Indiana University Health North Hospital

“PATIENT RIGHTS: PERSONAL PRIVACY CFR(s): 482.13(c)(1) The patient has the right to personal privacy. This Standard is not met as evidenced by: 49709 Based on document review, interview and observation, the facility failed to limit the release or disclosure of patient information in 1 of 10 medical records (MRs) reviewed (P1). Findings include: 1. Review of policy/procedure titled, “Reasonable Safeguards for Privacy and Confidentiality of Protected Health Information,” Publication date 09/28/2023, indicates the following: Under VI. Procedures: A. Confidentiality Requirements: 1. All individuals engaged in collection, handling, uses or dissemination of Patient Health Information (PHI) shall exercise reasonable safeguards to protect the confidentiality of PHI. 2. Discussions involving PHI shall be conducted in settings which protect confidentiality, to the extent practical and possible. Activities at Nursing Stations and in Clinical Units: 2. In these circumstances, reasonable precautions may include the following in addition to a general awareness of the use and disclosure of individual health information at nursing stations and other similar locations: b. Proper telephone etiquette and confidentiality awareness when using telephone, cell phones, pagers, or voice message systems. 2. Review of Complaint and Grievance log from (07/01/24 - 01/31/25) contained a complaint related to P1. On 01/23/25 P1’s child filed a complaint with the facility regarding P1 being upset with the provider talking about their diagnosis history with their child. The privacy office emailed the ED (Emergency Deparment) medical director to remind their staff to double check with patients before discussing treatment or diagnosis while visitors are around or on the phone. HIPAA/Privacy Office mailed P1 a letter informing them they were filing a grievance on their behalf. Resolution to this was listed as unresolved. 3. On 04/28/25 at 3:34 p.m., this surveyor, accompanied by A2 ( Medicine Service Line Director) and A3 (Emergency Room Manager), was given a tour of the ED (Emergency Department). During this observation, there were 2 patients in hallway beds. As we were walking by, the discussion between the provider and the patient was able to be heard. There were no curtains or dividers up around the patients in the hallway beds. 4. In interview with A9 (Physician Assistant), on 04/30/25 at approximately 5:36 p.m., indicated P1 handed them their phone and asked A9 to update their child on their medications. A9 indicated they summarized P1’s visit with the child. A9 confirmed they did not ask P1 if it was ok to discuss information regarding P1 with their child, they indicated they thought it was implied as P1 handed them their phone. 5. In interview with P1 (complainant) on 05/01/25 at approximately 1:47 p.m., indicated when the provider was going over discharge instructions, they handed the provider their phone and asked them to inform their child of the new medications they were prescribed. At this point in the conversation, P1 started crying and indicated the provider discussed their diagnosis history with their child. P1 indicated the provider did not ask if it was ok to do that and they did not give the provider permission to discuss this information.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 49709 Based on document review nursing services failed to complete an initial pain assessment and failed to implement interventions after reassessment of pain in 2 of 10 medical records (MRs) reviewed (P1 and P10). Findings include: 1. Review of policy/procedure titled, “Pain Assessment and Management,” Publication date 10/12/2023, indicates the following: Under I. Purpose: A. All patients have the right to appropriate assessment and management of pain. V. Policy Statements: A. Patients will receive interventions (pharmacologic and/or non-pharmacologic) to reduce or eliminate pain associated with their diagnosis, procedure, or treatment and will be re-assessed for the effectiveness of the intervention. VI. Procedures: B. Pain Reassessment 1. The frequency of reassessment should be done individually based on pain level and the patient’s comfort-function goal. 2. For both pharmacological and non-pharmacological pain interventions, effectiveness of the intervention is evaluated through reassessment. 3. If upon reassessment the patient’s pain is not reduced, relieved, or at the comfort-function goal; implement additional interventions or consider contacting the patient’s practitioner. C. Documentation 1. Pain assessment, comfort-function goal, pain interventions and patient/family education are documented in the patient’s medical record as it occurs. 2. Unless otherwise documented, all pain reassessments following an intervention are completed and within acceptable limits. 2. Review of policy/procedure titled, “Triage,” Publication date 09/16/2024; indicates the following: Under V. Policy Statements: C. All patients will be reassessed depending on the patient’s presenting condition and pertinent clinical findings. VI. Procedures: A. All patients should have an initial assessment by a nurse as soon as possible, ideally within 10 minutes of arrival. 2. The initial assessment should include quick registration in the electronic health record, vital signs, medications, allergies, and a brief history of the presenting problem including pain assessment. 3. MR review for P1 indicated patient had a pain assessment completed on 01/24/25 at 1:19 a.m., approximately 1 hour prior to their discharge, and rated their pain at 7/10. MR lacked documentation of a pain intervention. 4. MR review for P10 indicated they did not have pain assessments completed by nursing personnel from admission on 01/24/25 at 2:16 p.m. to discharge on 01/24/25 at 6:16 p.m. At 2:41 p.m., P10 had an order to receive Ibuprofen 600 mg orally, ONCE NOW and received it at 2:55 p.m. MR lacked assessment and reassessment of pain for this medication given. At 5:09 p.m., P10 had an order to receive hydrocodone-acetaminophen orally, ONCE NOW and received it at 5:18 p.m. MR lacked assessment and reassessment of pain for this medication given.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48061 Based on document review and interview, facility staff member failed to include a POA (Power of Attorney) and/or HCR (Health Care representative) in the decision making and implementation of the patient’s plan of care for 1 of 10 patient medical records reviewed (P1), failed to obtain a non-violent mitten restraint order prior to, as soon as possible, but not longer than 4 hours of applying restraints, failed to document/complete soft wrist restraint order as indicated in provider order for 1 of 10 patient medical records reviewed. (P1) and failed to document every two hour restraint safety checks including rationale for continued restraint use and patient safety/comfort for 1 of 10 patient medical records reviewed. (P1) The cumulative effects of this systemic problem resulted in the facility’s inability to ensure that Patient Rights were promoted.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility staff member failed to include a POA (Power of Attorney) and/or HCR (Health Care representative) in the decision making and implementation of the patient’s plan of care for 1 of 10 patient medical records reviewed. (P1) Findings Include: 1. Facility policy titled, Patient/Parent Rights and Responsibilities, Complaint and Grievances, no policy number, publication date 06/20/2023, indicated under IX. FORMS/APPENDICES: Your rights as a patient. To participate in decisions about care, treatment and services, which may include family and loved ones, as permitted by the or decision maker; this includes the development and implementation of an inpatient treatment or care plan, outpatient treatment care plan, pain management and discharge plan. If unable to make decisions, to have a decision maker as defined in Indiana law; your decision maker then has the right to refuse care, treatment or services in accordance with law and regulation. 2. Review of P1’s MR (Medical Record) indicated PA1 (Physician Assistant Certified) was consulted to evaluate P1 for acute urinary retention. Note documentation dated 10/1/2024 at approximately 4:42 pm indicated PA1 evaluated P1 who was noted to be a poor historian d/t (due/to) dementia, acute stroke, and slurred speech. Nursing reported incontinence, in and out catheterization being successful when implemented, urinary urgency and retention as evidence by bladder scans completed by nursing staff members. PA1 indicated he/she communicated with nursing, and determined an indwelling urinary catheter will be anchored if next bladder scan remained high. Order documentation dated 10/1/24 at 6:00 pm indicated PA1 placed an order for urinary catheter insertion (Foley Catheter). Nursing documentation dated 10/1/24 at 7:56 pm the indwelling urinary catheter was placed. The catheter was removed on 10/2/24 at 6:48 pm. MR documentation lacked the inclusion and/or notification of D1 (complainant) who was the patient’s POA and/or HCR. 3. In telephone interview on 10/24/24 at approximately 1:30 pm with PA1 confirmed he/she did not include D1 in the plan of care for P1 r/t (related /to) catheter placement. 4. In telephone interview on 10/22/24 at approximately 4:41 pm with N3 (Registered Nurse) confirmed he/she placed the indwelling urinary catheter without notifying D1 but should have, N3 was aware D1 was P1’s POA, N3 relayed to the visitors at bedside to relay the information to the POA regarding the need for the catheter placement, P1 was answering some questions but did have on going dementia, PA1 was consulted for urinary retention, completed his/her assessment and plan of care for the patient’s urinary retention but did not include or phone D1 with his/her findings and/or plan of care for the patient.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 48061 Based on document review and interview, nursing staff failed to obtain a non-violent mitten restraint order prior to, as soon as possible, but not longer than 4 hours of applying restraints and failed to document/complete soft wrist restraint order as indicated in provider order for 1 of 10 patient medical records reviewed. (P1) Findings include: 1. Facility policy titled, Use of Restraints and Seclusion, no policy number, Publication Date: 12/06/2022, indicated under VI: PROCEDURES: P. Use of Physical Restraints for Non-violent Behavior. 2. Obtain/Provide a Non-Violent Restraint Order. a. A non-violent restraint order must be obtained from a LIP prior to as soon as possible but not longer than 4 hours of applying restraints. 2. Review of P1’s MR (Medical Record) indicated the following: (A) An order was received for non-violent restraint initiation on 9/29/24 at 12:02 am, type of restraint ordered was soft wrist restraints, location was bilateral wrists. An order was received on 10/3/24 at 7:46 am to discontinue the soft wrist restraints. (B) The MR lacked an order for non-violent mitten restraints and lacked documentation of soft wrist restraint placement by facility staff per MD order. 3. In interview on 10/18/24 at approximately 2:50 pm with A4 (Clinical Operations Director) confirmed documentation was not completed per policy for non-violent bilateral soft wrist restraints by nursing but should have been, confirmed nursing staff failed to obtain an order for mitts used as non-violent restraints for P1. 4. In telephone interview on 10/22/24 at approximately 5:48 pm with N1 (Registered Nurse) confirmed P1 had restraint mittens on when he/she arrived for duty on the evening of 10/1/24. 3. In interview on 10/18/24 at approximately 2:50 pm with A4 (Clinical Operations Director) confirmed documentation was not completed per policy for non-violent bilateral soft wrist restraints by nursing but should have been, confirmed nursing staff failed to obtain an order for mitts used as non-violent restraints for P1. 4. In telephone interview on 10/22/24 at approximately 5:48 pm with N1 (Registered Nurse) confirmed P1 had restraint mittens on when he/she arrived for duty on the evening of 10/1/24.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(16)(v) [there must be documentation in the patient’s medical record of the following:] The patient’s response to the intervention(s) used, including the rationale for continued use of the intervention. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility nursing staff failed to document every two hour restraint safety checks including rationale for continued restraint use and patient safety/comfort for 1 of 10 patient medical records reviewed. (P1) Findings Include: 1. Facility policy titled, Use of Restraints and Seclusion, no policy number, Publication Date: 12/06/2022, indicated under VI: PROCEDURES: P. Use of Physical Restraints for Non-violent Behavior. 8. Monitoring-Non-Violent Restraint. Monitoring is used to provide for patient comfort, patient safety, and to determine when restraints can be safely discontinued. Vital signs are monitored as ordered and/or warranted by patient’s status. On-going monitoring is documented a minimum of every two (2) hours. 9. Monitoring Includes: a. Patient Safety. Based on the restraint employed, assessment of the following elements includes but is not limited to, breathing, circulation, distress and injury. b. Patient Comfort. Assessment includes but is not limited to patient need for food, hydration, toileting, range of motion, repositioning and other comfort measures. c. Continue/Discontinue. The need for continued restraint use is determined by assessment of the presence or absence of the circumstances triggering the restraint use. Possible assessments include patient’s mental status, cognitive function, level of distress or agitation and continued presence of the medical device that triggered restraint application. 5. Discontinue Restraints. Discontinue the restraints at the earliest possible time while allowing for continued safety for the patient. Document when the restraints are removed. 2. Review of P1’s MR (Medical Record) indicated a order for non-violent restraint initiation was placed on 9/29/24 at 12:02 am, rationale for use indicated P1 was pulling at essential lines and tubes, type of restraint ordered was soft wrist restraints, location was bilateral wrists, criteria for discontinuation listed demonstrates ability to maintain own safety. Physician order documentation dated 10/3/24 at 7:46 am indicated the restraint order for bilateral soft wrist restraints was discontinued. Lesser invasive methods used prior to using restraints included redirection, use of busy board to keep P1’s hands occupied, and mitts. MR of P1 lacked every 2 hour restraint documentation that included safety/comfort, and lacked rationale for continued restraint use as required by policy. 3. In interview on 10/18/24 at approximately 2:50 pm with A4 (Clinical Operations Director) confirmed documentation was not completed per policy for non-violent bilateral soft wrist restraints by nursing but should have been, confirmed nursing staff failed to obtain an order for mitts used as non-violent restraints for P1. 4. In interview on 10/21/24 at approximately 2:20 pm, during unit observation with N8 (Registered Nurse) confirmed restraint safety charting should be documented every two hours by nursing staff. 5. In telephone interview on 10/22/24 at approximately 5:41 pm with N7 (Registered Nurse) confirmed P1 was placed in restraints d/t (due/to) safety concerns r/t (related/to) patient safety and pulling at lines, restraint charting includes an initiation order with rationale, which type of restraint is indicated, why the patient needs the restraint, and criteria for discontinuation.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48061 Based on document review and interview, facility nursing staff failed to document intake every eight hours as ordered by a physician for 1 of 10 patient medical records reviewed and failed to document when restraints were discontinued and if discontinuation criteria was met according to the restraint order for 1 of 10 patient medical records reviewed. (P1) Findings include: 1. Facility policy titled, “Documentation Standards--Inpatient”, no policy number, Publication date 11/27/2023, indicated under V. POLICY STATEMENTS: A. GENERAL DOCUMENTATION STANDARDS. 3. Registered Nurses (RN’s) are accountable for the patient assessment and documentation process. 2. Facility policy titled, Use of Restraints and Seclusion, no policy number, Publication Date: 12/06/2022, indicated under VI: PROCEDURES: P. Use of Physical Restraints for Non-violent Behavior. 8. Monitoring-Non-Violent Restraint. Monitoring is used to provide for patient comfort, patient safety, and to determine when restraints can be safely discontinued. Vital signs are monitored as ordered and/or warranted by patient’s status. On-going monitoring is documented a minimum of every two (2) hours. 9. Monitoring Includes: a. Patient Safety. Based on the restraint employed, assessment of the following elements includes but is not limited to, breathing, circulation, distress and injury. b. Patient Comfort. Assessment includes but is not limited to patient need for food, hydration, toileting, range of motion, repositioning and other comfort measures. c. Continue/Discontinue. The need for continued restraint use is determined by assessment of the presence or absence of the circumstances triggering the restraint use. Possible assessments include patient’s mental status, cognitive function, level of distress or agitation and continued presence of the medical device that triggered restraint application. 5. Discontinue Restraints. Discontinue the restraints at the earliest possible time while allowing for continued safety for the patient. Document when the restraints are removed. 3. Review of P1’s MR (Medical Record) indicated an order was placed for intake documentation every 8 hours as ordered by the physician on 9/29/24, indicated a order for non-violent restraint initiation was placed on 9/29/24 at 12:02 am, rationale for use indicated P1 was pulling at essential lines and tubes, type of restraint ordered was soft wrist restraints, location was bilateral wrists, criteria for discontinuation listed demonstrates ability to maintain own safety. Physician order documentation dated 10/3/24 at 7:46 am indicated the restraint order for bilateral soft wrist restraints was discontinued. Lesser invasive methods used prior to using restraints included redirection, use of busy board to keep P1’s hands occupied, and mitts. MR of P1 lacked completed intake documentation every 8 hours, lacked documentation when restraints were discontinued and lacked documentation of restraint discontinuation criteria met as required by policy. 4. In interview on 10/18/24 at approximately 2:50 pm with A4 (Clinical Operations Director) confirmed documentation was not completed per policy for non-violent bilateral soft wrist restraints by nursing but should have been, confirmed nursing staff failed to obtain an order for mitts used as non-violent restraints for P1. 5. In interview on 10/18/24 at approximately 3:55 pm with A4 (Clinical Operations Director) confirmed there wasn’t, but should have been, nursing documentation indicating P1 consumed meals and/or fluids regularly, nor did nursing staff document intake every eight hours as ordered but should have. 6. In telephone interview on 10/22/24 at approximately 5:23 pm with N5 (Registered Nurse) confirmed P1 ate and drank with the help of D1 during the day on 10/1/24 and 10/2/24, and he/she did not document the patient’s intake on the intake and output flowsheet but should have.”