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Based on observation, document review, and interview, it was determined that the Hospital failed to ensure patients' rights were protected. This has the potential to affect 22 patients admitted to the Pediatric Unit. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights was not in compliance.

Findings include:

1. The Hospital failed to ensure that the elevators were locked down during a Code Pink (missing child alarm). See deficiency at A-144.

2. The Hospital failed to ensure that patients' protected health information was secured to prevent unauthorized access. See deficiency at A-147.

3. The Hospital failed to ensure that staff properly monitored and assessed the condition of patients in restraints. See deficiency at A-175.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on March 26 - 27, 2019, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were cited. Also see A710.

Based on document review, observation, and interview, it was determined that the Hospital failed to ensure that elevators were locked down during a Code Pink (missing child alarm). This has the potential to affect 20 pediatric patients on census on 3/27/19.

Findings Include:

1. On 3/27/19 at approximately 12:45 PM, The Hospital's policy titled, "Missing Child (Code Pink)" (revised 12/2018) was reviewed and included, "... Security Lead Officer or Security Senior Officer...Requests that facilities staff bring down all elevators to the first floor, lock them down and open the doors to provide more control of individual access to floors and facilitate movement of appropriate staff throughout (the) building during search..."

2. On 3/27/19 at 1:37:34 PM, a Code Pink was called on the 18th floor Pediatric Unit, and was cleared at 1:42:26 PM.

3. On 3/27/19 at 2:43 PM, the video footage of the 1st floor staff elevator bank and 1st floor patient/visitor elevator bank on 3/27/19 from 1:34:00 PM to 1:43:00 PM was reviewed and indicated that all elevators were operational and staff, patients, and visitors were observed entering and exiting the elevators while the Code Pink was active.

4. On 3/27/19 at approximately 2:35 PM, an interview was conducted with the Director of Security (E#15). E#15 stated that the elevators may be locked down "when we need to ... it's a judgement call."

5. On 3/27/19 between 3:10 PM and 3:19 PM, interviews were conducted with Security Officers (E#16 and E#17). E#16 and E#17 stated that during a code pink, the elevators should be locked down.

Based on document review, observation, and interview, it was determined that for 1 of 1 Pediatric Unit, the Hospital failed to ensure that patient information was secured to prevent unauthorized access. This had the potential to affect the privacy of 21 patients (Pts. #13-33) admitted to the Pediatric Unit.

Findings include:

1. The Hospital's policy titled, "Release of Medical Records and Other Protected Health Information (PHI)" (revised 03/2019), was reviewed on 3/27/19 and included, "...Employees have an obligation to maintain the confidentiality of patient information and such information should only be accessed, discussed or disclosed on a limited "need to know only" ... Employees shall refrain from accessing or revealing any personal or confidential information concerning patients... At no time should confidential patient... information be discussed with or disclosed to non-[Hospital] personnel..."

2. The Hospital's Patient Handbook was reviewed on 3/27/19 and included, "... Patient Rights... 10. You have the right to confidentiality of your medical records..."

3. An observational tour of the Pediatric Unit was conducted on 3/26/19 between 10:00 AM to 1:00 PM and again between 1:12 PM and 2:19 PM. At approximately 10:20 AM, a binder labeled, "Pediatric Emergency Medication Reports," was observed on top of a pediatric crash cart in the West Hallway (across from patient rooms #1814 and #1815). The binder contained a printed report for 21 patients (Pts. #13-33), which contained the patients' name, date of birth/age, gender, admission date, medical record number, facility identification number, attending physician's name, and a photograph of the patient. The West Hallway where the crash cart was located was accessible to patients and visitors and was not supervised by an authorized staff member at all times.

4. An interview was conducted with the Clinical Nurse Coordinator for the Pediatric Unit (E#4) on 3/26/19 at approximately 1:53 PM. E#4 stated that the binder is usually left on top of the crash cart so that it can be readily available during an emergency, and is updated when a patient is admitted or discharged.

5. Interviews were conducted with the Nurse Manager for the Pediatric Unit (E#5) on 3/26/19 between 1:54 PM and 2:13 PM. E#5 stated that patient information should be kept confidential under staff supervision. E#5 stated that the binder was not supervised at all times by staff and could have been accessed by anyone.

Based on document review and interview, it was determined that for 2 of 3 (Pt. #14 and Pt. #15) patient records reviewed for the use of medical restraints, the Hospital failed to ensure that the patients were assessed every 2 hours while in restraints, as required.

Findings include:

1. The Hospital's policy titled, "Restraint Use Safety Considerations" (revised 11/2018), was reviewed on 3/26/19 at 3:39 PM and included, "...types of restraints used... bed enclosures; ... mitts... Care of Patient in Restraint: Clinical Staff Applies and removes restraints every two hours; Offers toileting and hydration, checks patient safety, circulation, well being and comfort at least every two hours and PRN [as needed]; Documents plan and assessment data..."

2. The clinical record of Pt. #14 was reviewed on 3/26/19 at 11:07 AM. Pt. #14 was a 8 year old male, admitted on 2/21/19, with diagnoses of subdural empyema [an infection with the presence of pus in the brain] and right hemiparesis [weakness or paralysis of one entire side of the body]. The physicians medical restraint orders dated 3/25/19 at 6:06 AM and 3/26/19 at 6:44 AM included, "...Fall Prevention: Bed Enclosure, Harm to Self or Others: Bed Enclosure..." However, on 3/26/19 at approximately 11:18 AM, the last patient assessment while in restraint on 3/26/19 was documented at 1:00 AM (approximately 10 hours and 18 minutes without an assessment).

3. The clinical record of Pt. #15 was reviewed on 3/26/19 at 11:26 AM. Pt. #15 was a 14 year old male, admitted on 3/19/19, with a diagnosis of traumatic brain injury due to gunshot wound. The physician's medical restraint orders dated 3/25/19 at 10:33 AM and 3/26/19 at 6:55 AM included, "...Pulling Tubes: Bilateral Mittens; Fall Prevention: Bed Enclosure | Wraparound..." However, on 3/26/19 at approximately 11:30 AM, the last patient assessment while in restraint on 3/26/19 was documented at 5:00 AM (approximately 6 hours and 30 minutes). On 3/25/19, Pt. #15's assessment while in restraint was also missing between 3:00 PM and 7:00 PM (approximately 4 hours without an assessment).

4. An interview was conducted with the Clinical Nurse Coordinator for the Pediatric Unit (E#4) on 3/26/19 at 11:31 AM. E#4 stated that clinical staff (nurses) are expected to conduct and document restraint assessments every 2 hours as long as the restraint order is in place. E#4 stated, "Whether the restraints are temporarily removed or the patient is off the unit, the documentation should be completed every 2 hours and indicate the status of the restraint and patient." E#4 was unable to find any documentation in the record indicating if the patient was not present on the unit or if the restraints were removed.

Based on observation, document review and interview it was determined that for 1 of 3 Rx Stations (automated medication dispensing system) on the 19th floor, the Hospital failed to ensure medication discrepancies were resolved, potentially affecting 29 patients on census as of 03/26/19.

Findings include:

1. On 03/26/19 at approximately 9:30 AM, an observational tour on the 19th floor (Medically Complex Unit) was conducted. During the tour, 1 of the 3 medication dispensing stations showed the following medication discrepancies: On 02/05/19 at 10:34 AM, Clonazepam (anti-convulsant medication) 0.25 mg (miligram) two tablets and on 02/26/19 at 8:41 PM, Hydrocodone (narcotic pain medication/controlled substance ) 325 mg (milligram) one tablet.

2. On 03/27/19 at approximately 9:30 AM, the Hospital's policy titled, "Controlled Substance Handling, Security" (effective 03/2019) was reviewed and included, "Drug Diversion: Surveillance 6. Discrepancies and Distinctive Activity a. Controlled substance discrepancies will be resolved by the end of each shift (nursing, pharmacist, pharmacy technician, provider) with appropriate personnel (e.g. manager), or as soon as possible, following notification of a discrepancy."

3. On 03/27/19 at approximately 9:45 AM, the Hospital's policy titled, "Automated Dispensing System (RxStation)" (effective 07/2017) was reviewed and included, "Replenishment of Medications into the RxStation... 7. ii. In the event a discrepancy is created or discovered, a discrepancy task is assigned to the pharmacy staff. It is the responsibility of the pharmacy staff to resolve the discrepancy with the help of their manager."

4. On 03/26/19 at approximately 10:35 AM, an interview was conducted with the Nurse Manager (E #3). E #3 stated, "I check for medication discrepancies every Monday. Unfortunately, I did not check." Upon asking regarding February medication discrepancies, E #3 stated, "I was unaware of the discrepancies. I see one of it is a narcotic. It is my responsibility to check narcotic discrepancies everyday."

5. On 03/26/19 at approximately 2:20 PM, an interview was conducted with the Pharmacy Clinical Coordinator (E #10). E #10 stated, "Nurse Managers should check all medication discrepancies on a daily basis." E #10 added that the pharmacy department sends notification of medication discrepancies to the nurse managers on a daily basis.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on March 26 - 27, 2019, the facility failed to comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with the K-Tags.