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Based on document review, observation and interview, it was determined for 3 of 3 inpatients psychiatric units (2 south, 2 north, and 3 north) and 3 of 11 (Pt #7, 10, and 11) clinical records reviewed, the Hospital failed to ensure patients' rights were protected. This potentially affected 20 patients (maximum capacity) on the 2 north unit, 20 patients (maximum capacity) on the 2 south unit, and 12 patients (unit capacity) on the 3 north unit. As a result, the Condition of Participation for Patient Rights 42 CFR 482.13, was not met.

Findings include:

1. The Hospital failed to ensure patients' privacy was protected, (A 143).

2. The Hospital failed to ensure that unit contraband checks were completed as required, (A 144 A).

3. The Hospital failed to ensure the unit was equipped with security cameras, as required by policy, (A 144 B).

4. The Hospital failed to ensure the patients' care plans were amended to include the usage of restraints, (A 166).

5. The Hospital failed to ensure restrained patients were monitored as required, (A 175).

Based on document review and observation, it was determined that for 2 of 3 inpatient psychiatric units (2 south and 2 north) the Hospital failed to ensure patients' privacy was protected. This potentially affected 20 patients (maximum capacity) on the 2 north unit and 20 patients (maximum capacity) on the 2 south unit.

Findings include:

1. Hospital policy entitled, "Use of Observation Cameras in Mental Health Network", (reviewed 1/11) required, "Policy: to allow patients and/or staff to be observed via camera, for centralized ability to locate patients...in patient rooms...and to provide continuous observation during restraint/seclusion episodes. Procedure: Observation cameras are located on the Mental Health inpatient units in all patient rooms. These cameras provide a partial view of the patient area, excluding the bathroom..."

2. On 2/25/16 at approximately 1:15 PM observational tours were conducted on the 2 south (geriatric psych) and 2 north (adult psych) units. During the tours, ceiling-mounted cameras were observed in all patient rooms except for 4 rooms on the geriatric psych unit that were not numbered.

3. On 2/26/16 at approximately 10:45 AM the Director of Behavioral Health stated that when patients are admitted to the psych units they are notified of the cameras in the rooms.

A. Based on document review and interview, it was determined that for 17 of 48 days reviewed (1/7, 1/8, 1/11, 1/12, 1/13, 1/17, 1/19, 1/20, 1/21, 1/22, 1/25, 1/27, 2/1, 2/4, 2/9, 2/15, and 2/19/16) the Hospital failed to ensure the unit contraband checks were completed as required. This potentially affected the safety of all patients (maximum census of 12) admitted on the adolescent unit.

Findings include:

1. The Mental Health Services Daily Contraband Checks (undated) indicated, "Contraband checks are to be done once on day shift and once on PM shift... Each room must be searched completely... Signing of the form indicates the signer did a complete contraband check per policy."

2. Policy number VI-Ia "Belongings and Room Searches" (revised 1/15) required, "...Room searches are conducted twice per day. They are conducted on the day and evening shift and as needed."

3. On 2/23/16 at approximately 1:00 PM, Mental Health Services Daily Contraband checks of the Adolescent Unit (3 north) from 1/9/16 to 2/23/16 were reviewed. The following were noted:

- Missing contraband check on the following day shifts: 1/7, 1/8, 1/13, 1/17, 1/21, 2/1, 2/9, 2/15, and 2/19/16
- Missing contraband checks either on the day or evening shift on: 1/11, 1/12, 1/19, 1/20, 1/22, 1/25, 1/27, and 2/4/16.

4. On 2/23/16 at approximately 9:45 AM, an interview was conducted with the charge nurse who stated that unit contraband checks are done two times a day, once on the day shift and once on the evening shift.

5. On 2/24/16 at approximately 10:15 AM, an interview was conducted with the Director of the Behavioral Network who stated that it is the "expectation that unit contraband checks are done at least twice daily, once on the day shift, evening shift, and then as needed."



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B. Based on observation, document review, and interview, it was determined that for 1 of 1 adolescent psych unit (3 north) the Hospital failed to ensure the unit was equipped with security cameras, as required by policy. This potentially placed up to 12 patients (unit capacity) and 25 active adolescent psych staff members at risk for harm.

Findings include:

1. On 2/22/16 between 9:45 AM and 10:30 AM an observational tour was conducted on the 3 north adolescent psych unit. The unit has a capacity of 12 patients in 10 rooms. During the tour, no security cameras seen in the halls... day rooms or nurses station.

2. Hospital policy entitled, "Use of Observation Cameras in Mental Health Network", (review date 1/11) required, "Purpose: To provide increased patient/staff safety on the Adult (KB2N) and Adolescent (KB2S) mental health units...Procedure: Observation cameras are located on the Mental Health inpatient units...in the group rooms, classrooms and center hallway. These cameras provide a view of staff members and patients during activities, and allow for quick intervention if needed..."

3. The Director of the Behavioral Health Network stated during an interview on 2/25/16 at approximately 10:15 AM that the adolescent unit moved from the 2 south unit to the 3 north unit on 1/7/16 and there are no cameras anywhere on the adolescent psych unit.

Based on document review and interview , it was determined that in 2 of 4 (Pt #10 and 11) clinical records reviewed of patients with restraint usage, the Hospital failed to ensure the patients' care plans were amended to include the usage of restraints.

Findings include:

1. Hospital policy entitled, "Restraint Use and Indications," (reviewed 9/1/12) was reviewed on 2/25/16. The policy lacked the requirement that patient care plans are to be amended to include restraints, when applied.

2. The clinical record of Pt #10 was reviewed on 2/26/16 at approximately 11:00 AM. Pt #10 was a 12 year old male admitted on 12/29/15 with a diagnosis of bipolar disorder. Pt #10's clinical record included that Pt #10 was in restraints from 11:48 AM to 12:37 PM on 12/29/15. Pt #10's care plan failed to include that restraints were used.

3. The clinical record of Pt #11 was reviewed on 2/26/16 at approximately 11:00 AM. Pt #11 was a 12 year old female admitted on 1/11/16 with a diagnosis of suicide ideation. Pt #11's clinical record included that Pt #11 was in restraints from 5:00 PM to 6:00 PM on 1/11/16. Pt #11's care plan failed to include that restraints were used.

4. The Director of the Behavioral Health Network stated during an interview on 2/25/16 at approximately 1:30 PM that the care plans lacked documentation of restraints.

Based on document review and interview, it was determined that in 2 of 4 (Pt #7 and 11) clinical records reviewed of patients that required restraint usage, the Hospital failed to ensure restrained patients were monitored as required.

Findings include:

1. Hospital policy entitled, "Restraint Use and Indications", (revised 9/1/12) required, "...Procedure...11. The condition of patients in the restraint is observed and evaluated ongoingly. Observations and care provided are documented on the Restraint/Seclusion Monitors at least every two hours...Documentation includes...In addition, the condition of patients in restraints for behavioral management is observed continuously, either face to face through presence of a sitter or observer, or through continuous audio-visual monitoring...Observations and care provided are documented at least every 15 minutes..."

2. The clinical record of Pt #7 was reviewed on 2/24/16 at approximately 10:00 AM. Pt #7 was a 79 year old male admitted on 11/2/15 with a diagnosis of right pulmonary nodule. Pt #7's clinical record contained documentation that included Pt #7 was placed in a restraint device (vest) on 11/6/15 at 4:35 PM with continued usage and a renewal order until 11/7/15 at 7:00 PM. Pt #7's clinical record lacked the required observation from 1:00 AM on 11/7/15 until 7:00 AM on 11/7/15 (6 hours).

3. The clinical record of Pt #11 was reviewed on 2/26/16 at approximately 11:00 AM. Pt #11 was a 12 year old female admitted on 1/11/16 with a diagnosis of suicide ideation. Pt #11's clinical record contained a physician's order dated 1/11/16 for 4 point restraints. Pt #11's clinical record contained a restraint monitoring sheet that required, "Restraint for behavioral management - document behavior, location, and other pertinent data every 15 min." Pt #11's monitor tool contained documentation at 5:00 PM, 5:30 PM and 6:00 PM and lacked the required 15 minute checks.

4. The Director of the Behavioral Health Network stated during an interview on 2/25/16 at approximately 10:15 AM that the 15 minute checks were not documented as required (Pt #11) and the Executive Director of Critical Care Services stated during an interview at approximately 10:30 AM that the required 2 hour checks were missed (Pt #7) as required.