HospitalInspections.org

The Condition of Participation of Patient's Rights was not met.

Findings include:

The Hospital failed to ensure for one (Patient #1) patient of 10 sampled patients that the Hospital protected and promoted each patient's rights.

Refer to TAG: A-0143

Based on records reviewed and interviews for one (Patient #1), patients of 10 sampled patients, the Hospital failed to prevent unauthorized disclosures of Patient #1's presence in the Emergency Department during an involuntary visit (Section 12), his/her medical condition and arrest. Both Patient #1's sensitive clinical information, and false information that he/she was in uniform (on duty), was communicated to the media which adversely affected Patient #1's reputation, career and emotional well-being. In addition, false information was documented in Patient #1's medical record, that he/she was operating a law enforcement vehicle while intoxicated.

Findings include:

The Hospital Policy, Health Insurance Portability and Accountability Act (HIPPA) and the Comprehensive Security Plan, dated 1/3/19, indicated that:

- HIPPA is to protect sensitive health information in all areas where patient confidentiality or privacy could be breached.
- Patient Rights under the privacy rule indicated that the patient has the right to have his/her health information protected.
- Employee responsibilities require that the patients have a right to expect that their medical information will be kept confidential. Employees have a responsibility to ensure that this patient right is met. Not only is it an ethical issue it is also the law.
- Social Media refers to any internet-based tools or platforms that allow people to publish and share their own content on line and to create virtual social networks. Social media is used in a manner that is professional, lawful, and beneficial to the organization and the patients.

Review of Patient #1's Hospital Face Sheet, dated 4/16/20 at 12:26 P.M., indicated he/she arrived in the Emergency Department, mode of arrival was the State Police.

Review of Patient #1's Physician's Emergency Department History and Physical, dated 4/16/20, indicated that Patient #1, a Law Enforcement Official was found operating a law enforcement vehicle while intoxicated, was sectioned 12 (an involuntary visit). On 4/16/20 at 3:41 A.M., Patient #1 was clinically sober, declined any need for further treatment and was discharged from the Emergency Department.

Review of the Police Report dated 4/16/20, indicated there was no documentation to indicate Patient #1 was operating a law enforcement vehicle nor on duty, when he/she was arrested.

During an interview on 12/7/20 at 4:04 P.M. and on 12/8/20 at 12:00 P.M., the Police Officer, who arrested Patient #1, said that on 4/16/20, Patient #1 was not on duty (at work) nor in uniform nor in a law enforcement vehicle when he/she was arrested and transported to the Hospital Emergency Department.

During an interview on 12/8/20 at 12:40 P.M., the Emergency Physician who treated Patient #1 said he did not know, on 4/16/20, who in the Emergency Department had told him that Patient #1 was intoxicated while operating a law enforcement vehicle, which he then documented into Patient #1's medical record.

The Health Care Facility Reports, dated 10/19/20, indicated a Law Enforcement Official's hospital information for an Emergency Department visit, had been released to the local newspaper by the Family Member of a Hospital Employee. In addition, this spouse communicated in social media messages, false patient information regarding Patient #1 being intoxicated while at work (on duty) and that he/she was in uniform.

Review of social media messages, undated, from the Security Supervisor's Family Member on-line, indicated that, the Security Supervisor at (abbreviation for the Hospital) was notified in the morning (4/16/20), of Patient #1's arrest, by the Lead Security Guard, that Patient #1 had been brought to the Hospital Emergency Department by a State Trooper, Patient #1 was in uniform, cuffed and under arrest for driving while under the influence (DWI). The Security Supervisor's Family Member indicated that they treat it as if it was any other joe shmo off the street and that she had spoken to a woman from the (name of the local newspaper) about this matter.

The Hospital's Investigation, dated 4/23/20, included an undated copy of the Security Supervisor's Family Member's post on social media, "Has anyone heard about another (the name of Patient #1's town where he/she is employed) (a Law Enforcement Official) being arrested for DUI (driving while under the influence)?"

The Hospital investigation, dated 4/23/20, conducted one interview, that was with the Security Supervisor, performed a query of who had access to Patient #1's clinical record and reviewed phone records to the Security Supervisor, and the Hospital found there was no HIPPA violation.

During an interview on 12/8/20 at 10:15 A.M. and on 12/8/20 at 1:15 A.M., the Privacy Officer said that the Security Supervisor did not have a need to know Patient #1's emergency room visit information and they did not have any other social media messages that the Security Supervisor's Family Member had entered on the internet related to Patient #1.

Review of the Hospital Safety and Security Department Tour Report, dated 4/15/20, during the 11:00 P.M. to 7:30 A.M. shift, was written by Security Officer #1 (assigned to work at the Security Operations Desk and the dispatch role), indicated that at 1:45 A.M., Patient #1 was searched by the Security Officers in the Emergency Department and there were no issues.

During an interview on 12/9/20 at 6:54 A.M., Security Officer #1 said that on 4/16/20 during the 11:00 P.M. to 7:30 A.M. shift, he worked at the Security Operations Desk, in the Dispatch role, received calls from the Community Police Officers, if Patients are in route for section 12 visits, this information is documented in a report. Security Officer #1 said he and the Lead Security Officer had to perform a routine search of Patient #1, who was not pleased with this because of previous interactions with Security Officer #1 in the community. Security Officer #1 said that as part of his job he gave a hand off report, with what had happened in the Emergency Department during his shift to the Security Supervisor.

During an interview on 12/9/20 at 7:27 A.M., the Lead Security Officer said on 4/16/20 during the 11:00 P.M. to 7:30 A.M., he worked in the lead security role overseeing the security shift issues for the Hospital. He said as the Lead Security Officer he gave a verbal report to the next Lead Security Officer on days and he also scanned a written report of the significant events of the night and sent this report to the Security Supervisor and the Director of Safety and Security, as his usual protocol.

Review of the written information from the Vice President of Support Services, dated 12/10/20, indicated that the Security Officer on 4/16/20 during the 11:00 P.M. to 7:30 A.M., shift, gave a hand off report on 4/16/20 at 7:00 A.M., to the Security Supervisor (who was in the role of Lead Security Officer for the Day shift).

During an interview on 12/8/20 at 10:15 A.M., the Privacy Officer said that due to a previous complaint in the community, this HIPPA complaint had already been investigated. The Privacy Officer said the Hospitals investigation found that there was no inappropriate action by any Hospital employee related to a privacy breach. However, the Privacy Officer said she had not investigated how the local newspaper received Patient #1's Hospital information, nor if there were additional social media messages, and the only employee who was interviewed was the Security Supervisor by his/her immediate manager.

During an interview on 12/10/20 at 3:20 P.M., Patient #1 said that the breach of his/her confidential hospital emergency visit to the local newspaper and then on the internet by someone at the Hospital had upset him/her and had negatively impacted both his/her career and reputation as a Law Enforcement Official and resident in the community.

The Condition of Participation for Quality Assessment and Performance Improvement Program was not met. Based on record review, observations and interviews, the Hospital failed to review their internal incident report to identify opportunities for improvement, consider the incidence, prevalence, and severity of problems and implement changes that will lead to improvement.

Findings include:

Based on records reviewed, observations and interviews for two (Patient #1 & Patient #3) patients of 10 sampled patients, the Hospital failed to identify opportunities for improvement, implement changes that will lead to improvement, and thoroughly review two incidents involving:

1) Unauthorized disclosures of Patient #1's presence in the Emergency Department during an involuntary visit (Section 12), regarding his/her medical condition and arrest.

2) Inaccurate assessment of Patient #3's suicide risk in the Emergency Department and on the Medical Surgical Unit. Twenty-two hours prior to Patient #3's suicide attempt, he/she had threatened to harm him/herself and said that Patient #3 was suicidal. However, after this suicidal risk change, the staff did not follow the Hospital's suicide prevention procedure. Suicide precautions were not in place, both on the day prior and on the day of his/her suicide attempt.

Refer to TAG: A-0286

The Hospital failed to investigate, implement immediate and long-term corrective actions to prevent the reoccurrence of adverse events:

Regarding Patient #1:

The Hospital failed to implement preventive correction actions similar to Patient #1's adverse event. The adverse event was unauthorized disclosures of Patient #1's presence in the Emergency Department during an involuntary visit (Section 12), his/her medical condition and arrest. Both Patient #1's sensitive clinical information, and false information that he/she was in uniform (on duty), was communicated to the media. In addition, false information was documented in Patient #1's medical record, that he/she was operating a law enforcement vehicle while intoxicated.

The Hospital Policy, Health Insurance Portability and Accountability Act (HIPPA) and the Comprehensive Security Plan, dated 1/3/19, indicated that it was the Hospitals responsibility to protect sensitive health information in all areas where patient confidentiality or privacy could be breached. Employee responsibilities require that the patients have a right to expect that their medical information will be kept confidential. Employees have a responsibility to ensure that this patient right is met. Not only is it an ethical issue, but it is also the law.

The Health Care Facility Reports, dated 10/19/20, indicated a Law Enforcement Official's hospital information for an Emergency Department visit had been released to the local newspaper by the family member of a Hospital employee. In addition, this spouse communicated in social media messages, false patient information regarding Patient #1 being intoxicated while at work (on duty) and that he/she was in uniform.

The QAPI (Quality Assurance Performance Improvement) activities:

a. Failed to effectively analyze and evaluate a breach in Patient #1's confidential medical information.

Review of social media messages, undated, from the Security Supervisor's Family Member on-line, indicated that the Security Supervisor at (abbreviation for the Hospital) was notified in the morning (4/16/20), of Patient #1's arrest, by the Lead Security Guard, that Patient #1 had been brought to the Hospital Emergency Department by a State Trooper, Patient #1 was in uniform, cuffed and under arrest for driving while under the influence (DWI). The Security Supervisor's Family Member indicated that they treat it as if it was any other joe shmo off the street and that she had spoken to a woman from the (name of the local newspaper) about this matter.

The Hospital's Investigation, dated 4/23/20, included an undated copy of the Security Supervisor's Family Member's post on social media, "Has anyone heard about another (the name of Patient #1's town where he/she is employed) (a Law Enforcement Official) being arrested for DUI (driving while under the influence)?" The investigation conducted one interview, that was with the Security Supervisor, performed a query of who had access to Patient #1's clinical record and reviewed phone records to the Security Supervisor, and the Hospital found there was no HIPPA violation. The direct manager of the Security Supervisor interviewed him, which was not their usual protocol.

b. Failed to conduct an in-depth investigation and identify opportunities for improvement.

During an interview on 12/8/20 at 10:15 A.M. and on 12/8/20 at 1:15 A.M., the Privacy Officer said the Hospital did not have any other social media messages that the Security Supervisor's Family Member had entered on the internet related to Patient #1.

c. Failed to review their internal investigation report to identify the scope of the HIPPA breach.

During an interview on 12/8/20 at 10:15 A.M., the Privacy Officer said that due to a previous complaint in the community, this HIPPA complaint had already been investigated. The Privacy Officer said the Hospitals investigation found that there was no inappropriate action by any Hospital employee related to a privacy breach. However, the Privacy Officer said she had not investigated how the local newspaper received Patient #1's Hospital information, nor if there were additional social media messages, and the only employee interviewed was the Security Supervisor by his/her immediate manager.

d. Failed to consider the severity and scope of the adverse event and implement changes that would lead to improvement..

During an interview on 12/10/20 at 3:20 P.M., Patient #1 said that the breach of his/her confidential hospital emergency visit to the local newspaper and then on the internet by someone at the Hospital had upset him/her and had negatively impacted both his/her career and reputation as a Law Enforcement Official and resident in the community.

Regarding Patient #3:

The Hospital failed to accurately assess Patient #3's risk for suicide, by not assessing previous hospital admissions for suicide attempts. Patient #3's second suicide attempt occurred 6 weeks prior to this admission, at this Hospital. At the Satellite Emergency Room on 6/16/20, Patient #3 attempted suicide by wrapping a call bell cord around his/her neck. On 7/27/20 on a Medical Surgical Unit, Patient #3 attempted suicide by wrapping a call bell cord around his/her neck.

The Hospital failed to intervene twenty-two hours prior to the suicide attempt, when Patient #3 had threatened to harm him/herself, and a suicide risk assessment indicated Patient #3 said that he/she was suicidal. However, after this suicidal risk change, the staff did not follow the Hospital's suicide prevention procedure. Suicide precautions were not in place, neither on the day prior nor on the day of his/her suicide attempt.

Review of Patient #3's Psychiatric Note dated 7/27/20, indicated Psychiatry was consulted after Patient #3, had a suicide attempt by wrapping a cord around his/her neck. Patient #3 became hypoxic (had an inadequate supply of oxygen) and a medical emergency team was called, he/she had prior attempts in the setting of feeling depressed. An imminent risk factor was irritability. His/her current suicide attempt was in the context of frustration and being in pain, an act of desperation. Continue with 1:1 sitter (one to one supervision) and address appropriate pain management.

The Hospital's Policy, Suicide Prevention Procedure, dated 6/24/19, indicated that these interventions were intended to prevent self-inflicted injuries or death in suicidal patients.

A Patient assessed to be at high risk for suicide will be placed on Suicide Precautions, which include: 1:1 supervision until released by a provider as recommended by a Psychiatry assessment, remove all items that a suicidal patient could use for self-harm that isn't necessary for care, including any cords or tubing.

The QAPI (Quality Assurance Performance Improvement) activities:

a. Failed to identify the ineffectiveness of the self-reporting suicide risk assessment in the Emergency Department and on the Medical Surgical Unit.

Review of Patient #3's, Emergency Department, Suicide Risk Assessment, dated 7/19/20, indicated when he/she was asked, "Have you ever done, started or prepared anything to end your life, he/she answered, No (although this was not true)". The subsequent risk assessment rating score with this tool found Patient #3 was not at risk for suicide.

Review of Patient #3's Medical Surgical Unit, Suicide Risk Assessment, dated 7/26/20 at 3:34 P.M., indicated Patient #3 was asked, are you suicidal today and he/she answered, Yes. Patient #3 was then found only to be at risk for suicide, however, a self-harm safety plan was not implemented.

b. Failed to identify previous suicide attempts in the medical record.

Review of Patient #3's record on 12/8/20 at 10:36 A.M., with the Vice President of Quality Assurance indicated prior to Patient #3's Emergency Department visit on 7/19/20, he/she had a history of two prior suicide attempts with psychiatric admissions during the past year.

c. Failed to implement suicide precautions when Patient #3 was at high risk for suicide, twenty-two hours prior to his/her suicide attempt, with no determination of why this did not happen.

Review of Patient #3's medical record, indicated there was no evidence that Suicide Precautions were implemented. The interventions of 1:1 supervision and a ligature assessment of his/her room were not documented as having been performed.

d. Failed to develop a plan of care for suicide prevention.

Review of Patient #3's medical record, indicated there was no evidence that a suicide risk care plan was developed (prior to Patient #3's suicide attempt on 7/27/20).

e. Failed to identify the early warning signs of suicide, twenty-two hours before the suicide attempt, failed to document a change in condition, and failed to notify the physician for further assessment when he/she had threatened to harm him/herself and said he/she was suicidal today.

Review of Patient #3's Nursing Progress Note, dated 7/26/20 at 6:26 P.M., indicated there was no documentation to support that any interventions were implemented for suicide precautions, or a psychiatric assessment, when Patient #3 talked about hurting him/herself and being suicidal. There no documentation to support that he/she was placed him/her on suicide precautions.

During an interview on 12/8/20 at 3:30 P.M., the Vice President of Quality Assurance said on 7/26/20, Patient #3 was at high risk for suicide when the suicidal risk assessment indicated Patient #3 said he/she was suicidal today and the monitoring sheets indicated he/she was talking about hurting him/herself. The Vice President of Quality Assurance said she had expected the Hospital's Suicide Prevention Procedure to be followed, however, it was not followed.

f. Failed to determine why the Nursing Staff did not implement suicide precautions on 7/27/20.
Review of Patient #3's Root Cause Analysis, dated 7/27/20, indicated that, although he/she was found to be at high risk for suicide, the Hospital policy for suicide precautions was not followed.

The Quality and Performance Improvement Plan, dated 1/2020, indicated that the four steps for continual improvement over time are to plan an intervention that responds to the analysis of data, pilot the intervention, study the effectiveness of the interventions and act on the results of the intervention and repeat the cycle as necessary. These four steps were not taken regarding these Patients.

The Condition of Participation of Nursing Services was not met.

Findings include:

The Hospital failed to ensure for one patient (Patient #3), out of 10 sampled patients that the Hospital supervised and evaluated the nursing care of each patient.

The Hospital failed to ensure for one patient (Patient #3), out of 10 sampled patients that the Hospital provided care in a safe setting.

Refer to TAG: A-0395

Based on records reviewed and interviews, for one (Patient #3), patients of 10 sampled patients, the Hospital failed to adequately assess and develop interventions for a patient who had a history of previous suicide attempts in the past year. Approximately twenty-two hours prior to Patient #3's suicide attempt, there was a change in Patient #3's condition, increased suicide ideation and threats to hurt him/herself, there was no documentation in the medical record of a nursing assessment nor a suicide at risk care plan. The Hospital policy for Suicide prevention was not followed to ensure Patient #3's safety.

Findings include:

The Hospital Policy, Nursing Assessment Process, dated 4/15/19, indicated that all patients will be assessed upon admission to determine initial care needs, assessment will be ongoing in response to changes as they occur.
Re-assessment of patients is an ongoing process concurrent evaluation of response to treatment and nursing interventions and documented therapy.

The Hospital's Policy, Suicide Prevention Procedure, dated 6/24/19, indicated that these interventions were intended to prevent self- inflicted injuries or death in suicidal patients. High Risk patients include patients (or a supporting source) that have answered yes to of the following screening questions: currently suicidal or suicidal thoughts over the past week with thoughts and intent on acting on them.

A Patient assessed to be at high risk for suicide will be placed on Suicide Precautions: 1:1 supervision until released by a provider as recommended by a Psychiatry assessment, remove all items that a suicidal patient could use for self-harm that isn't necessary for care including an cords or tubing.

Review of the Physician History and Physical Report, dated 7/19/20, indicated Patient #3, presented to the Emergency Department with acute hip pain, had a history of polysubstance abuse, bipolar disorder, and two prior admissions for suicide ideation and suicide attempts.

Review of the Hospital Emergency Record, dated 6/16/20, only 6 weeks previously, indicated that Patient #3's most recent suicide attempt on 6/16/20, was in this Hospital's Emergency Department. Patient #3 was found with an ophthalmoscope cord around his/her neck and was admitted to an inpatient Psychiatry Unit.

Review of Patient #3's Root Cause Analysis, dated 6/16/20, indicated that, although he/she was found to be at high risk for suicide, the Hospital policy for suicide precautions was not followed.

Review of Patient #3's, Emergency Department Suicide Risk Assessment, dated 7/19/20, indicated when he/she was asked, "Have you ever done, started or prepared anything to end your life, he/she answered, No (although this was not true)". The subsequent risk assessment rating score found Patient #3 was not at risk for suicide.

Review of Patient #3's record on 12/8/20 at 10:36 A.M., with the Vice President of Quality Assurance indicated prior to Patient #3's Emergency Department visit on 7/19/20, he/she had a history of two prior suicide attempts with psychiatric admissions during the past year.

Review of the Nurse Progress Note dated 7/19/20 at 11:24 P.M., indicated Patient #3 was admitted to a Medical Surgical Unit.

Review of the Nursing Assistant Monitor Tech Report Form, dated 7/20/20, indicated Patient #3 was placed on constant video monitoring because he/she was at risk for suicide and to watch him/her for suspected suicidal behavior.

Review of Patient #3's medical record, indicated there was no evidence that a suicide risk plan of care was developed (prior to Patient #3's suicide attempt on 7/27/20), and no evidence that Suicide Precautions were implemented. The interventions of 1:1 supervision and a ligature assessment of his/her room were not documented as having been performed.

During an interview on 12/8/20 at 3:30 P.M., the Vice President of Quality Assurance said for Patient #3, a suicide risk plan of care was not developed even though he/she was at high risk for suicide, nor were the suicide precautions implemented.

Review of the Nursing Assistant Monitor Tech Report Form, dated 7/26/20, indicated at 3:30 P.M., the Medical Surgical Unit notified the Monitoring Technician that Patient #3 was talking about hurting him/herself.

Review of the Suicide Risk Assessment dated 7/26/20 at 3:34 P.M., indicated Patient #3 was asked, are you suicidal today and he/she answered, Yes. Patient #3 was then found only to be at risk for suicide, however, a self-harm safety plan was not implemented.

Review of the Nurses Progress Note, dated 7/26/20 at 6:28 P.M., indicated Patient #3 requested an extra dose of Motrin (an anti-inflammatory medication) and the provider was notified. Patient #3 became very upset, agitated and started crying. Ativan (an anti-anxiety mediation) 0.5 milligrams was administered with good effect.

Review of Patient #3's Nursing Progress Note, dated 7/26/20 at 6:26 P.M., indicated there was no documentation to support that any interventions were implemented for suicide precautions, or a psychiatric assessment, when Patient #3 talked about hurting him/herself and being suicidal. There no documentation to support that he/she was placed him/her on suicide precautions

During an interview on 12/9/20 at 12:57 P.M., Nurse #2, assigned to Patient #3 during the 3:00 P.M. to 11:00 P.M., shift on 7/26/20, said she could not recall if Patient #3 talked about hurting him/herself, nor if he/she was placed on suicide precautions, nor if the Psychiatrist was notified when Patient #3 said he/she was suicidal today.

During an interview on 12/8/20 at 3:30 P.M., the Vice President of Quality Assurance said on 7/26/20, Patient #3 was at high risk for suicide when the suicidal risk assessment indicated Patient #3 said he/she was suicidal today and the monitoring sheets indicated Patient #3 was talking about hurting him/herself. The Vice President of Quality Assurance said she had expected the Hospital's Suicide Prevention Procedure to be followed, however, it was not followed.

Review of the Nurse Progress Note, dated 7/27/20 at 1:14 P.M., indicated that Patient #3 rang his/her call bell and told the Nurse that, "(he/she) could not take it anymore (referring to his/her pain)." There was no pain medication available, and Patient #3 said, I am going to kill myself if I don't get something. The Nurse notified the Provider, who then notified the crisis team to speak with Patient #3. When Patient #3 was told that the crisis team was on their way, Patient #3 again said, If someone didn't do something, he/she was going to kill him/herself. A few minutes later, the CVM alarm sounded, and Patient #3 was found with a call bell cord wrapped around his/her neck. The staff untied the cord, called the Medical Emergency team, and administered oxygen. A Computerized Tomography (CT) scan of the neck was performed, there was no acute injury. Patient #3 was placed on 1:1 supervision for safety, per Psychiatry, without any call bells, television remote controls, and gowns that tie.

The Hospital failed to identify Patient #3's suicide risk, implement their suicide precautions in a timely manner and assess the potential for Patient #3 to wrap a call bell around his/her neck from his/her patient room. Patient #3 told the nursing staff that he/she was suicidal, was heard talking about hurting him/herself twenty-two hours before the suicide attempt. Patient #3 was not placed in a ligature free room (anything that could be used to attach, a cord, rope or other material for the purpose of hanging or strangulation) nor provided 1:1 supervision for his/her safety.