HospitalInspections.org

Based on observations, record reviews, and interviews, the hospital failed to ensure patients had the right to personal privacy as evidenced by having video monitoring and recording in patient rooms with no documented evidence that patients were informed that video recording was present. The video monitor was placed in the nursing station in a location that allowed anyone who walked in the hall in front of the nursing station (used by all patients and staff) to view the inside of each patient room. This deficient practice affected the 4 (#1, #2, #4, #5) current patients and 1 discharged patient (#3) sampled and 1 (R1) random patient interviewed from a total census of 12 patients at the time of the survey and could affect any future patient admitted to the unit.
Findings:

Observation on 03/27/19 at 3:20 p.m. of a hospital-provided video recording of the night shift of 02/20/19 from 11:00 p.m. through 2:54 a.m. on 02/21/19 revealed Patient #3's roommate sat up in bed and removed the top of her clothing. Continuous observation revealed the roommate walked back and forth from her bed to the bathroom multiple times wearing only briefs with her breasts exposed.

Observation on 03/28/19 at 12:35 p.m., while standing in front of the half-walled, half glass nursing station in the hall that had patient bedrooms, the dining room, conference rooms, and shower rooms, the surveyor was able to view the video monitor that was mounted at a level that allowed it to be seen from the hall. Continuous observation revealed the monitor had each patient room visible on the monitor screen. Continuous observation revealed patients staff walking in the hall.

Observation on 03/28/19 at 12:53 p.m. in the entrance to the APU (able to be entered from the hospital atrium through an unlocked door) revealed a bulletin board with a sign that read "To All Patients / Visitors For Patient Safety This Unit Is Under Constant Video Surveillance." Further observation revealed one had to enter 2 locked doors from this lobby to gain entry to the APU.

Review of the policy titled "Patient Rights and responsibilities", presented as a current policy by S1AVPPI, revealed every patient has the tight to receive care in an environment that preserves dignity, respects each patient's psychosocial, spiritual, and cultural values and beliefs, and contributes to a positive self image. Further review revealed every patient has the right to personal privacy and confidentiality in treatment discussion, consultation, examination, and treatment.

Review of the "Acknowledgment Of Notification Of Rights" signed by Patients #1, #2, #4, and #5 revealed no documented evidence that they were informed that video recording in patient rooms was implemented.

In an interview on 03/28/19 at 12:33 p.m., Patient R1 indicated she was informed of her patient rights. When asked if she was informed by the staff that there was a video camera that recorded in each room, she indicated "I can see the cameras." She further indicated she didn't remember if staff informed her about the cameras.

In an interview on 03/28/19 at 12:53 p.m., S3UD indicated patients "probably don't see the sign, they're not in the right frame of mind" (referring to the sign in the lobby outside the unit).

Based on observations and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by having 13 beds (2 in each of 6 patient rooms and 1 in the seclusion room) that were an 8 - point restraint bed that had a metal bar in each point available for restraint application that had a space around the bar to which a ligature could be tied and the toilet in each patient bathroom, the seclusion bathroom, and the 2 shower rooms had a bolt on each side of the base that had squared edges around which a ligature could be tied.
Findings:


Observation on 03/27/19 at 9:10 a.m. revealed the 6 patient rooms had 2 beds, and the seclusion room had one bed. Further observation revealed each bed had 8 separate areas on the side and bottom the bed to be used for restraint application. The 8 areas had a metal bar to which restraints could be attached that had a space around the bar to which a ligature could be attached. Further observation revealed each patient bathroom, the seclusion room bathroom, and the 2 shower rooms had a toilet with a bolt on each side of the base to which a ligature could be attached. Further observation revealed Room "c" had 3 hospital gowns on the shelf with an approximate 12 inch tie on each shoulder that could be a ligature risk. This was observation was confirmed by S3UD.

Observation on 03/27/19 t 9:50 a.m. revealed when S3UD tied a gown tie around the bolt, the gown tie remained in place when pulled downward.

Observation on 03/28/19 at 12:45 p.m. of the hospital-provided video recording from the night shift of 03/27/19 with S3UD present revealed Room "a" was observed and had Patients R2 and R3 in their bed. Continuous observation of the recording of 10:00 p.m. through 11:51 pm. revealed S5RN made an observation at 11:03 p.m., and S4PCT made an observation at 11:33 p.m. Both patients were ordered to be on modified visual contact (required observations to be made every 15 minutes) and suicide precautions. There was no observation of a staff member visualizing Patients R2 and R3 for 30 minutes from 11:03 p.m. to 11:33 p.m. This observation was confirmed by S3UD.

Review of the literature on the 8 - point restraint bed, provided by S2PI, revealed the bed was designed to prevent injury to self or others, had no exposed fasteners, and no space for concealment.

Review of the "Mental Health Environment of Care Checklist for Sleeping Rooms", presented as the hospital's mitigation for the 8 - point restraint beds by S2PI, revealed the question "Are all beds free of anchor points for hanging?" Further review revealed the rationale / assessment method included "Platform beds are the safest for an acute psychiatric environment. Further revealed comments included "Beds are platform style, but do have attachment point for restraints, which could be potential ligature risk. Patients are monitored per physician order, at a minimum of every 15 minutes. Patients at high risk for suicide have a 1:1 (one-to-one) sitter even while the patient is sleeping. Patient rooms may be searched at any time for contraband or potential ligatures.

In an interview on 03/28/19 at 2:09 p.m., S2PI indicated there was a clinical need for 8 - point restraint beds on the unit. She indicated they sometimes need restraints for a patient when the seclusion room bed is already in use. She referred to the mitigation plan that addressed the every 15 minute observations by staff. When informed by the surveyor that the plan was not effective as evidenced by observation from the previous night shift that observations were not made for 30 minutes for the 2 patients (R2, R3) in Room "a" who were on suicide precautions and ordered to be observed every 15 minutes, S2PI offered no further explanation.

Based on observation, record review, and interview, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by failure of the RN to ensure that Patient R2 and Patient R3 were observed every 15 minutes as ordered by the physician on the night shift of 03/27/19. There was no observation of staff observing Patients R2 and R3 from 11:03 p.m. to 11:33 p.m. (30 minutes) on 03/27/19 as observed by review of a hospital-provided video recording.
Findings:

Observation on 03/28/19 at 12:45 p.m. of the hospital-provided video recording from the night shift of 03/27/19 with S3UD present revealed Room "a" was observed and had Patients R2 and R3 in their bed. Continuous observation of the recording of 10:00 p.m. through 11:51 pm. revealed S5RN made an observation at 11:03 p.m., and S4PCT made an observation at 11:33 p.m. Both patients were ordered to be on modified visual contact (required observations to be made every 15 minutes) and suicide precautions. There was no observation of a staff member visualizing Patients R2 and R3 for 30 minutes from 11:03 p.m. to 11:33 p.m.

Review of the policy titled "Levels of Observation", presented as a current policy by S1AVPPI, revealed modified visual observation required unit personnel to document patient behavior and location every 15 minutes.

Review of Patients R2 and R3 "Observation / Restraint Checklist" revealed on 03/27/19 at 11:15 p.m. S6MHA documented Patients R2 and R3 were sleeping.

In an interview on 03/28/19 at 12:45 p.m., S3UD confirmed observation of the video recording revealed no staff entered Room "a" from 11:03 p.m. to 11:33 p.m. on 03/27/19. She further confirmed S6MHA documented an observation that she did not make on 11/27/19 at 11:15 p.m.