HospitalInspections.org

Based on document review and interview, the facility failed to ensure care in a safe setting in one instance. (Patient # 3).

Findings include:

1. The hospital policy titled, "Patient Rights and Responsibilities", PolicyStat ID 10359862, indicated on page 3, under PROCEDURE, have right to; 18. "Receive care in a safe setting, free from... physical abuse", Last revised 9/2021.

2. The hospital policy titled, "Patient Abuse and Neglect", PolicyStat ID 11795580, indicated on page 1, under POLICY; "All patients have the right to be free from abuse", and on page 2, under DEFINITIONS: A. Abuse - "any willful.... physical....mistreatment of any person receiving treatment in a mental health facility"; 1. Abuse, physical - "An act that results, or has the potential to result in...pain"; Examples include..."slapping". Last revised 1/2020.

3. Review of Patient # 3's MR (Medical Record) indicated the following:
(a). Patient # 3 admitted on 12/18/2022; diagnosis of Bi-polar & history of Autistic Disorder.
(b). Nurse note dated 12/22/2022 at 7:42 am, reflected patient # 3 with increasing anxiety, wanted his/her laser stick; hits to nurses panel at nurses station. Note at 7:50 am, reflected provider contacted; order received to administer Thorazine 100 mg (milligram) and Ativan 2 mg IM (Intramuscular). Administered with the assist of 3; patient laid on floor, held for safe delivery of injections; patient remained laying past injections; patient up independently, began yelling, stating a desire to be given laser light; continues to hit nurses station panel; yells and making threats. Note at 8:05 am, reflected CPI (Crisis Prevention Intervention) hold to seclusion to protect safety of patient and other patients in milieu, due to increasingly aggressive behavior and threats.
(c). The MR lacked any documentation related to the staff to patient abuse; patient slapped in face; patient's face held, and/or the improper CPI hold by staff.

4. Review of APH # 60's (Acute Psychiatric Hospital) internal investigation related to incident on 12/22/2022, that involved patient # 3 and staff, indicated the following:
A. Date of investigation: 12/27/2022; conducted by HR (Human Resource) staff, A # 2 (Chief Executive Officer), and review by A # 1 (Registered Nurse - Vice President of Quality & Compliance).
B. Interviews from 5 witnesses, were conducted by HR staff & A # 3.
C. Interview and written statement obtained on 12/22/2022, from N # 21 (Behavioral Health Associate), reflected patient # 3's occurrence on 12/22/2022 am. N # 21 stated patient # 3 began to turn his/her body; try to bite N # 21's arm; but N # 21 moved it and held patient # 3's face.

5. In interview on 1/18/2023 at approximately 2:30 pm, with administrative staff member A # 8 (Social Services), confirmed the following:
A. Was present on 200 unit at 8:00 am; A # 8 had heard patient screaming on unit; responded to unit, to check on patients and staff.
B. Witnessed patient # 3 on floor, doorway to room, on ground; in an inappropriate hold x 4 BHA's (Behavioral Health Associate). N # 21 sitting on/straddling patient; another BHA holding patient behind his/her head; other staff were monitoring. Patient # 3 spit up in air; with N # 21 nearest patient #3's face; N # 21 smacked patient # 3 across the face; staff looked at A # 8; and patient was screaming that he/she had been slapped in face.

6. In interview on 1/18/2023 at approximately 1:10 pm, with A # 1, indicated the following:
A. Recalled 1 of the MRs reviewed. Was aware of an occurrence on the 200 unit, in December 2022, that involved a staff member and a patient.
B. That N # 21 did not act willfully; did not intend to hurt Patient # 3.
C. That N # 21 did not do a proper CPI hold.
D. That no incident report was completed, due to the investigation that was completed; that the belief was that the slap did not occur, and that N # 21 did not willfully or intentionally try to hurt patient # 3.

Based on document review and interview, the Registered Nurse failed to follow the P&P (Policy & Procedure) related to Patient personal care for daily bathing/showering for 6 of 10 MR's (Medical Record) reviewed (Patients # 1, # 3, # 4, # 5, # 8, # 10); failed to follow the P&P related to Patient Observation documentation completed in the patient's record, for 3 of 10 MR's reviewed (Patients # 1, # 3, # 4); failed to follow P&P related to Incident Reports related to completion of for an event not consistent with routine operation of hospital for 3 of 10 MR's reviewed (Patients # 3, # 4, # 8), and failed to accurately document events that occurred, for 1 of 10 MR's reviewed (Patient # 1).

Findings include:

1. The hospital policy titled: "Patient Personal Care", PolicyStat ID 12197137, last revised 1/2020, indicated on page 1, under POLICY, "All patients admitted to the hospital will be supported....on personal hygiene", on page 2, under Education, "Bathing/showers will be offered daily"; under General Care, first point, "All patients shall be encouraged or assisted in grooming daily".

2. The hospital policy titled: "Patient Observation", PolicyStat ID 12931622, indicated on page 1, under PROCEDURE, 1. "provider will order ...observation levels; all patients will be admitted to the patient care unit with a minimum of 'every 15 minutes' observation level"; on page 3, Documentation: A. "Documentation of all observations will be completed in the patient's record per their ordered observation status". Originated date 1/2020.

3. The hospital policy titled: "Incident Reports", PolicyStat ID 12386386, indicated on page 1 under PURPOSE, "An incident is defined as any event which is not consistent with the routine operation of the hospital and that adversely affects....the well being of the patients"; under Time frame for Completing an Incident Report, A. "hospital staff must complete and submit an incident report as soon as possible; preferably, the report should be submitted before leaving the hospital at the end of the work shift, but no later than twenty-four (24) hours"; on page 2, A. "This should be done by the employee who witnessed or was informed of the incident", and reports shall include "nurse's notes". Last revised 9/2022.

4. Review of MR's for the Patients # 1, # 3, # 4, # 5, # 8, # 9 and # 10, reflected the following:
A. Patient # 1's MR; a lack of daily hygiene - bathing/showering for days of 9/15, 9/16, 9/17, 9/18, 9/20 and 9/21/2022. The MR also lacked an Observation round sheet/form for 9/19/2022.
1. Documentation in nurse note on 9/18/2022 at 1:50 am, reflected patient noted to be on floor, hitting the back of his/her head. Incident report completed on 9/18/2022 at 2:15 am, reflected patient ran into by another patient; that patient fell back, striking head; found on floor.
2. Not able to determine actual event that occurred on 9/18/2022.
B. Patient # 3's MR; a lack of daily hygiene - bathing/showering for days of 12/18, 12/19, 12/22, 12/23, 12/24, 12/25, 12/26, 12/27 and 12/28/2022. The MR also lacked an Observation round sheet/form for 12/20 and 12/21/2022.
C. Patient # 4's MR; a lack of daily hygiene - bathing/showering for days of 12/22, 12/23, 12/25, 12/27 and 12/28/2022. The MR also lacked an Observation round sheet/form for 12/24/2022.
D. Patient # 5's MR; a lack of daily hygiene - bathing/showering for days of 1/4, 1/5, 1/6 and 1/8/2023.
E. Patient # 8's MR, a lack of daily hygiene - bathing/showering for days of 12/20, 12/21, 12/22, 12/23, 12/24, 12/25, 12/26, 12/28, and 12/29/2022.
F. Patient # 10's MR; a lack of daily hygiene - bathing/showering for days of 11/27, 11/28, 11/29, 11/30, 12/1 and 12/2/2022.

5. Review of Patient # 3's MR reflected the following:
(a). Patient # 3 admitted on 12/18/2022; diagnosis of Bi-polar & history of Autistic Disorder.
(b). Nurse note dated 12/22/2022 at 8:05 am; reflected a CPI (Crisis Prevention Intervention) hold.
No incident report completed for an inappropriate CPI hold.

6. Review of Patient # 4's MR, and Patient # 8's MR reflected the following:
(a). Patient # 4; 66 year old, admitted on 12/22/2022; diagnosis of Major depressive disorder, Dementia & Anxiety.
(b). Patient # 8; 40 year old, admitted on 12/19/2022; diagnosis of Bi-polar disorder & Anxiety.
(c). Nurse notes for both patient # 4 and patient # 8, on 12/23/2022 at 9:00 pm (7 pm to 7 am shift), reflected patient # 4 was approached and his/her chest was grabbed/groped by patient # 8; while standing by the nurses station.
(d). No incident report completed for the inappropriate touching that occurred.

7. Review of APH # 60's (Acute Psychiatric Hospital) internal investigation related to incident on 12/22/2022, that involved patient # 3 and staff, indicated the following:
A. Date of investigation: 12/27/2022; conducted by HR (Human Resource) staff, A # 2 (Chief Executive Officer), and review by A # 1 (Registered Nurse - Vice President of Quality & Compliance).
B. Interviews from 5 witnesses, were conducted by HR staff & A # 1.
C. Interview and written statement obtained on 12/22/2022, from N # 21 (Behavioral Health Associate), reflected patient # 3's occurrence on 12/22/2022 am. N # 21 stated patient # 3 began to turn his/her body; try to bite N # 21's arm; but N # 21 moved it and held patient # 3's face.

8. In interview on 1/18/2023 at 2:24 pm, and at approximately 4:00 pm, with administrative staff member A # 4 (Executive Assistant), the following was confirmed:
A. That the daily flowsheets were missing for Patient # 1 x 1 day - 9/19/2022. The flowsheets were not found.
B. That the daily flowsheets were missing for Patient # 3 x 2 days - 12/20 & 12/21/2022, and for Patient # 4 x 1 day - 12/24/2022. The flowsheets were not found.

9. In interview on 1/17/2023, at approximately 12:15 pm, with administrative staff member A # 3 (Director of Social Services), indicated that daily hygiene is to be offered and documented on flowsheets.

10. In interview on 1/17/2023, at approximately 4:00 pm, with administrative staff member A # 5 (Infection Control), confirmed that daily hygiene - bathing/showering is not documented on flowsheet(s) for patients # 1, # 3, # 4, # 5, # 8 and # 10.

11. In interview on 1/18/2023 at approximately 11:50 am, and at approximately 1:10 pm, with A # 1, indicated the following:
A. Recalled 1 of the MRs reviewed. Was aware of an occurrence on the 200 unit, in December 2022, that involved a staff member and a patient.
B. That N # 21 did not act willfully; did not intend to hurt Patient # 3.
C. That N # 21 did not do a proper CPI hold.
D. That no incident report was completed, due to the investigation that was completed; that the belief was that the slap did not occur, and that N # 21 did not willfully or intentionally try to hurt patient # 3.
E. That no incident report was completed for the occurrence on 12/23/2022, on the 200 unit; regarding patient # 8 grabbed patient # 4's chest. Patient # 4 was not harmed by patient # 8.