HospitalInspections.org

Based on policy reviews, medical record review, staff, and physician interviews, the hospital staff failed to provide patient care in a safe setting for two of four behavioral health inpatients (Patient #4 and Patient #5) by failing to adjust the level of observation for a patient with known aggressive behaviors (Patient #5).

Findings included:

Review on 12/06/2018 of the policy titled "Behavioral Health - Inpatient Levels of Observation", revised 05/15/2018 revealed, "Policy: Each patient admitted to a Behavioral Health Unit is assigned a level of observation appropriate to symptom intensity based on assessment data obtained at admission. Ongoing reassessment of patient condition and need for supervision continues during hospitalization. Levels of supervision can be increased or decreased at any time during hospitalization, depending on the patient's level of risk. Purpose: 1. The patient's level of supervision is determined by initial assessment and ongoing reassessment; an increased level of supervision can be initiated by the nurse to provide appropriate care, followed as soon as possible by an order by the physician or provider.... 3. The minimum level of supervision is 15 minute checks. ...When checks are done by staff, the welfare and safety of the patient are observed. 4. Patients who are low risk for suicidal or violent behavior are on 15 minute checks...5. Line-of-sight observation is the next intense level of care, ordered by physician or provider, for patients who are at moderate risk of suicidal or violent behavior. This level is carried out by staff's keeping the patient in "line-of-sight" at all times, including their bedrooms and bathrooms. ...7. 1:1 Observation is a provider-ordered level of supervision for patients at high risk of suicidal or violent behavior. ..."

Review on 12/06/2018 of the policy, "Precautions" effective 01/25/2018 revealed, "Purpose: To promote patient safety. To outline interventions for various precautions status on the inpatient Behavioral Health Units. ...Aggression Precautions Indications: History of assaultive or aggressive behavior or verbalization of intent to harm others. Interventions: 1. During 15 minute rounds and each interaction, observe for symptoms of escalating behavior. Intervene quickly with a team presence. Patients who are actively assaultive towards others may be managed on a higher level of observation ..."

1. Closed medical record review on 12/04/2018 revealed Patient #5, was an 80 year old male admitted to the facility from 09/19/2018 to 10/04/2018 (16 days) with a Psychiatric Diagnostic Formulation of "dementia, agitation, confusion concerning for harm to self and others. ..." Information from the transferring facility indicated, "... He has been increasingly intrusive, has struck another pt. (patient), has been more confused and anxious. He has caused another pt. to hit their head against the wall. Med (medication) changes have not helped, needing 1:1 supervision. Staff do not feel safe with him currently at their facility. ..." Review of the Emergency Room Record revealed "...When he's told no, he quickly becomes aggressive, including striking another individual..." On 09/19/2018 at 0453, Patient #5 was ordered "q15 minute checks." On 09/20/2018 at 0453, "Clinical Assessments Results" revealed "...Patient became combative." At 2200, "...Becomes angry, curses and threatens staff when redirected." Record review had no evidence of nursing assessment or physician notification of changes in Patient #5's behavior warranting the change in medication on "09/24/2018 to increase Zoloft to 150mg po q day (every day) targeting anxiety, will also add low dose trazodone 12.5mg po q noon in anticipation of afternoon agitation/sundowning". On "09/25/2018 increase trazodone to 25mg pc lunch and dinner (after lunch and dinner) targeting aggression, will stop is klonipin due to concern of disinhibition". On "09/26/2018 increase trazodone to 50mg pc lunch and dinner targeting pm intrusiveness and aggression, monitor for sedation and fall risk". On 09/26/2018 and 10/01/2018, Patient #5 became aggressive and struck Patient #4. Review revealed from 9/19/2018 through 10/04/2018 there were no orders for an increase level of observation.

2. Closed medical record review on 12/04/2018 revealed, Patient #4 was a 77 year old woman admitted to the hospital on 09/23/2018 through 10/01/2018. The medical record review revealed a Psychiatric Diagnostic Formulation of "dementia, agitation, confusion with SI (Suicidal Ideation) concerning for harm to self and others. ..." Medical record review of the "BH (Behavioral Health) Intake Assessment" revealed "BH Clinical Symptoms: Agitation, Anxious, Memory problems, Sad/Depressed, Wandering. BH Subjective/Objective: Cooperative" The patient was placed on observation every 15 minutes as standard. The admitting physician (MD) was MD #1, however on 09/27/2018 MD #2 assumed the attending physician role. Review of the record revealed a male patient entered Patient #4's room on 09/26/2018 at 1930, and Patient #4 became upset and insisted he leave the room. Review revealed a certified nursing assistant (CNA #1) intervened in an effort to deescalate the confrontation, but not before the male patient slapped Patient #4. Medical record review revealed, on 09/27/2018 at 1720 the "BH Progress Note" of MD #2 who was now the attending physician for Patient #4 had spoken with the patient's daughter and heard her concerns. Medical record review of a MD #2 reported, "... It was startling for her but there are no marks on her...". On 10/01/2018, the closed medical record review revealed a second incident between Patient #4 and the male patient in the previous incident. Again, Patient #4 was struck by the male patient with staff present and who attempted to intervene. Review of Patient #4's medical record for the dates 9/23/2018 through 10/01/2018 revealed her level of observation remained 15 minute checks throughout the inpatient admission.

Interview on 12/05/2018 at 0815 with CNA #1 revealed on the evening of 09/26/2018, the nursing assistant worked on the geriatric BH (Behavioral Health) unit; in which, Patient #5 was seen wandering into the room of Patient #4. Interview revealed Patient #4 could be heard loudly telling Patient #5 to leave. At some point, the nursing assistant re-directed Patient #5 from Patient #4's room. During the re-direction, Patient #5 raised a hand to strike at Patient #4. The nursing assistant "was able to soften the blow by stopping his swing somewhat." Interview revealed during shift change report, it was recommended "...to try to keep them (Patient #4 and Patient #5) from being together because they seem to rub each other the wrong way." Interview revealed CNA #1 recalled no change in observation level for either Patient #4 or Patient #5.

Interview on 12/05/2018 at 0930 with RN #2 revealed Patient #4 "Was more oriented than Patient #5..." The nurse recalled Patients #4 and #5 "were on opposite ends of the halls, but Patient #5 was a wanderer. There was no change in observation ordered, we just watched them more closely.... The process is case by case related to aggression ...sometimes we have put them on 1:1 observation. The admitting physician or attending would make that judgment of what type of observation surveillance the patient would be placed on." Interview revealed no increased level of observation was ordered.

Interview on 12/05/2018 at 0950 with MD #1 revealed "...Historical information, or the family and eyes on observation will delegate the level of observation I place.... For a known aggressor, the care would be tailored by the information given initially, a patient is not automatically placed on a 1:1 observation. It is a qualitative assessment made based on judgment at the time of admission to meet criteria. ...If I heard that a patient with known aggression that was admitted because he hit a resident prior to admission and then while here in the facility hit a patient under the care of the hospital, my next step would have been to place that aggressive patient into a 1:1 observation for the safety of the staff and other patients." Interview revealed no increased level of observation was ordered.

Interview on 12/05/2018 at 1153 with MD #1 revealed the physician admitted and wrote treatment orders for Patient #5. The Physician stated, "I don't believe I ever spoke with (named outside facility). Usually folks don't come in on a 1:1 observation. I am listening to the nurses and CNA's about the patient interactions with staff and other patients. ...I do not recall ever ordering a 1:1 observation on this patient. I adjusted his medications before and after the incident. I was managing his care throughout the hospitalization. He was wandering and more intrusive in the evening which led me to believe he was sundowning. In hindsight, it makes me want to look at the process of evaluation closer. Because the process of ordering a 1:1 observation is reactionary, sort of after the fact. But if staff who are more closely working with these patients felt in any way that a patient was an aggressive risk to patients or staff or self, I would order a 1:1 sitter." Interview revealed no increased level of observation was ordered.

Telephone interview on 12/05/2018 at 1530 with RN #1 revealed, he conducted the "Behavioral Intake Assessment" for Patient #5 on 09/19/2018. RN #1 could not recall any communication with the provider regarding Patient #5's aggression or inquiring about possible need for increased observation. "In retrospect it seems like this person should have been on line of sight observation or maybe even 1:1 observation. I tend to mention it to the doctor if the patient was aggressive to another patient or staff."

Telephone interview with RN #4 on 12/06/2018 at 1055 revealed, she was asked to work the Behavioral Health unit as float staff (facility staff temporarily assigned to another unit to cover a staffing gap) on 10/01/2018. RN #4 recalled the incident on 10/01/2018, and indicated when Patient #4 saw the male patient walking past her door, she began to yell at the male patient. Interview with RN #4 revealed, "She was the instigator in the incident. ...I stepped in between the two, I told him it is was okay to keep walking. I asked (Patient #4) to let him walk and stop yelling at him. He started to take a swipe at her ... brushed her cheek contact was made at her cheek and shoulder." Interview with RN #4 confirmed, no change in observation status was requested or made for either Patient #4 or Patient #5 on 10/01/2018.

NC00143885