HospitalInspections.org

Based on medical record review and interview, the facility failed to ensure the nursing staff fully documented the patients' condition, interventions, and physician notifications upon changes in patient medical condition and/or behavioral changes during the month of January 2023, for 2 of 6 patients (#2 and #4) of patient's #1 through #6 who's records were reviewed.

This deficient practice had the likelihood to affect all patients of the facility.


Findings included:

On 1/24/2023, during a complaint investigation, the medical record (MR) for patient (Pt/pt) #2 was reviewed with the assistance of the Director of Nursing (DON). The MR review indicated pt #2 had an unwitnessed ground level fall (GLF) during the night shift. The nurse's note documented on 1/10/2023 at 4:30 AM, "This nurse alerted to pt sitting down in the shower into room. ...Nurse went to pt room to assess the patient. Pt was ambulating with assistance from the mental health tech (MHT) from bathroom to the bed. Pt A&O (alert and oriented) x 4 (person, place, time, and date). (Pt) states she did not hit her head. States, "I was turning the water off and slipped. I sat down. My hip hurts but I don't thing (sic) I did any damage."
This nurse assessed pt. No redness or bruising noted. Pt ambulating with unsteady gait, assisted by MHT. ..." When asked, the DON stated, "I was aware of the fall and was told by the RN she had notified the physician."

The nurse's note failed to record complete vital signs, and failed to record the physician was notified. The nurse failed to record how the patient's hip was assessed other than observing her ambulate with assistance and observing no bruise.

Further review of the every 15 minute "Direct Observation of Patient Clinical and Location Status" document recorded the patient was asleep from 9:00 PM until 6:00 AM. This document allowed space for the recording of vital signs. The only vital signs documented for the night shift were at 7:00 PM. the document also provided a location to document a physician had been notified. This space was left blank. The DON stated, "The Registered Nurse (RN) should have gotten vital signs and should have documented the pt's physician was notified."


During this complaint investigation the complainant alleged pt #4 was found in her room with a male patient with her pants and panties pulled down and "white stuff" on her pants.

The DON stated she had been made aware this had occurred by the RN, Staff 11, who was on duty when the patient had been found in pt #5's room by the MHTs. There was no documentation found indicating what date this occurred or how long pt #4 had been in pt #5's room. The MR for pt #4 was reviewed with the assistance of the DON. The DON was unable to identify any documentation where pt #4 was found in her room with a male. The DON stated pt #4 was on "line of sight" observation and on SAO (sexually acting out) precautions. Pt #4's MR did contain a care plan for "Sexually acting out", that had been initiated 1/14/2023 by Staff #11, however there was no documentation found in the medical record to indicate what specific behavior(s) prompted the care plan or when the behaviors occurred. It could not be determined if this was the date the patient was found in pt #5's room. Further review of the MR identified no description of how or when #4 had sexually acted out. The DON stated she had been told pt #4 became fixated on a male patient and followed him where ever he went. She sat by him during meals and sat by him during free time. She further stated, " Dr.#12, the psychiatrist, had also spoken with pt #4 and told her she did not need to be in another persons room."

Interview with the Psychiatrist, staff #12, stated, "She told pt #4 she could not go into other persons bedrooms and needed to stay out of the male patient's room."

In the absence of MR documentation, the facility's video recordings beginning 1/14/2023 forward were reviewed for each day, and at no time was pt #4 seen unattended in the hallway. She was seen in the eating area and day room and being monitored as she went into her room. No other pt was seen entering her room other than her roommate. While the DON was aware of the incident, a review of the video and medical record was not able to determine when the incident occurred.

The MR could not be used to determine if pt #4 acted out sexually, more than following a male patient and sitting next to him. The nurse's note failed to contain descriptive documentation of a single action exhibited by pt #4 that would support "sexually acting out" and failed to document the psychiatrist had been notified.