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UNIVERSITY OF MINNESOTA MEDICAL CENTER, FAIRVIEW 2450 RIVERSIDE AVENUE MINNEAPOLIS, MN 55454 June 5, 2015
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and document review, the hospital failed to ensure that all patients placed on an emergency hold who present a danger to themselves or others, received adequate supervision for 2 of 10 patients reviewed.

Therefore the hospital was unable to meet the condition of Participation of Patient Rights at 42 CFR 482.13. This deficient practice had the potential to affect patients on medical units and other patients on the same unit when a patient is placed on an emergency hold.

See A-0144 - Based on interview and document review the hospital failed to ensure each patient received care in a safe setting for 2 of 10 patients reviewed, Patient (P-1 and P-2) when P-2 was placed on an emergency hold, was left unsupervised, wandered into P-1's room, and touched P-1 inappropriately.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, video and document review the hospital failed to ensure each patient received care in a safe setting for 2 of 10 patients reviewed, Patient, (P-1 and P-2) when P-2 was placed on an emergency hold, was left unsupervised, wandered into P-1's room, touched P-1 inappropriately.

Findings include:

Medical record reviewed revealed P-1's admission to the hospital occurred on 4/12/2015. P-1's diagnoses included pneumonia and bacteremia. P-1 was cognitively intact and P-1's room was located on 5B, a medical care unit.

Medical record review revealed P-2's admission to the hospital occurred on 4/21/2015. P-2's diagnoses included heroin withdrawal. P-2's room was located on 5B, a medical care unit.

Nursing notes dated 4/23/2015 at 2:44 a.m. written by Registered Nurse (RN)-E revealed that P-2 was exhibiting unsafe behavior and wandering in and out of other patient rooms. P-2 was holding conversations with people not present, and stated seeing small children and dogs.

P-2's Examiner Statement in Support of Emergency Admission (72 Hour Hold), dated 4/23/2015 at 3:00 a.m. and signed by P-2's physician revealed the patient was "in imminent danger of causing injury to him or herself if not immediately restrained because: Frequently trying to leave the floor, having hallucinations, answering inappropriately, unable to reliably perform self cares. She has a history of substance abuse and frequently leaving AMA (against Medical Advice) in the setting of acute on chronic illness."P-2's physicians note dated 4/23/2015 at 3:41 a.m. revealed P-2 was wandering in and out of other patient rooms, was hallucinating, talking to people not there, and wanted to leave AMA. P-2 was placed on an emergency hold.

During an interview on 6/5/2015 at 8:40 a.m., RN-G stated that she was working charge on the night of 4/22/2015 into 4/23/2015. RN-G stated P-2 was wandering on the unit including attempting to enter other patient rooms. Staff members implemented a plan to have staff observe P-2 from the nursing desk, and called for a door alarm to alert staff members if P-2 left her room. RN-G stated the practice on the unit has been to place a door alarm when patients are placed on an emergency hold. At some point (exact time unknown) RN-G stated she responded to a call light, entered P-1's room and found P-2 sitting on P-1's bed. RN-G redirected P-2 out of P-1's room. P-1 told RN-G that P-2 touched P-1's pajamas and stated she wanted to sleep with her. RN-G stated P-1 told her the next day, that P-2 touched her breasts and buttocks during the incident. RN-G stated she had no explanation as to how P-2 got into P-1's room unobserved.

During an interview on 6/5/2015 at 8:10 a.m. RN-E stated P-2 started having behavior concerns, including crawling on the floor, walking randomly, and attempting to enter other patient's rooms at about 1:00 a.m on 4/23/15. RN-E stated she was watching P-2 closely, due to these behaviors, but could not recall if P-2 had a door alarm to alert staff when P-2 left her room. RN-E stated she had no explanation as to why P-2 was able to enter P-1's room unobserved.

During an interview in 6/1/2015 at 2:50 p.m. Interim Nurse Manager- (NM-F) stated she was informed on 4/23/2015 when she arrived for her shift that P-2 was found in P-1's room during the night. NM-F stated she spoke with P-1 about the incident. P-1 stated that P-2 came into her room during the night and got into bed with her. P-1 put on her call light and staff responded and escorted P-2 out of her room. P-1 stated she was upset by the incident and later requested the number of the police.

A hospital video was viewed on 6/1/2015 at 9:00 a.m. During a review of the hallway video from the night of 4/23/2015 it is observed that P-2 is in the unit hallway at 4:06 a.m. No staff are in the area. At 4:07 a.m. P-2 is seen entering P-1's room. At 4:09 a.m. a staff member is seen entering P-1's room and escorting P-2 out.

During an interview on 5/26/2015, P-1 stated another patient entered her room on 4/23/2015 during the night, and crawled into bed with her and touched her inappropriately. P-1 stated she turned her call light on and staff responded and redirected P-2 out of her room. P-1 stated she has been anxious since this incident occurred.

During an interview with Interim Director of Regulatory Compliance on 6/2/2015 at 1:40 p.m. a policy on the level of supervision for patient's placed on an emergency hold was requested. The Interim Director of Regulatory Compliance stated they hospital had no policy related to what level of supervision to provide. The policy titled Emergency hospitalization Hold effective date 5/16/2013 revealed under the section titled Policy ii. An Emergency hospitalization allows the hospital to hold a patient for 72 hours exclusive of weekends or legal holidays, because he or she is: A: Mentally ill, mentally retarded, or chemically dependent; and B: In imminent danger to self or others; and C: An order from the court cannot be obtained in time to prevent anticipated injury.

P-2 was discharged on [DATE]. At the time of the investigation there were no patients identified on medical units who were on an emergency hold.