse. Also noted at the same nursing station was a vendor, who on interview stated s/he did not work at the facility. Noted in the same hallway where the monitor was displayed were staff who were not associated with the ED and not involved in the care of Patient #2.

Observation of the monitor was conducted over 5 minutes and included Patient #2 changing into a gown and having his/her blood drawn. During this time, staff did not attempt to protect Patient #2 from being exposed via the monitor from public view.

An interview with the Charge Nurse (Registered Nurse, RN #1), was conducted during the observation. RN #1 stated patients, patients' families, staff and others within the ED had access to the hallway along the front of the nursing station where the monitor was displayed.

b) On 11/30/17 at 7:50 a.m., another observation was conducted of the ED. During the observation the monitor was fully visible to public view and displayed a patient lying in his/her bed in a hospital gown.

c) On 11/29/17 at 2:42 p.m., an interview was conducted with an ED Registered Nurse (RN #2). RN #2 stated patients deserved privacy even while being monitored via video camera. RN #2 confirmed visitors were allowed in the hallway where the monitor was displayed and confirmed it could be viewed by anyone in the hallway or at the nursing station. RN #2 stated patient rights to privacy were important to respect the patient.

d) On 11/30/17 at 8:08 a.m., an interview was conducted with the Director of Nursing (Director #3) for the ED. Director #3 stated patients who were monitored in the ED room were not made aware they were being monitored via the camera. This was in contrast to the facility's patient rights which stated, patients had the right to consent or refuse to have filming or recording of their care.

Director #3 stated the monitor was in place to observe patient and staff activity. Director #3 stated having the monitor in view of the public posed a risk to patient's privacy and stated the facility had an opportunity to change the process.

Based on interviews and document review, the facility failed to ensure an order was obtained from a physician or Licensed Independent Practitioner (LIP) prior to, or immediately after, the initiation of physical restraints in 3 of 6 medical records reviewed of patients with documented use of physical restraints (Patients #1, #5 and #8).

This failure created the potential for an unsafe patient care environment in which the responsible attending physicians or practitioners were not aware of patients' medical needs and current health status.

FINDINGS

POLICY

According to Restraint Use in Acute Care Areas, an order for restraints may be obtained from a Physician or Licensed Independent Provider (LIP). A qualified Registered Nurse may initiated the use of restraints based on an assessed need, in an emergent situation, before an order is obtain for the physician or LIP. As soon as possible after the emergent application, a qualified RN notifies the physician or LIP to enter an order and consult with him/her about the patient's physical and psychological condition. The order for restraint must include the type of restraint, reason for use and criteria for removal.

1. The facility did not ensure restraint orders were obtained prior to or immediately after placing patients in physical restraints.

a) A review of the medical record for Patient #5 revealed s/he was placed in soft restraints on 08/31/17 at 9:00 p.m. There was no documentation of an order for the restraints by the physician or LIP.

Review of the medical record for Patient #1, revealed Patient #1 was in non-locking, non-violent wrist restraints on 09/10/17 at 1:00 p.m.; however, review of documentation revealed there was no order for the soft restraints.

Review of the medical record for Patient #8, revealed s/he was placed in locking wrist restraints for violent or self-destructive behavior on 07/13/17 at 3:30 a.m. On review of the Patients Restraint Documentation, dated 07/13/17 at 3:30 a.m., the restraint type was noted to be leather restraints. Review of the physician orders, noted the patient only had orders for soft restraints.

b) On 11/29/17 2:42 p.m., an interview was conducted with the Registered Nurse (RN #2), who stated an order from a physician was required to initiate restraints and stated the facility's expectation was for staff to obtain a doctor's order within the hour of initiation of physical restraints. RN #2 stated an order from a physician to initiate restraints was important for patient safety.

c) On 11/30/17 at 8:08 a.m., an interview was conducted with the Director of the Emergency Department (Director #3). After reviewing the medical record of Patients #1, #5 and #8, Director #3 confirmed there were no orders for the restraints. Director #3 stated this was outside of the expectation and policy of the facility for restraints. Director #5 stated it was important to have a physician order due to the risk of injury to the patient while in restraints.

Based on interviews and document review , the facility failed to evaluate physically restrained patients face to face within one hour, to include the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition and the need to continue or terminate the restraint or seclusion in 5 of 6 medical records involving restraint documentation reviewed (Patients #1, #5, #6, #8 and #10).

This failure created incidents of patients who were physically restrained to be without the required evaluations of their status.

FINDINGS

POLICY

According to the policy, Restraint Use in Acute Care Areas, Restraints for Management of Violent/Self-destructive Behaviors, a physician or Licensed Independent Practitioner (LIP) must see and evaluate the patient, face to face within one hour after the initiation of restraints. This in-person evaluation should include: an evaluation of the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition and the need to continue or terminate the restraint. Non-violent/non-self-destructive restraints require a physician or LIP to conduct a face-to-face evaluation of the patient and enter an order within one hour of initiation.

1. The facility failed to ensure patients who were physically restrained were evaluated within 1 hour of the application of the restraint by staff determined by policy to determine the patient's condition and the need to continue or terminate the restraints.

a) On review of Patient #5's medical record, the patient was admitted on 08/31/17 for a suicide
attempt. At 9:00 p.m. the physician in charge of Patient #5's care documented the patient required restraints due to the patients' attempts to leave the facility. There was no further documentation of an evaluation of the patient by the appropriate staff, within one hour of the application of the restraints, to include the patient's condition and the need to continue or terminate the restraints.

On review of Patient #6's medical record, the patient was admitted on 10/29/17 for suicidal ideation and required restraints. An order for restraints was placed at 2:26 p.m. by the physician. However, there was no documentation by a Physician or Licensed Independent Practitioner (LIP) of an evaluation within one hour of the application of the restraints, to include the patient's condition and the need to continue or terminate the restraints. This was in contrast to facility policy.

On review of Patient #8's medical record, the patient was admitted on 07/13/17 for altered mental status and combative behavior and required 4 point restraints at 3:30 a.m. Upon review of Patient #8's medical record there was no evidence of an evaluation of the patient face to face within one hour of the application of the restraints, to include the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition and the need to continue or terminate the restraints.

On review of Patient #10's medical record, the patient was admitted on 10/13/17 for paranoid behavior and required behavioral restraints on 10/13/17 at 10:45 p.m. and then again on 10/14/17 at 2:10 a.m. No documentation was noted of a face to face by a Physician or LIP as required for either incident of restraints.

On review of Patient #1's medical record, the patient was admitted on 09/10/17 and required restraints from 09/10/17 until 09/11/17 at 8:30 a.m. However, there was no documentation by a Physician or Licensed Independent Practitioner (LIP) of an evaluation within one hour of the application of the restraints, to include the patient's condition and the need to continue or terminate the restraints. This was in contrast to facility policy.

b) On 11/29/17 at 2:42 p.m., an interview was conducted with the Registered Nurse (RN #2). RN#2 stated a face to face evaluation was required by the physician within one hour of the application of restraints. RN #2 stated the purpose of the one hour face to face was to assess the patient and to verify the need for continuing the restraints. RN #2 stated the importance of the face to face was for ensuring patient safety.

c) On 11/30/17 at 7:50 a.m., an interview was conducted with the Emergency Department (ED) Attending Physician(Physician #4). Physician # 4 stated a face to face after the application of restraints was required within 4 hours, or before a new order for restraints was placed. This was in contrast to facility policy which stated a face to face evaluation was required within one hour of the application of restraints.

Physician #4 further stated the importance of a face to face was to assess the patient to ensure the patient was stable and no injury had occurred to the patient while in restraints. Physician #4 stated a face to face was required to assess for the continuation of the restraints.

d) On 11/30/17 at 8:08 a.m., an interview was conducted with the Director of the ED (Director
#3) who had oversight of emergency department staff. Director #3 stated all staff, to include physicians were required to follow hospital policy. Director #3 stated a face-to-face evaluation by a physician was required within one hour of the application of restraints to evaluate the patient's status and the needed continuation of the restraints. Director #3 stated the risks of not performing the evaluation of a face to face by a physician as required would be risk of patient limb injuries and life threatening injuries to include aspiration (breathing foreign objects into the airway).