HospitalInspections.org

Based on document review and interview, the facility staff failed to ensure a patient has right to be free from harassment; for 1 of 13 MRs reviewed (Patient # 10); failed to follow the P&P (Policy & Procedure) related to patient precautions for 1 of 13 MRs (Medical Record) reviewed (Patient # 12), and failed to follow the P&P related to Patient Observation for 1 of 13 MRs reviewed (Patient # 12).


Findings include:

1. Review of established hospital policy titled "Patient Rights", Policy Stat ID 13517670, indicated on page 1, under PROCEDURE, 1. "Receive .... respectful care"; and on page 3, 18. "Receive care in a safe setting, free from ... harassment". This policy was last approved 4/2023.

2. Review of established hospital policy titled: "Precautions", Policy Stat ID 12401049, indicated on page 1, under POLICY, "Patient will be assessed and monitored during their treatment and precautions will be ordered... as appropriate"; under PROCEDURE, 2., "Precautions can be ordered by a provider or implemented as a nursing measure"; 4. "Precautions and interventions can include (but are not limited to): on page 2, 4th point, "Sexually Acting Out"; point(s): 2nd point, "Establishing appropriate body boundaries"; 4th point, "Report any inappropriate behavior to treatment team"; 8th point (top of page 3), "If appropriate, obtain an order for 10-foot restriction from peers".
Policy lacked language for documentation on patient safety observation forms, for ordered or implemented precaution related to sexually acting out. This policy was last revised on 9/20/2022.

3. Review of established policy titled: "Patient Observation", Policy Stat ID 12931622, on page 1, under PROCEDURE, "Observation levels can be increased and decreased by a provider's order"; A. "Provider Orders: Providers will order specific observations for any patient(s) who requires level of monitoring other than routine, included, but not limited to:"; 7. "Sexually acting out"; B. "Observation Levels"; page 2, "Level II - Every 5 minutes", 2. "This is an increased level of observation for patients at an increased risk"; "Level III - 1:1 Observation", 3. "Staff will continuously monitor the patient's behavior and immediately report any changes... to the nurse". And on page 2, 6., A. "Documentation of all observations will be completed in the patient's record per their ordered observation status". This policy was last revised 1/2023.

4. Review of MR (Medical Record) for patient # 10, indicated the following:
A. Patient was on 200 unit (room # 210-A); patient moved to 300 unit (room # 307-B) on 9/7/2023.
B. Nurse note on 9/7/2023 at 7:45 am, reflected patient found in room; hyperventilating. Patient stated she/he wanted to leave, because men keep hitting on her/him, making sexual advances on her/him; keeps seeing naked people. Patient made call to SO # 1 (significant other/friend). Note at 8:00 am, patient yelled for staff because a male left that patient bathroom naked.

5. Review of MR for patient # 12, indicated the following:
A. Patient was/is on 200 unit (room # 204-A).
B. Admission orders on 9/6/2023, under Precautions, included: suicide, assault, self harm; lacked for sexual acting out. Orders for remaining days and to current; lacked added precautions for sexual acting out, and for any increase in level of observation status.
C. Medical progress note on 9/7/2023, by NP # 53 (Nurse Practitioner - Medical), reflected patient with flight of ideas. Per report, patient stripped down and was exposing himself/herself on the unit last night. NP note lacked under plan any increase in precautions or level of observation status.
D. Psychiatric progress note on 9/8/2023, by NP # 51 (NP - Psychiatric), reflected patient with flight of ideas. NP note lacked documentation related to patient behavior on 9/7/2023; and under plan lacked any increase in precautions or level of observation status.
E. Nurse note on 9/6/2023 at 8:00 am, reflected patient advances on staff and does not stay a safe distance. Patient takes off clothing on unit, and gets too close to other patients. Patient redirected. Note on 9/7/2023 for 7 am -7 pm; patient is manic and does not know boundaries; such as taking a shower & walking out into the milieu naked; he/she is intrusive of others. NP # 50 (NP - Psychiatric) aware.
F. Patient Safety Observation flowsheets (included, but not limited to): reflected the following:
1. Observation level documentation = every 15 minutes.
2. Precaution level documentation on 9/6/2023: assault, self-harm, suicide, sexually acting out. On 9/7/2023: assault, self-harm, suicide.
3. Precaution level documentation for day of: 9/7/2023 lacked precaution for sexually acting out. For days of 9/8/2023, 9/9/2023, 9/10/2023, 9/11/2023, 9/12/2023 and 9/13/2023; lacked entry(ies) for any precaution level(s).

6. In interview with S # 20 (unit clerk), while on tour of 200 unit, at approximately 3:07 pm, the following was confirmed:
A. Patient # 12 likes to get naked.
B. RN's (Registered Nurse) see it; last time, last week.

Based on document review and interview, the facility failed to ensure an electronic incident report was completed in one (1) instance.

Findings include:

1. Review of established hospital policy titled, "Incident Reports", Policy Stat ID 13033981, indicated an incident report should be completed; for any event which is not consistent with the routine operation of the hospital, in the system by the end of the shift in which the incident occurred but no later than twenty-four (24) hours from the time of the event occurred. This policy was last revised in 01/2023.

2. Review of the facilities incident report log indicated the following:
A. Lacked an incident report related to police officer from OE #1 (Outside Entity) to APH # 60 (Acute Psychiatric Hospital) on 9/7/2023.
B. Call to OE # 1; received from SO # 1 (significant other/friend) on 9/7/2023, related to patient # 10.
C. Patient # 10 felt uncomfortable on unit; due to other patient's behaviors.

3. Review of OE # 1- police officer report on 9/7/2023, indicated the following:
A. Police officer arrived to APH # 60 for a welfare check on patient # 10.
B. Police officer spoke with A # 3 (LSW {Licensed Social Worker}- Director of Clinical Services). A # 3 informed police officer that patient had been moved to a different unit.
C. Police officer spoke with Patient # 10. related to patient's concerns for discharge and other patient's behaviors (i.e. male patient exposed self).

4. Review of MR (Medical Record) for patient # 10, indicated the following:
A. Patient was on 200 unit (room # 210-A); patient moved to 300 unit (room # 307-B) on 9/7/2023.
B. Progress note by NP # 53 (Nurse Practitioner - Medical) on 9/8/2023, reflected patient reports a male peer exposed himself to her/him last night.
C. Nurse note on 9/7/2023 at 7:45 am, reflected patient found in room; hyperventilating. Nurse helped her/him to calm down. Patient stated she/he wanted to leave, because men keep hitting on her/him, making sexual advances on her/him; keeps seeing naked people. Patient made call to SO # 1. Note at 8:00 am, patient yelled for staff because a male left that patient bathroom naked. That patient taken back to bathroom and ordered patient to put clothes on and not do that again. Another patient was acting as a protector to patient # 10, but he/she was overbearing. Note at 9:00 am, patient moved to unit 300 for her/his safety and to help keep her/him calm.
D. Nurse notes lacked entry related to patient # 10; having spoke with police officer; after 11:00 am and prior to next nurse note at 1:15 pm.

5. In interview on 9/14/2023 at approximately 1:10 pm, with A # 1 (Chief Executive Officer), the following was confirmed:
A. Did not fill out an incident report, did not think needed. No patient assault.

6. In interview on 9/14/2023 at approximately 11:50 am, with A # 3, the following was confirmed:
A. Police came to APH # 60 to speak with patient # 10.
B. Patient # 10 felt uncomfortable on unit; moved to different unit, before police had arrived. Patient had spoke with A # 1, when he/she was on 200 unit, with DMHA (Division of Mental Health and Addiction) staff.
C. No incident report; for police having been here to see/speak with patient.

Based on document review, the Registered Nurse failed to follow the P&P (Policy & Procedure) related to Precautions, for documentation completed in the patient's record, for 1 of 13 MR's reviewed (Patient # 12).

Findings include:

1. Review of established hospital policy titled: "Precautions", Policy Stat ID 12401049, indicated on page 1, under POLICY, "Patient will be assessed and monitored during their treatment and precautions will be ordered... as appropriate"; under PROCEDURE, 2., "Precautions can be ordered by a provider or implemented as a nursing measure"; 4. "Precautions and interventions can include (but are not limited to): on page 2, 4th point, "Sexually Acting Out"; point(s): 2nd point, "Establishing appropriate body boundaries"; 4th point, "Report any inappropriate behavior to treatment team"; 8th point (top of page 3), "If appropriate, obtain an order for 10-foot restriction from peers".
Policy lacked language for complete documentation on patient safety observation flowsheets, for ordered or implemented precautions. This policy was last revised on 9/20/2022.

2. Review of MR for patient # 12, indicated the following:
A. Patient was/is on 200 unit (room # 204-A).
B. Patient Safety Observation flowsheets (included, but not limited to): reflected the following:
1. Precaution level documentation on 9/6/2023: assault, self-harm, suicide, sexually acting out. On 9/7/2023: assault, self-harm, suicide.
2. Precaution level documentation for day of: 9/7/2023 lacked precaution for sexually acting out.
3. For days of 9/8/2023, 9/9/2023, 9/10/2023, 9/11/2023, 9/12/2023 and 9/13/2023; lacked entry(ies) for any precaution level(s).