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Based on facility provided information and staff interview, the facility failed to protect the privacy for one of eight patients (#8) and follow appropriate reporting of an alleged incident to the Privacy Officer in the facility.
"The right to personal privacy" includes, that patients have privacy during medical/nursing treatments, and when requested as appropriate. The right to personal privacy would also include limiting the release or disclosure of patient information such as the patient's presence in the facility or location in the hospital, or personal information such as name, age, address, income, health information without prior consent from the patient, as required by the Standards for Privacy of Individually Identifiable Health Information (the Privacy Rule).


People not involved in the care of the patient should not be present without his/her consent while he/she is being examined or treated, nor should video or other electronic monitoring/recording methods be used while he/she is being examined without his/her consent.

The findings include:


Patient #8 visited the Emergency Department on 5/24/2010 at 5:59am after suffering a severe facial laceration in a motor vehicle accident. Per the physician exam, the patient was alert and oriented at the time of entry into the facility and was in moderate distress. There was dental injury present and a severe complex avulsion laceration involving the lower lip/chin and face. The record continued to state that certain medical information was given by the family. The patient was transferred to a hospital trauma center at 7:40am.

Review of the facility grievance records on 6/24/2010 at 9:45am revealed that the patient's family had filed a grievance with the facility on 6/15/2010 via telephone with the patient Guest Services Manager. Per the form, the family member stated that he/she came to the facility medical record department to obtain photographs that were taken of the patient during a visit to the emergency department on 5/14/2010. When the family member was told there were no photographs taken of the patient during the visit, he/she stated that two staff members came to the patient bedside to view the patient's injuries after two other staff members took photographs of the patient's injuries on their cell phones. Per the grievance form, the family member stated the patient was upset and felt like he/she was made a spectacle of. The facility provided written documentation that the grievance was responded to the family member, on behalf of the patient on 6/17/10.
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The Guest Services Manager was interviewed on 6/24/10 at 11:00am and was questioned why the grievance was not categorized under the heading of Patient Rights & Responsibilities. She responded "I did not consider this a patient rights issue or HIPAA issue, as there was no transfer of patient information.

The Facility Privacy Officer was interviewed on 6/24/10 at 12:12pm. Per the Privacy Officer, he was not aware of this allegation and if he were, he would not consider this a violation of Patient Rights, as taking a picture of a patient lacks specific health information.


The Chief Nursing and Ethics Officer was interviewed on 6/24/10 at 12:00pm regarding the allegation contained in the grievance. She agreed this was a serious allegation and should have been reported to the Facility Privacy Officer as a breach in patient rights/confidentiality.


Review of the facility policy on Complaints and Grievances on 6/24/10 at 11:30am revealed that the Facility Privacy Officer shall be responsible for overseeing the investigation and resolution of grievances related to Health Insurance Portability and Accountability Act (HIPAA).

Based on medical record review, staff interview and facility provided information, the facility failed to ensure patient rights for 2 of 8 sampled patients, (#1 and #7 ) pertaining to the use of restraints and that the use of restraints must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient.



The findings include:



Patient # 1 was admitted to the facility on 5/30/2010 via ambulance to the emergency department with complaints of tremors, incoordination and was found to have evidence of septic shock. The patient was evaluated by Critical Care services, as well as nephrology, endocrinology and was found to have acute or chronic renal disease, hypertension, rhabdomyolysis, electrolyte imbalance, severe dehydration, anemia of chronic illness, diabetes mellitus, hypothyroidism, chronic pain syndrome, fibromyalgia syndrome, intact parathyroid hormone, hypoalbumenia, pulmonary edema, cardiomyopathy with an ejection fraction in the range of 45%, low grade temperature without source of infection, since resolved and general debility, progressive decline in functional status.



The medical record reflected that the patient was placed on bilateral soft wrist and bilateral soft ankle restraints on 5/30/10 at 11:30 for the reason of threatening placement and or patency of necessary therapeutic lines/tubes, interfering with necessary medical treatment and unable to follow directions to avoid self injury and appropriate alternative measures had been evaluated and were unsuccessful. Physician's order for restraints was reviewed and was timed and dated. Nursing monitor sheets for this day were reviewed and per the sheets, the patient was monitored for the use of restraints every 15 minutes. The following day (5/31/10), the patient had another order for soft wrist restraints for the same reasons stated on the previous day, along with bed rails, signed and dated by the physician. The nursing monitoring sheets were reviewed for this day and reflect that the patient was monitored every 15 minutes for the use of restraints. Restraints were removed on this day after extubation.



The record reflected post extubation, the patient was progressing well and on 6/10/10 there was a physician's order for the case manager to discuss rehabilitation options with patient, along with a physical therapy and occupational therapy consult. Case Management consulted with the patient and arranged for the appropriate services. The following day on 6/11/2010, there is a physicians order to discharge the patient to the skilled facility, if nephrology approved the discharge. The following day, the record reflected the facility was waiting on skilled bed availability to discharge the patient. On 6/14/2010, the physician's progress notes stated the patient discharge was delayed secondary to bed availability at the skilled facility. Prior to the discharge on on 6/15/2010, the patient was found to have worsening chronic kidney disease, and a drop in hemoglobin. The following day, the patient continued with anemia, was transfused and vital signs were stable. The plan remained to discharge the patient when a bed was available and send the patient for an outpatient colonoscopy.



On 6/16/2010 the patient was found in respiratory failure, bilateral pneumonia, severe sepsis and worsening renal failure. The patient was intubated and transferred to ICU with questionable pulmonary embolus. On 6/17/2010, the patient had worsening deterioration, hemodynamically unstable with refractory hypoxemia. Restraint monitoring sheets reflect that on 6/16/2010 at 12:00pm, the patient was placed on restraints. There was no order for patient restraints on this date. The patient then proceeded to code, the situation was discussed with the family and the code was stopped.



The chart was reviewed with the chief nursing officer (CNO), on 6/28/10 at 3:30pm. She agreed there was not order for patient restraints on the date of 6/16/2010.


Patient #7 was admitted to the facility on 12/29/2009 via ambulance after falling over oxygen tubing in the home, with complaints of pain in the right hip. The patient had a history of osteoarthritis and had difficulty walking. Past medical history included hypertension, hyperlipidemia, type II diabetes and Parkinson's disease and tardive dyskinesia, secondary to either Sinemet or Nameda. On exam in the ED, vital signs were normal, chest x-ray showed cardiomegaly with no acute process. On the day of admission, the patient underwent a right ORIF (open reduction internal fixation) and was successfully extubated and the patient was progressing well and was transferred to the intensive care unit postoperatively. On 12/30/2009, the patient was placed on soft wrist bilateral restraints for the reason of threatens placement and/or patency of necessary therapeutic lines/tubes, interfering with necessary medical treatment and unable to follow directions to avoid self-injury and appropriate alternative measures had been evaluated and were unsuccessful. The form on this date was signed by the nurse, but not signed by the physician.


On 12/31/2009,the patient was transferred to the step-down unit. There was an order on the chart for bilateral soft wrist restraints for 12/31/2009, dated but not signed by either the nurse or the physician. Reasons for the restraints were the same as stated on 12/20/2009.


The following day, on 1/1/10, the patient was transferred to telemetry and there was another order for soft wrist restraints, left and right, reasons same as stated on 12/30/2009, The restraint order for 1/1/2009 was dated, but not signed by the nurse or the physician. On 1/2/2010, there was another order for restraints, same reasons as stated on 12/30/09 signed by the nurse, but not the physician. On 1/3/2010, there was another order for soft wrist bilateral restraints, same reasons as stated on 12/30/2009, signed by the nurse and dated, but not signed by the physician. The following day on 1/4/2010, there was another order for restraints in the chart, dated only, not signed by the nurse or physician. On the same day, there was a physician order written for case management to arrange for placement in a skilled facility. The patient was discharged for skilled care on 1/4/2010. Restraint monitoring sheets were reviewed for the dates the patient was in restraints between the dates of 12/30/2009 and 1/2/2009. There were no restraint monitoring sheets for the dates of 1/3/09 and 1/4/09.


The CNO reviewed the patient's medical record on 6/28/2010 at 3:40pm and agreed that the orders for restraints were not signed by the physician, per the policy.

Review of the facility policy on Restraints and Seclusion on 6/29/2010 at 9:00am revealed that the facility policy calls for an order for restraint to be obtained from an LIP/physician who is responsible for the care of the patient prior to the application of the restraint. If a telephone order is required, the registered nurse must write down the order while the physician is on the phone and read back the order to verify accuracy. The order must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint and behavior based criteria for release. When an LIP/physician is not available to issue a restraint order, an RN with demonstrated competence may initiate restraint use based on face to face assessment of the patient. In these emergency situations, the order must be obtained during the emergency application or immediately (within minutes) after the restraint is applied. The duration of the order for restraint must not exceed 24 hours, and must specify clinical justification for the restraint, the date and time ordered, the duration of use, the type of restraint and behavior based criteria for release. To continue restraint use beyond the order duration, the LIP/physician must see the patient, perform clinical assessment and determine if continuation of restraint is necessary. If reassessment indicates an ongoing need for restraint, a new order must be written each calendar day by the LIP/physician. Patients are assessed by an RN immediately after restraints are applied to assure safe application of the restraint and at least every 2 hours. A face to face assessment by a physician or LIP with demonstrated competence, must be done within one hour of restraint/seclusion initiation or administration of medication to manage violent or self destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or others.