The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on review of clinical record, policy and procedure and staff interview, it was determined the Facility failed to assure the patient's right to personal privacy was maintained while in seclusion for one (Patient #20) of two (Patient #17 and #20) closed clinical records reviewed in which seclusion was ordered. The patients' basic right to privacy during treatments was not assured as the patient's clothing was removed by staff while in seclusion. The failed practice affected Patient #20 and had the potential to affect any patient in seclusion. The findings are:

A. Clinical record review on 03/12/13 and 03/13/12 revealed Patient #20 was a patient at the facility from 02/01/12-02/06/12. On 02/02/12 at 2230, documentation on the Seclusion Flow Sheet by the Registered Nurse stated, "Patient began hollering, cursing, yelling, and aggressive toward staff. Placed in seclusion. Patient banging on door. Threatening to kill self. Placed fingers in throat and made self throw up. Patient threw up on the floor. Threatening to put sheet around neck. Patient clothes taken until he calms self down. Continues to bang on door, hollering and cursing that he is going to blow his brains out. Informed patient that he needed to calm down so he could be able to get out. Patient would not redirect. Kept on hollering and screaming and cursing at staff." An entry at 2300 stated "...hollering, still wanting to get out...will leave in seclusion until calms down more." Another entry at 2400 stated "Patient continues to beat on door not stopping, screaming and yelling and cursing. Not redirectable. Will not listen to staff. Will continue seclusion until calms down more." A note at 0130 on 02/03/12 stated "Patient much calmer. Cooperative...released from seclusion and went to room and went to bed."

B. The facility Policy "Behavioral Health Seclusion" was reviewed on 02/12/13 and stated "Protect the patient and preserve the patient's rights, dignity, and well-being during seclusion use by respecting the patient as an individual, maintain a safe environment, maintaining the patient's modesty, preventing inappropriate visibility to others and maintaining comfortable body temperature."

C. A tour of the Facility on 03/12/12 revealed the seclusion room on the Unit was equipped with the capability for continuous visual monitoring via camera. The monitor for the seclusion room was located at the nurses station and any staff at the nurses station could view the patient.

D. The findings were confirmed by RN #1 at 1610.