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Based on record review and staff interview it was determined the hospital failed to ensure the personal privacy of patients, including limiting the release or disclosure of patient information, in one (1) of ten (10) records reviewed (Patient #2). Failure to maintain the personal privacy of patients has the potential to place patients at risk for disclosure of personal information to unauthorized person(s).

Findings include:

1. Review of the medical record for Patient #2 revealed her daughter was listed as her health care surrogate. Documentation on 1/18/18 revealed a therapist disclosed information to the health care surrogate's husband without the daughter's consent.

2. An interview conducted with the Therapist on 2/13/18 at 2:45 p.m. revealed on 1/18/18 she disclosed patient information to Patient #2's daughter's husband without the daughter's consent.

Based on observation, document review and staff interview it was determined the hospital failed to provide care in a safe setting for one (1) of ten (10) records reviewed (patient #1). This failure has the potential to adversely affect the care of all patients.

Findings include:

1. A tour of 1 East (Forensic Unit) was conducted on 2/13/18 at 10:15 a.m. with the House Nurse Supervisor/Day shift. The unit has a ten (10) bed capacity and a current census of eight (8). All bathrooms are locked and no patient may enter unless staff assists.

2. On 2/13/18 at 11:30 a.m. a review of the video footage for one (1) East (Forensic Unit) on 1/19/18 from 3:01 a.m. to 7:30 a.m. revealed patient #1 went into the bathroom at 3:03:56 a.m. A night shift Mental Health Technician (MHT) unlocked the bathroom door and walked away. Fifteen (15) minute checks were not completed per policy by the night shift MHT. No visualization of patient #1 was completed except by the night shift Charge Nurse/Registered Nurse (RN) at 5:00 a.m. and 6:45:15 a.m. The night shift Charge Nurse/ RN did the 5:00 a.m. fifteen (15) minute checks, opened the bathroom door to visualize patient #1, looked inside and shut the bathroom door. At 6:45:15 a.m. the night shift Charge Nurse stopped by the bathroom where patient #1 was located, opened the bathroom door then closed the door and walked back to the nurse's station. At 7:02:16 a.m. the Day shift Charge Nurse/RN walked back to the nurse's station after report from the night shift RN. At 7:10:51 a.m. the Day shift Charge Nurse walked to the bathroom where patient #1 was located; she knocked on the bathroom door (she did not open the door) and appeared to have said something, then she walked back to the nurse's station. At 7:12:17 MHT #2 went to the bathroom where patient #1 was located, opened the door then closed it. MHT #2 walked back to the nurse's station, appeared to say something then got her sandwich out of a bag and began to eat. At 7:14:39 a.m. MHT #1 walked to the bathroom where patient #1 was located, opened the door, looked inside and closed the bathroom door. MHT #1 walked to the nurse's station, put on his jacket and walked to the front of the nurse's station. At 7:21 a.m. MHT #1 started getting ready to do care for patient #1, donning personal protective equipment (PPE). At 7:25:56 a.m. MHT #1 was in the bathroom with patient #1 and at 7:30:36 a.m. the Charge nurse/RN was in the bathroom with patient #1 and MHT #1.

3. An interview was conducted with the Charge Nurse on 2/13/18 at 8:50 a.m. She stated in report the night shift Charge Nurse had told her that patient #1 was in the bathroom since 3:30 a.m. and there was poop everywhere. She stated the night shift Charge Nurse did not call the Doctor. She noted patient #1 did not have any clothes on when MHT #1 went into the bathroom and told her he needed help. She reported the patient was delusional. She stated there was feces on the gown, on the dressings on his arms and a spot of blood and feces on his face where he had scratched his face She noted the feces was dried. She reported they walked him to the shower across hall with no clothes on. She stated the feces was not diarrhea; it was formed stool. She stated when MHT #1 took patient #1 to the shower, she called the day shift supervisor and questioned if the night shift supervisor knew of the condition of patient #1. She stated she felt the night shift nurse left him like that.

4. An interview was conducted with MHT #1 on 2/13/18 at 9:30 a.m. He stated when he came on shift he was told patient #1 was in the bathroom from 3:00 a.m. or 3:30 a.m., was sick on the toilet and night shift had heard patient #1 passing gas. He stated the night shift staff did not go into detail. He noted patient #1 had feces on him, formed dried stool and it was hard to get off of him. Patient #1's legs were swollen more than normal and he was really delusional. He stated patient #1 had feces on his nails and he was trying to put his fingers in his mouth. He stated in his opinion patient #1 was trying to clean himself up because he had toilet paper in his hand. He noted feces in patient #1's beard where he was touching his face. He stated washable wipes did not work. He reported patient #1 was showered at approximately 7:30 a.m. He stated night shift made it sound like patient #1 was just sick. He noted the night shift MHT was the staff who informed him of patient #1.

5. An interview was conducted on 2/13/18 at 2:40 p.m. with MHT #2. She stated when she looked in the bathroom she could see feces on the gown and the diaper was soiled and laying in the floor. She stated it had been there a while because the stool was dried. She reported she could see feces under patient #1's fingernails. When asked why she did not start to help patient #1, she stated: "Didn't start because it would take two (2) people." She stated she asked the night shift staff why patient #1 had been in bathroom since 4:00 a.m. and they did not change him. She stated the night shift staff did not answer her. She stated when doing hand off from the night shift she stated that is when she opened the bathroom door.

6. A review of the policy and procedure titled "Patient Care Shift Assignments", last reviewed 07/17, revealed it stated, in part: "The charge nurse shall plan, supervise and evaluate the nursing care of each patient. Each nursing staff member is responsible for familiarizing him/herself with the treatment needs of assigned patients at the beginning of the shift to promote safety and quality of care. Although duties and responsibilities are delegated to other RN's, LPN's, and MHT's, responsibility and accountability for patient care remains with the Charge Nurse."

7. An interview was conducted with the Director of Nursing on 2/14/18 at 11:15 a.m. She stated when they discovered this incident had occurred, she and the Chief Executive Officer watched the video. They decided to terminate the night shift staff from 1/19/18 for neglect. She stated the video showed the night shift Charge Nurse and the MHT not checking on patient #1 on 1/19/18, not visualizing him. She stated the nursing staff did not follow nursing policy and procedures. She acknowledged she did not realize the time frame it took the day shift to assist patient #1. She concurred with the above findings.

Based on observation, document review and staff interview it was determined the hospital failed to ensure nursing staff followed their own policies and procedures for nursing care provided, including timely and appropriate patient checks. This deficient practice was identified in one (1) of ten (10) records reviewed (patient #1). This failure has the potential to adversely affect the care of all patients.

Findings include:

1. A tour of 1 East (Forensic Unit) was conducted on 2/13/18 at 10:15 a.m. with the House Nurse Supervisor/Day shift. The unit has a ten (10) bed capacity and a current census of eight (8). All bathrooms are locked and no patient may enter unless staff assists.

2. On 2/13/18 at 11:30 a.m. a review of the video footage for one (1) East (Forensic Unit) on 1/19/18 from 3:01 a.m. to 7:30 a.m. revealed patient #1 went into the bathroom at 3:03:56 a.m. A night shift Mental Health Technician (MHT) unlocked the bathroom door and walked away. Fifteen (15) minute checks were not completed per policy by the night shift MHT. No visualization of patient #1 was completed except by the night shift Charge Nurse/Registered Nurse (RN) at 5:00 a.m. and 6:45:15 a.m. The night shift Charge Nurse/ RN did the 5:00 a.m. fifteen (15) minute checks, opened the bathroom door to visualize patient #1, looked inside and shut the bathroom door. At 6:45:15 a.m. the night shift Charge Nurse stopped by the bathroom where patient #1 was located, opened the bathroom door then closed the door and walked back to the nurse's station. At 7:02:16 a.m. the Day shift Charge Nurse/RN walked back to the nurse's station after report from the night shift RN. At 7:10:51 a.m. the Day shift Charge Nurse walked to the bathroom where patient #1 was located; she knocked on the bathroom door (she did not open the door) and appeared to have said something, then she walked back to the nurse's station. At 7:12:17 MHT #2 went to the bathroom where patient #1 was located, opened the door then closed it. MHT #2 walked back to the nurse's station, appeared to say something then got her sandwich out of a bag and began to eat. At 7:14:39 a.m. MHT #1 walked to the bathroom where patient #1 was located, opened the door, looked inside and closed the bathroom door. MHT #1 walked to the nurse's station, put on his jacket and walked to the front of the nurse's station. At 7:21 a.m. MHT #1 started getting ready to do care for patient #1, donning personal protective equipment (PPE). At 7:25:56 a.m. MHT #1 was in the bathroom with patient #1 and at 7:30:36 a.m. the Charge nurse/RN was in the bathroom with patient #1 and MHT #1.

3. An interview was conducted with the Charge Nurse on 2/13/18 at 8:50 a.m. She stated in report the night shift Charge Nurse had told her that patient #1 was in the bathroom since 3:30 a.m. and there was poop everywhere. She stated the night shift Charge Nurse did not call the Doctor. She noted patient #1 did not have any clothes on when MHT #1 went into the bathroom and told her he needed help. She reported the patient was delusional. She stated there was feces on the gown, on the dressings on his arms and a spot of blood and feces on his face where he had scratched his face She noted the feces was dried. She reported they walked him to the shower across hall with no clothes on. She stated the feces was not diarrhea; it was formed stool. She stated when MHT #1 took patient #1 to the shower, she called the day shift supervisor and questioned if the night shift supervisor knew of the condition of patient #1. She stated she felt the night shift nurse left him like that.

4. An interview was conducted with MHT #1 on 2/13/18 at 9:30 a.m. He stated when he came on shift he was told patient #1 was in the bathroom from 3:00 a.m. or 3:30 a.m., was sick on the toilet and night shift had heard patient #1 passing gas. He stated the night shift staff did not go into detail. He noted patient #1 had feces on him, formed dried stool and it was hard to get off of him. Patient #1's legs were swollen more than normal and he was really delusional. He stated patient #1 had feces on his nails and he was trying to put his fingers in his mouth. He stated in his opinion patient #1 was trying to clean himself up because he had toilet paper in his hand. He noted feces in patient #1's beard where he was touching his face. He stated washable wipes did not work. He reported patient #1 was showered at approximately 7:30 a.m. He stated night shift made it sound like patient #1 was just sick. He noted the night shift MHT was the staff who informed him of patient #1.

5. An interview was conducted on 2/13/18 at 2:40 p.m. with MHT #2. She stated when she looked in the bathroom she could see feces on the gown and the diaper was soiled and laying in the floor. She stated it had been there a while because the stool was dried. She reported she could see feces under patient #1's fingernails. When asked why she did not start to help patient #1, she stated: "Didn't start because it would take two (2) people." She stated she asked the night shift staff why patient #1 had been in bathroom since 4:00 a.m. and they did not change him. She stated the night shift staff did not answer her. She stated when doing hand off from the night shift she stated that is when she opened the bathroom door.

6. A review of the policy and procedure titled "Patient Care Shift Assignments", last reviewed 07/17, revealed it stated, in part: "The charge nurse shall plan, supervise and evaluate the nursing care of each patient. Each nursing staff member is responsible for familiarizing him/herself with the treatment needs of assigned patients at the beginning of the shift to promote safety and quality of care. Although duties and responsibilities are delegated to other RN's, LPN's, and MHT's, responsibility and accountability for patient care remains with the Charge Nurse."

7. An interview was conducted with the Director of Nursing on 2/14/18 at 11:15 a.m. She stated when they discovered this incident had occurred, she and the Chief Executive Officer watched the video. They decided to terminate the night shift staff from 1/19/18 for neglect. She stated the video showed the night shift Charge Nurse and the MHT not checking on patient #1 on 1/19/18, not visualizing him. She stated the nursing staff did not follow nursing policy and procedures. She acknowledged she did not realize the time frame it took the day shift to assist patient #1. She concurred with the above findings.