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Based on video review, document review and staff interviews it was determined the hospital failed to ensure that care was provided in a safe setting (see tag A 144 ). This failure led to the patient inflicting serious injury on herself (see tag A 145). The hospital failed to provide proper monitoring (see tag A 167) and failed to ensure staff followed hospital policy (see tag A 175).

Based on video review, record review, policy review and staff interviews it was determined the hospital failed to ensure that patient #1 was safe while being placed in seclusion. This failure led to the patient inflicting scratches to her right wrist and a laceration to her left antecubital requiring an emergency room visit to receive sutures.

Findings include:

1. A review of the hospital monitoring video for 8/3/20 revealed patient #1 coming out of her room running towards another patient in the hall. She attacked the female patient at 3:45:22 p.m. with hospital staff immediately intervening. The staff was unable to get the patient to commit to safety and received an order from the physician to place the patient in the seclusion room. She was placed in the seclusion room at 3:50:50 p.m. She stands on the bed and begins hitting the camera while in the seclusion room. She was taken out of seclusion at 4:02:10 p.m. to go to the restroom with multiple staff assisting the patient. She returned to the seclusion room at 4:07:36 p.m. She continued to bang on the walls and camera. She removed socks and shoes at 4:12:20 and pulls down pants at 4:12:34 and squats down, facing away from the camera. She uses socks to wipe her buttocks and precedes to smear the sock on the seclusion room window. Staff can be seen periodically looking through the seclusion room window at the patient. At 4:41:48 p.m. she pushed the bed over to the sprinkler head and starts punching the sprinkler. The patient was up and down standing on the bed multiple times pulling at the sprinkler head. At 4:47:43 p.m. she pulled the sprinkler head down. At 4:50:32 p.m. patient #1 turns her back to the camera with an object in her hand. She sits on the bed in the corner with her back turned away from the camera and staff could not visualize the front of the patient from the window. The patient disassembled the sprinkler head and proceeded to use the metal piece to self-inflict scratches and lacerations to both arms. No staff member entered the seclusion room until 5:09:42 p.m., leaving the patient without anyone doing a full body view of patient #1 for nineteen (19) minutes and ten (10) seconds. She was eventually transferred to a local hospital where she received four (4) sutures in her left antecubital.

2. A review of the hospital document entitled 'Restraint/Seclusion Record' reveals a physician's order was received on 8/3/20 at 3:55 p.m. to place patient #1 in seclusion.

3. A review of the hospital policy entitled 'Guidelines for: Seclusion/Restraint,' effective date 6/30/16, states: "During the use of seclusion or restraints, the patient will be continuously observed one-on-one with appropriate documentation at the initiation of the seclusion or restraint and at five (5) minutes intervals thereafter." The policy also states: "The patient will be assessed by staff members trained in the use of restraint and seclusion every fifteen (15) minutes for the following: 1. Signs of any injury associated with applying restraint or seclusion; 2. Circulation and range of motion in the extremities; 3. Vital signs; 4. Hygiene and elimination; 5. Physical and psychological status and comfort; 6. Readiness for discontinuing restraint or seclusion."

4. A review of the hospital document entitled 'Restraint/Seclusion Record' reveals five (5) minute checks were documented.

5. On 10/19/20 at approximately 12:00 p.m. the Chief Executive Officer (CEO) conducted a FaceTime video of the seclusion room on Unit A-3 where the incident occurred with patient #1 on 8/3/20. During the video it was noted that one corner of the room could not be visualized through the monitoring video of the seclusion room. The CEO concurred that the corner could not be visualized on the monitoring video. During the video it was noted that the sprinkler head had been repaired.

6. A telephone interview was conducted with Registered Nurse (RN) #1 on 10/20/20 at approximately 10:15 a.m. While discussing the incident on 8/3/20 she stated, "She had been acting out all day. She was upset another patient had been moved off the unit. She had tried to elope while out for fresh air that morning and we called the doctor and got an order for 2:1 observation. We asked for gown and mitts prior to the incident and was told it would be punitive. After she attacked the patient she would not commit to safety, had already given her a prn (as needed) medication earlier, we called and got an order from the doctor to place her in the seclusion room. The doctor came up and watched how she was acting and we asked him if we could restrain and he said she was safe in the seclusion room." During the interview RN #1 concurred you were unable to fully view the patient with the video monitoring and if the patient's back was to you, they could not be fully visualized from the seclusion room window.

7. A telephone interview was conducted with RN #2 on 10/20/20 at approximately 11:00 a.m. While discussing the incident with patient #1 on 8/3/20 she stated, "Her behavior had been escalating. She was upset that a patient she liked had been moved to another unit. She tried to elope during fresh air. She came in threatening to hurt herself by swallowing something she should not. Called the doctor and asked for an order for gown and mitts and was told I was being punitive. She attacked an elderly patient pulling her hair out and putting a gash in her head. Staff immediately restrained her. She would not commit to safety, had already had a prn (as needed) med. We received an order for her to be placed in seclusion room. Health Service Worker (HSW) was monitoring her on the camera. She was banging the walls, hitting the camera. The doctor came up and saw how the patient was acting. He refused to order restraints, said the patient was safe in the seclusion room." RN #2 stated she could not see the patient through the seclusion room window if back is turned away.

8. A telephone interview was conducted with the HSW on 10/20/20 at approximately 1:00 p.m. In regards to the incident on 8/3/20 he stated, "I was just coming on the unit to start my shift when she ran and attacked the patient. Staff was immediately there to help control the patient. She was ordered to be placed in seclusion and I was monitoring her with the video camera. The doctor came up and viewed the patient hitting and punching but refused to order restraints." The HSW stated he monitored the patient by video and documented every five (5) minutes but did not enter the seclusion room until the patient injured herself.

9. A telephone interview was conducted with the Deputy Medical Director on 10/20/20 at approximately 1:30 p.m. While speaking about the incident with patient #1 on 8/3/20 he stated, "Been having trouble during the day. Had tried to elope earlier in the day and was ordered to be placed on 2:1 observation. The patient took medicine for anxiety prior to attacking the other patient. The patient would not commit to stop harming so was placed in seclusion. I went up and saw the patient was acting strangely." The physician stated it was his expectation to have a full body view of the patient being monitored. He stated he was unaware that the patient could not be fully viewed on the monitor or through the seclusion room window.

Based on video review, record review, policy review and staff interviews it was determined the staff neglected to ensure care was provided in a safe setting for one (1) out of ten (10) records reviewed (patient #1). This failure led to the patient inflicting injuries on herself requiring sutures for lacerations to her left antecubital.

Findings include:

1. A review of the hospital monitoring video for 8/3/20 revealed patient #1 coming out of her room running towards another patient in the hall. She attacked the female patient at 3:45:22 p.m. with hospital staff immediately intervening. The staff was unable to get the patient to commit to safety and received an order from the physician to place the patient in the seclusion room. She was placed in the seclusion room at 3:50:50 p.m. She stands on the bed and begins hitting the camera while in the seclusion room. She was taken out of seclusion at 4:02:10 p.m. to go to the restroom with multiple staff assisting the patient. She returned to the seclusion room at 4:07:36 p.m. She continued to bang on the walls and camera. She removed socks and shoes at 4:12:20 and pulls down pants at 4:12:34 and squats down, facing away from the camera. She uses socks to wipe her buttocks and precedes to smear the sock on the seclusion room window. Staff can be seen periodically looking through the seclusion room window at the patient. At 4:41:48 p.m. she pushed the bed over to the sprinkler head and starts punching the sprinkler. The patient was up and down standing on the bed multiple times pulling at the sprinkler head. At 4:47:43 p.m. she pulled the sprinkler head down. At 4:50:32 p.m. patient #1 turns her back to the camera with an object in her hand. She sits on the bed in the corner with her back turned away from the camera and staff could not visualize the front of the patient from the window. The patient disassembled the sprinkler head and proceeded to use the metal piece to self-inflict scratches and lacerations to both arms. No staff member entered the seclusion room until 5:09:42 p.m., leaving the patient without anyone doing a full body view of patient #1 for nineteen (19) minutes and ten (10) seconds. She was eventually transferred to a local hospital where she received four (4) sutures in her left antecubital.

2. A review of the hospital document entitled 'Restraint/Seclusion Record' reveals a physician's order was received on 8/3/20 at 3:55 p.m. to place patient #1 in seclusion.

3. A review of the hospital policy entitled 'Guidelines for: Seclusion/Restraint,' effective date 6/30/16, states: "During the use of seclusion or restraints, the patient will be continuously observed one-on-one with appropriate documentation at the initiation of the seclusion or restraint and at five (5) minutes intervals thereafter." The policy also states: "The patient will be assessed by staff members trained in the use of restraint and seclusion every fifteen (15) minutes for the following: 1. Signs of any injury associated with applying restraint or seclusion; 2. Circulation and range of motion in the extremities; 3. Vital signs; 4. Hygiene and elimination; 5. Physical and psychological status and comfort; 6. Readiness for discontinuing restraint or seclusion."

4. A review of the hospital document entitled 'Restraint/Seclusion Record' reveals five (5) minute checks were documented.

5. On 10/19/20 at approximately 12:00 p.m. the Chief Executive Officer (CEO) conducted a FaceTime video of the seclusion room on Unit A-3 where the incident occurred with patient #1 on 8/3/20. During the video it was noted that one corner of the room could not be visualized through the monitoring video of the seclusion room. The CEO concurred that the corner could not be visualized on the monitoring video. During the video it was noted that the sprinkler head had been repaired.

6. A telephone interview was conducted with Registered Nurse (RN) #1 on 10/20/20 at approximately 10:15 a.m. While discussing the incident on 8/3/20 she stated, "She had been acting out all day. She was upset another patient had been moved off the unit. She had tried to elope while out for fresh air that morning and we called the doctor and got an order for 2:1 observation. We asked for gown and mitts prior to the incident and was told it would be punitive. After she attacked the patient she would not commit to safety, had already given her a prn (as needed) medication earlier, we called and got an order from the doctor to place her in the seclusion room. The doctor came up and watched how she was acting and we asked him if we could restrain and he said she was safe in the seclusion room." During the interview RN #1 concurred you were unable to fully view the patient with the video monitoring and if the patient's back was to you, they could not be fully visualized from the seclusion room window.

7. A telephone interview was conducted with RN #2 on 10/20/20 at approximately 11:00 a.m. While discussing the incident with patient #1 on 8/3/20 she stated, "Her behavior had been escalating. She was upset that a patient she liked had been moved to another unit. She tried to elope during fresh air. She came in threatening to hurt herself by swallowing something she should not. Called the doctor and asked for an order for gown and mitts and was told I was being punitive. She attacked an elderly patient pulling her hair out and putting a gash in her head. Staff immediately restrained her. She would not commit to safety, had already had a prn (as needed) med. We received an order for her to be placed in seclusion room. Health Service Worker (HSW) was monitoring her on the camera. She was banging the walls, hitting the camera. The doctor came up and saw how the patient was acting. He refused to order restraints, said the patient was safe in the seclusion room." RN #2 stated she could not see the patient through the seclusion room window if back is turned away.

8. A telephone interview was conducted with the HSW on 10/20/20 at approximately 1:00 p.m. In regards to the incident on 8/3/20 he stated, "I was just coming on the unit to start my shift when she ran and attacked the patient. Staff was immediately there to help control the patient. She was ordered to be placed in seclusion and I was monitoring her with the video camera. The doctor came up and viewed the patient hitting and punching but refused to order restraints." The HSW stated he monitored the patient by video and documented every five (5) minutes but did not enter the seclusion room until the patient injured herself.

9. A telephone interview was conducted with the Deputy Medical Director on 10/20/20 at approximately 1:30 p.m. While speaking about the incident with patient #1 on 8/3/20 he stated, "Been having trouble during the day. Had tried to elope earlier in the day and was ordered to be placed on 2:1 observation. The patient took medicine for anxiety prior to attacking the other patient. The patient would not commit to stop harming so was placed in seclusion. I went up and saw the patient was acting strangely." The physician stated it was his expectation to have a full body view of the patient being monitored. He stated he was unaware that the patient could not be fully viewed on the monitor or through the seclusion room window.

2020-3-047

Based on video review, policy review and staff interviews it was determined the hospital failed to ensure staff properly monitored patient #1 while in seclusion. This failure led to the patient being able to disassemble the sprinkler head and using part of the sprinkler to scratch her right wrist and lacerate her left antecubital requiring sutures at the emergency room.

Findings include:

1. A review of the hospital monitoring video for 8/3/20 revealed patient #1 coming out of her room running towards another patient in the hall. She attacked the female patient at 3:45:22 p.m. with hospital staff immediately intervening. The staff was unable to get the patient to commit to safety and received an order from the physician to place the patient in the seclusion room. She was placed in the seclusion room at 3:50:50 p.m. She stands on the bed and begins hitting the camera while in the seclusion room. She was taken out of seclusion at 4:02:10 p.m. to go to the restroom with multiple staff assisting the patient. She returned to the seclusion room at 4:07:36 p.m. She continued to bang on the walls and camera. She removed socks and shoes at 4:12:20 and pulls down pants at 4:12:34 and squats down, facing away from the camera. She uses socks to wipe her buttocks and precedes to smear the sock on the seclusion room window. Staff can be seen periodically looking through the seclusion room window at the patient. At 4:41:48 p.m. she pushed the bed over to the sprinkler head and starts punching the sprinkler. The patient was up and down standing on the bed multiple times pulling at the sprinkler head. At 4:47:43 p.m. she pulled the sprinkler head down. At 4:50:32 p.m. patient #1 turns her back to the camera with an object in her hand. She sits on the bed in the corner with her back turned away from the camera and staff could not visualize the front of the patient from the window. The patient disassembled the sprinkler head and proceeded to use the metal piece to self-inflict scratches and lacerations to both arms. No staff member entered the seclusion room until 5:09:42 p.m., leaving the patient without anyone doing a full body view of patient #1 for nineteen (19) minutes and ten (10) seconds. She was eventually transferred to a local hospital where she received four (4) sutures in her left antecubital.

2. A review of the hospital policy entitled 'Guidelines for: Seclusion/Restraint,' effective date 6/30/16, states: "During the use of seclusion or restraints, the patient will be continuously observed one-on-one with appropriate documentation at the initiation of the seclusion or restraint and at five (5) minutes intervals thereafter." The policy also states: "The patient will be assessed by staff members trained in the use of restraint and seclusion every fifteen (15) minutes for the following: 1. Signs of any injury associated with applying restraint or seclusion; 2. Circulation and range of motion in the extremities; 3. Vital signs; 4. Hygiene and elimination; 5. Physical and psychological status and comfort; 6. Readiness for discontinuing restraint or seclusion."

3. A review of the hospital document entitled 'Restraint/Seclusion Record' reveals five (5) minute checks were documented.

4. On 10/19/20 at approximately 12:00 p.m. the Chief Executive Officer (CEO) conducted a FaceTime video of the seclusion room on Unit A-3 where the incident occurred with patient #1 on 8/3/20. During the video it was noted that one corner of the room could not be visualized through the monitoring video of the seclusion room. The CEO concurred that the corner could not be visualized on the monitoring video. During the video it was noted that the sprinkler head had been repaired.

5. A telephone interview was conducted with Registered Nurse (RN) #1 on 10/20/20 at approximately 10:15 a.m. While discussing the incident on 8/3/20 she stated, "She had been acting out all day. She was upset another patient had been moved off the unit. She had tried to elope while out for fresh air that morning and we called the doctor and got an order for 2:1 observation. We asked for gown and mitts prior to the incident and was told it would be punitive. After she attacked the patient she would not commit to safety, had already given her a prn (as needed) medication earlier, we called and got an order from the doctor to place her in the seclusion room. The doctor came up and watched how she was acting and we asked him if we could restrain and he said she was safe in the seclusion room." During the interview RN #1 concurred you were unable to fully view the patient with the video monitoring and if the patient's back was to you, they could not be fully visualized from the seclusion room window.

6. A telephone interview was conducted with RN #2 on 10/20/20 at approximately 11:00 a.m. While discussing the incident with patient #1 on 8/3/20 she stated, "Her behavior had been escalating. She was upset that a patient she liked had been moved to another unit. She tried to elope during fresh air. She came in threatening to hurt herself by swallowing something she should not. Called the doctor and asked for an order for gown and mitts and was told I was being punitive. She attacked an elderly patient pulling her hair out and putting a gash in her head. Staff immediately restrained her. She would not commit to safety, had already had a prn (as needed) med. We received an order for her to be placed in seclusion room. Health Service Worker (HSW) was monitoring her on the camera. She was banging the walls, hitting the camera. The doctor came up and saw how the patient was acting. He refused to order restraints, said the patient was safe in the seclusion room." RN #2 stated she could not see the patient through the seclusion room window if back is turned away.

7. A telephone interview was conducted with the HSW on 10/20/20 at approximately 1:00 p.m. In regards to the incident on 8/3/20 he stated, "I was just coming on the unit to start my shift when she ran and attacked the patient. Staff was immediately there to help control the patient. She was ordered to be placed in seclusion and I was monitoring her with the video camera. The doctor came up and viewed the patient hitting and punching but refused to order restraints." The HSW stated he monitored the patient by video and documented every five (5) minutes but did not enter the seclusion room until the patient injured herself.

8. A telephone interview was conducted with the Deputy Medical Director on 10/20/20 at approximately 1:30 p.m. While speaking about the incident with patient #1 on 8/3/20 he stated, "Been having trouble during the day. Had tried to elope earlier in the day and was ordered to be placed on 2:1 observation. The patient took medicine for anxiety prior to attacking the other patient. The patient would not commit to stop harming so was placed in seclusion. I went up and saw the patient was acting strangely." The physician stated it was his expectation to have a full body view of the patient being monitored. He stated he was unaware that the patient could not be fully viewed on the monitor or through the seclusion room window.




43303


2020-3-048

Based on document review, medical record review and staff interviews it was revealed the facility failed to ensure all licensed nurses who provide services in the hospital adhere to the hospital's policies and procedures. This failure was identified in one (1) of twenty (20) medical records reviewed (#11). This failure has the potential to place all patients at risk for harm or injury.

Findings include:

1. A review of the medical record for patient #11 reveals no documentation for safe and appropriate patient monitoring regarding the restraint event occurring on 5/13/20.

2. A review of hospital policy titled "Guidelines for: Seclusion/Restraint" reveals in part: "f. Where restraints are utilized, opportunity for motion and exercise shall be provided for a period of not less than ten (10) minutes during each two (2) hours in which restraints are employed. g. During the use of seclusion or restraint, the patient will be continuously observed one-on-one (1:1) with the appropriate documentation at the initiation of the seclusion or restraint and at five (5) minute intervals thereafter. h. The patient will be assessed by a staff member trained and competent in the use of restraint and seclusion every fifteen (15) minutes of the following: 1. Signs of any injury associated with applying restraints or seclusion; 2. Circulation and range of motion in the extremities; 3. Vital signs; 4. Hygiene and elimination; 5. Physical and psychological status and comfort; 6. Readiness for discontinuing restraint or seclusion."

3. During a telephone interview conducted on 10/20/2020 at 1:13 p.m. the Chief Compliance Officer concurred that patient #11's medical record contains no documentation for safe and appropriate monitoring for the restraint event occurring on 5/13/2020.

2020-3-047

Based on video review, policy review and staff interviews it was determined the staff failed to ensure hospital policy was followed while monitoring patient #1 while she was placed in the seclusion room. This failure led to the patient inflicting a laceration to her left antecubital and scratches to her right wrist.

Findings include:

1. A review of the hospital monitoring video for 8/3/20 revealed patient #1 coming out of her room running towards another patient in the hall. She attacked the female patient at 3:45:22 p.m. with hospital staff immediately intervening. The staff was unable to get the patient to commit to safety and received an order from the physician to place the patient in the seclusion room. She was placed in the seclusion room at 3:50:50 p.m. She stands on the bed and begins hitting the camera while in the seclusion room. She was taken out of seclusion at 4:02:10 p.m. to go to the restroom with multiple staff assisting the patient. She returned to the seclusion room at 4:07:36 p.m. She continued to bang on the walls and camera. She removed socks and shoes at 4:12:20 and pulls down pants at 4:12:34 and squats down, facing away from the camera. She uses socks to wipe her buttocks and precedes to smear the sock on the seclusion room window. Staff can be seen periodically looking through the seclusion room window at the patient. At 4:41:48 p.m. she pushed the bed over to the sprinkler head and starts punching the sprinkler. The patient was up and down standing on the bed multiple times pulling at the sprinkler head. At 4:47:43 p.m. she pulled the sprinkler head down. At 4:50:32 p.m. patient #1 turns her back to the camera with an object in her hand. She sits on the bed in the corner with her back turned away from the camera and staff could not visualize the front of the patient from the window. The patient disassembled the sprinkler head and proceeded to use the metal piece to self-inflict scratches and lacerations to both arms. No staff member entered the seclusion room until 5:09:42 p.m., leaving the patient without anyone doing a full body view of patient #1 for nineteen (19) minutes and ten (10) seconds. She was eventually transferred to a local hospital where she received four (4) sutures in her left antecubital.

2. A review of the hospital policy entitled 'Guidelines for: Seclusion/Restraint,' effective date 6/30/16, states: "During the use of seclusion or restraints, the patient will be continuously observed one-on-one with appropriate documentation at the initiation of the seclusion or restraint and at five (5) minutes intervals thereafter." The policy also states: "The patient will be assessed by staff members trained in the use of restraint and seclusion every fifteen (15) minutes for the following: 1. Signs of any injury associated with applying restraint or seclusion; 2. Circulation and range of motion in the extremities; 3. Vital signs; 4. Hygiene and elimination; 5. Physical and psychological status and comfort; 6. Readiness for discontinuing restraint or seclusion."

3. A review of the hospital document entitled 'Restraint/Seclusion Record' reveals five (5) minute checks were documented.

4. On 10/19/20 at approximately 12:00 p.m. the Chief Executive Officer (CEO) conducted a FaceTime video of the seclusion room on Unit A-3 where the incident occurred with patient #1 on 8/3/20. During the video it was noted that one corner of the room could not be visualized through the monitoring video of the seclusion room. The CEO concurred that the corner could not be visualized on the monitoring video. During the video it was noted that the sprinkler head had been repaired.

5. A telephone interview was conducted with Registered Nurse (RN) #1 on 10/20/20 at approximately 10:15 a.m. While discussing the incident on 8/3/20 she stated, "She had been acting out all day. She was upset another patient had been moved off the unit. She had tried to elope while out for fresh air that morning and we called the doctor and got an order for 2:1 observation. We asked for gown and mitts prior to the incident and was told it would be punitive. After she attacked the patient she would not commit to safety, had already given her a prn (as needed) medication earlier, we called and got an order from the doctor to place her in the seclusion room. The doctor came up and watched how she was acting and we asked him if we could restrain and he said she was safe in the seclusion room." During the interview RN #1 concurred you were unable to fully view the patient with the video monitoring and if the patient's back was to you, they could not be fully visualized from the seclusion room window.

6. A telephone interview was conducted with RN #2 on 10/20/20 at approximately 11:00 a.m. While discussing the incident with patient #1 on 8/3/20 she stated, "Her behavior had been escalating. She was upset that a patient she liked had been moved to another unit. She tried to elope during fresh air. She came in threatening to hurt herself by swallowing something she should not. Called the doctor and asked for an order for gown and mitts and was told I was being punitive. She attacked an elderly patient pulling her hair out and putting a gash in her head. Staff immediately restrained her. She would not commit to safety, had already had a prn (as needed) med. We received an order for her to be placed in seclusion room. Health Service Worker (HSW) was monitoring her on the camera. She was banging the walls, hitting the camera. The doctor came up and saw how the patient was acting. He refused to order restraints, said the patient was safe in the seclusion room." RN #2 stated she could not see the patient through the seclusion room window if back is turned away.

7. A telephone interview was conducted with the HSW on 10/20/20 at approximately 1:00 p.m. In regards to the incident on 8/3/20 he stated, "I was just coming on the unit to start my shift when she ran and attacked the patient. Staff was immediately there to help control the patient. She was ordered to be placed in seclusion and I was monitoring her with the video camera. The doctor came up and viewed the patient hitting and punching but refused to order restraints." The HSW stated he monitored the patient by video and documented every five (5) minutes but did not enter the seclusion room until the patient injured herself.

8. A telephone interview was conducted with the Deputy Medical Director on 10/20/20 at approximately 1:30 p.m. While speaking about the incident with patient #1 on 8/3/20 he stated, "Been having trouble during the day. Had tried to elope earlier in the day and was ordered to be placed on 2:1 observation. The patient took medicine for anxiety prior to attacking the other patient. The patient would not commit to stop harming so was placed in seclusion. I went up and saw the patient was acting strangely." The physician stated it was his expectation to have a full body view of the patient being monitored. He stated he was unaware that the patient could not be fully viewed on the monitor or through the seclusion room window.


43303


2020-3-048

Based on document review, medical record review and staff interviews it was revealed the facility failed to ensure all licensed nurses who provide services in the hospital adhere to the hospital's policies and procedures. This failure was identified in one (1) of twenty (20) medical records reviewed (#11). This failure has to potential to place all patients at risk for harm or injury.

Findings include:

1. A review of the medical record for patient #11 reveals no documentation for safe and appropriate patient monitoring regarding restraint event occurring on 5/13/2020.

2. A review of hospital policy titled "Guidelines for: Seclusion/Restraint" reveals in part: "f. Where restraints are utilized, opportunity for motion and exercise shall be provided for a period of not less than ten (10) minutes during each two (2) hours in which restraints are employed. g. During the use of seclusion or restraint, the patient will be continuously observed one-on-one (1:1) with the appropriate documentation at the initiation of the seclusion or restraint and at five (5) minute intervals thereafter. h. The patient will be assessed by a staff member trained and competent in the use of restraint and seclusion every fifteen (15) minutes of the following: 1. Signs of any injury associated with applying restraints or seclusion; 2. Circulation and range of motion in the extremities; 3. Vital signs; 4. Hygiene and elimination; 5. Physical and psychological status and comfort; 6. Readiness for discontinuing restraint or seclusion."

3. During a telephone interview conducted on 10/20/2020 at 1:13 p.m. the Chief Compliance Officer concurred that patient #11's medical record contains no documentation for safe and appropriate monitoring for the restraint event occurring on 5/13/2020.

2020-3-047

Based on review of policy, video review and staff interviews it was determined the staff failed to ensure all staff followed their policy entitled 'Guidelines for: Seclusion/Restraint.' This failure led to patient #1 disassembling the sprinkler head in the seclusion room and using part of the sprinkler to self-inflict scratches to her right wrist and a laceration to her left antecubital that required sutures.

Findings include:

1. A review of the hospital policy entitled 'Guidelines for: Seclusion/Restraint,' effective date 6/30/16, states: "During the use of seclusion or restraints, the patient will be continuously observed one-on-one with appropriate documentation at the initiation of the seclusion or restraint and at five (5) minutes intervals thereafter." The policy also states: "The patient will be assessed by staff members trained in the use of restraint and seclusion every fifteen (15) minutes for the following: 1. Signs of any injury associated with applying restraint or seclusion; 2. Circulation and range of motion in the extremities; 3. Vital signs; 4. Hygiene and elimination; 5. Physical and psychological status and comfort; 6. Readiness for discontinuing restraint or seclusion."

2. A review of the hospital monitoring video for 8/3/20 revealed patient #1 coming out of her room running towards another patient in the hall. She attacked the female patient at 3:45:22 p.m. with hospital staff immediately intervening. The staff was unable to get the patient to commit to safety and received an order from the physician to place the patient in the seclusion room. She was placed in the seclusion room at 3:50:50 p.m. She stands on the bed and begins hitting the camera while in the seclusion room. She was taken out of seclusion at 4:02:10 p.m. to go to the restroom with multiple staff assisting the patient. She returned to the seclusion room at 4:07:36 p.m. She continued to bang on the walls and camera. She removed socks and shoes at 4:12:20 and pulls down pants at 4:12:34 and squats down, facing away from the camera. She uses socks to wipe her buttocks and precedes to smear the sock on the seclusion room window. Staff can be seen periodically looking through the seclusion room window at the patient. At 4:41:48 p.m. she pushed the bed over to the sprinkler head and starts punching the sprinkler. The patient was up and down standing on the bed multiple times pulling at the sprinkler head. At 4:47:43 p.m. she pulled the sprinkler head down. At 4:50:32 p.m. patient #1 turns her back to the camera with an object in her hand. She sits on the bed in the corner with her back turned away from the camera and staff could not visualize the front of the patient from the window. The patient disassembled the sprinkler head and proceeded to use the metal piece to self-inflict scratches and lacerations to both arms. No staff member entered the seclusion room until 5:09:42 p.m., leaving the patient without anyone doing a full body view of patient #1 for nineteen (19) minutes and ten (10) seconds. She was eventually transferred to a local hospital where she received four (4) sutures in her left antecubital.

3. A review of the hospital document entitled 'Restraint/Seclusion Record' reveals five (5) minute checks were documented.

4. A telephone interview was conducted with Registered Nurse (RN) #1 on 10/20/20 at approximately 10:15 a.m. While discussing the incident on 8/3/20 she stated, "She had been acting out all day. She was upset another patient had been moved off the unit. She had tried to elope while out for fresh air that morning and we called the doctor and got an order for 2:1 observation. We asked for gown and mitts prior to the incident and was told it would be punitive. After she attacked the patient she would not commit to safety, had already given her a prn (as needed) medication earlier, we called and got an order from the doctor to place her in the seclusion room. The doctor came up and watched how she was acting and we asked him if we could restrain and he said she was safe in the seclusion room." During the interview RN #1 concurred you were unable to fully view the patient with the video monitoring and if the patient's back was to you, they could not be fully visualized from the seclusion room window.

5. A telephone interview was conducted with RN #2 on 10/20/20 at approximately 11:00 a.m. While discussing the incident with patient #1 on 8/3/20 she stated, "Her behavior had been escalating. She was upset that a patient she liked had been moved to another unit. She tried to elope during fresh air. She came in threatening to hurt herself by swallowing something she should not. Called the doctor and asked for an order for gown and mitts and was told I was being punitive. She attacked an elderly patient pulling her hair out and putting a gash in her head. Staff immediately restrained her. She would not commit to safety, had already had a prn (as needed) med. We received an order for her to be placed in seclusion room. Health Service Worker (HSW) was monitoring her on the camera. She was banging the walls, hitting the camera. The doctor came up and saw how the patient was acting. He refused to order restraints, said the patient was safe in the seclusion room." RN #2 stated she could not see the patient through the seclusion room window if back is turned away.

6. A telephone interview was conducted with the HSW on 10/20/20 at approximately 1:00 p.m. In regards to the incident on 8/3/20 he stated, "I was just coming on the unit to start my shift when she ran and attacked the patient. Staff was immediately there to help control the patient. She was ordered to be placed in seclusion and I was monitoring her with the video camera. The doctor came up and viewed the patient hitting and punching but refused to order restraints." The HSW stated he monitored the patient by video and documented every five (5) minutes but did not enter the seclusion room until the patient injured herself.

7. A telephone interview was conducted with the Deputy Medical Director on 10/20/20 at approximately 1:30 p.m. While speaking about the incident with patient #1 on 8/3/20 he stated, "Been having trouble during the day. Had tried to elope earlier in the day and was ordered to be placed on 2:1 observation. The patient took medicine for anxiety prior to attacking the other patient. The patient would not commit to stop harming so was placed in seclusion. I went up and saw the patient was acting strangely." The physician stated it was his expectation to have a full body view of the patient being monitored. He stated he was unaware that the patient could not be fully viewed on the monitor or through the seclusion room window.


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2020-3-048

Based on document review, medical record review and staff interview, it revealed the facility failed to ensure all licensed nurses who provide services in the hospital adhere to the hospital's policies and procedures. This failure was identified in one (1) of twenty (20) medical records reviewed (#11). This failure has to potential to place all patients at risk for harm or injury.

Findings include:

1. A review of the medical record for patient #11 reveals no documentation for safe and appropriate patient monitoring regarding restraint event occurring on 5/13/2020.

2. A review of hospital policy titled "Guidelines for: Seclusion/Restraint" reveals in part: "f. Where restraints are utilized, opportunity for motion and exercise shall be provided for a period of not less than ten (10) minutes during each two (2) hours in which restraints are employed. g. During the use of seclusion or restraint, the patient will be continuously observed one-on-one (1:1) with the appropriate documentation at the initiation of the seclusion or restraint and at five (5) minute intervals thereafter. h. The patient will be assessed by a staff member trained and competent in the use of restraint and seclusion every fifteen (15) minutes of the following: 1. Signs of any injury associated with applying restraints or seclusion; 2. Circulation and range of motion in the extremities; 3. Vital signs; 4. Hygiene and elimination; 5. Physical and psychological status and comfort; 6. Readiness for discontinuing restraint or seclusion."

3. During a telephone interview conducted on 10/20/2020 at 1:13 p.m. the Chief Compliance Officer concurred patient #11's medical record contained no documentation for safe and appropriate monitoring for restraint event occurring on 5/13/2020.

Based on record review and staff interviews it was determined the hospital failed to ensure the medical record was completed using the patient's legal name in one (1) out of ten (10) medical records reviewed. This failure has the potential to lead to false information being placed in a legal document.

Findings include:

1. A review of the facility document entitled 'Bateman Physician/NP Progress Note' dated 8/3/20 at 1:15 p.m. refers to patient #1 as he, rather than a she, and refers to the patient as a name that is not the patient's legal name. The note states: "Axel continues to have low mood. His coping skills have been helpful in the past and has been nonviolent for a long time until the past few days, at which time roommate changing units and conversation with parents may have triggered some stress and lack of utilizing coping skills in the moment."

2. An interview conducted with the Chief Executive Officer (CEO) was conducted on 10/19/20 at approximately 11:25 a.m. He stated that patient #1 was transgender and would be referred to as he and would be called by the name Axel in the medical record. He did state the patient was a female and her legal name was not Axel.

3. A telephone interview was conducted with the Health Informatic Management Supervisor on 10/21/20 at approximately 9:05 a.m. While discussing the issue of the transgender patient being referred to as Axel in the medical record she stated, "Some staff members have been charting the transgender name, not the legal name, in the medical record."

4. A telephone interview was conducted with the Chief Compliance Officer on 10/21/20 at approximately 9:40 a.m. She concurred the transgender patient should be documented in the medical record by their legal name.