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Based on observation, interview, and record review, the hospital failed to ensure the patient's rights to confidentiality of their medical records as evidenced by:

1. The electronic medical records were secured for two of 10 sampled patients (Patients 2 and 3).

2. The display board in the ED included the ED patients' full names and laboratory results.

These failures had the potential for the unauthorized individuals to access and view the patients' electronic medical records and violating the patients' rights.

Findings:

Review of the hospital's P&P titled Confidentiality dated January 2020 showed the purpose of the P&P is to ensure that each patient is afforded the right to full consideration of privacy regarding their medical care and confidential treatment of all communications and records pertaining to their care and stay in the hospital. The P&P also showed the following:

* Every patient admitted to the hospital has a right to confidentiality.
* Patient information and carts should not be left out in areas not attended and supervised by appropriate hospital personnel.

1. On 6/12/25 at 1000 hours, the Med/Telemetry unit was toured with the Director of Med/Telemetry.

a. Patient 2's electronic medical record was observed on the computer screen at the nursing station. Patient 2's electronic medical record was opened and unattended.

b. Patient 3's electronic medical record was observed on the computer screen at the nursing station. Patient 3's electronic medical record was opened and unattended.

When asked, the Director of Med/Telemetry stated other disciplinary departments such as EVS, rehabilitation staff who had no business with Patients 2 and 3 could enter the nursing station. The Director of Med/Telemetry verified the above findings.

2. On 6/13/25 at 1005 hours, the ED was toured with the Director of Emergency Department. It was observed the ED patients' log was displayed at nursing station on the big screen. The screen showed each patient's full name, age, and laboratory report (for one patient). When asked, the Director of Emergency Department stated other disciplinary department which had no business with the patients could see the information. The Director of the Emergency Department verified the above findings.

Based on interview and record review, the hospital failed to ensure the care plan was updated to reflect the use of violent restraints for one of 10 sampled patients (Patient 1). This failure created the risk of substandard outcomes to the patient.

Findings:

Review of the hospital's P&P titled Restraints dated May 2024 showed the use of restraint or seclusion (including drugs or medications used as restraint as well as physical restraint) must be documented in the patient's plan of care or treatment plan.

On 6/12/25, Patient 1's closed medical record was reviewed. Patient 1's closed medical record showed Patient 1 was admitted to the hospital on 5/14/25 and left the hospital AMA on 5/15/25.

Review of the physician's order dated 5/14/25 at 0914 hours, showed to apply hard restraints to all limbs; and restraints or seclusion shall be observed at intervals not greater than 15 minutes.

Review of the Flowsheets dated 5/14/25, showed the restraints were initiated at 0910 hours and were released at 1240 hours. However, further review of Patient 1's medical record failed to show the care plan for the use of restraints.

On 6/12/25 at 1250 hours, an interview and concurrent review of Patient 1's medical record was conducted with the Director of Emergency Department. When asked, the Director of Emergency Department verified there was no care plan updated for the use of the restraint for Patient 1.

Based on interview and record review, the hospital failed to ensure the face-to-face evaluation was performed within one hour of the initiation of the restraints for one of 10 sampled patients (Patient 1). This failure had the potential to result in the unsafe care and poor clinical outcomes to the patient.

Findings:

Review of the hospital's P&P titled Restraints dated May 2024 showed when restraint or seclusion is used to manage violent or self-destructive behavior, a physician or other LIP, or a registered nurse or physician assistant trained in accordance with this policy must see the patient face-to-face within one hour after the initiation of the intervention. The P&P also showed the following:

* The one hour face-to-face patient evaluation must be conducted in person. A telephone call or telemedicine methodology is not permitted.

* The one hour face-to-face evaluation should include both a physical and behavioral assessment of the patient. An evaluation of the patient's medical condition would include a complete review of systems assessment, behavioral assessment, as well as review and assessment of the patient's history, drugs and medication, most recent lab results, etc., as well as to evaluate 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.

On 6/12/25, Patient 1's closed medical record was reviewed. Patient 1's closed medical record showed Patient 1 was admitted to the hopsital on 5/14/25 and left the hospital AMA on 5/15/25.

Review of the physician's order dated 5/14/25 at 0914 hours, showed to apply hard restraints to all limbs; and restraints or seclusion shall be observed at intervals not greater than 15 minutes.

Review of the Flowsheets dated 5/14/25, showed the restraints were initiated at 0910 hours and were released at 1240 hours. However, further review of Patient 1's medical record failed to show the face-to-face evaluation was conducted within one hour after the initiation of the intervention.

On 6/12/25 at 1256 hours, the Director of the Emergency Department verified the above findings.

Based on interview and record review, the hospital failed to ensure the nursing staff documented the blood transfusion record as it was ordered and developed the care plan for blood transfusion for one of 10 sampled patients (Patient 6) as per the hospital's P&P. This failure posed the risk for potential complications, including undetected changes in the patient's condition, delayed interventions, and overall compromised patient safety during the blood transfusion process.

Findings:

Review of the hospital's P&P titled Blood Administration and Transfusion Reactions dated February 2024 showed to record date/time the transfusion was started (when blood hits the vein) as the time the blood entered the patient venous access on the blood transfusion form or in the patient electronic record. It is critical to correctly document this time as the first 15-30 minutes of a transfusion is when many reactions occur.

On 6/13/25, Patient 6's medical record was reviewed. Review of Patient 6's medical record showed Patient 6 was admitted to the hospital on 6/6/25.

1. Review of the physician's order dated 6/12/25, showed to transfuse one unit of PRBC STAT over 30 minutes due to active bleeding.

Review of the Blood Bank dated 6/12/25 at 0508 hours, showed the volume of the blood unit was 300 ml.

Review of the Blood Administration Record dated 6/12/25 at 0520 hours, showed the following:

* Transfusion Start Date/Time: 6/12/25 at 0520 hours
* Transfusion Rate: 999 ml/hr (about 18 minute to complete the transfusion one unit or 300 ml blood to the patient)
* Transfusion Stop Date/Time: 6/12/25 at 0550 hours (in 30 minutes)

On 6/13/25 at 1000 hours, an interview and concurrent review of Patient 6's medical record was conducted with the Director of ICU. When asked, the Director of ICU verified if the transfusion rate was 999 ml/hr, then the transfusion would have finished earlier than 30 minutes.

2. Review of the hospital's P&P titled Standards of Nursing Practice, Generic, Critical Care dated August 2024 showed the following:

* An individual plan of care will be initiated within the first eight hours of admission.
* Measurable and realistic outcome criteria will be identified.
* Plan of care will be reviewed every shift.
* The Plan of Care will be consistent with the medical plan of care.
* 12-hour chart checks will be completed and documented each shift.

Review of the Plan of Care dated 6/12/25, failed to show the plan of care for the blood transfusion due to active bleeding was not initiated for Patient 6.

On 6/13/25 at 1000 hours, the Director of ICU verified the above findings.