HospitalInspections.org

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Based on medical record review, document review and interview, in one (1) of 12 medical records reviewed, it was determined the medical staff failed to reassess and provide treatment for an agitated and combative patient prior to discharge (Patient #1).

Findings include:

Review of medical record for Patient #1 revealed a 22-year-old patient who was admitted to the facility on 9/13/20 at 3:25 PM with a diagnosis of left thigh abscess. She had a previous history of a blood borne infectious disease and Bipolar Disorder; Depression type. The patient presented to the ED three times on 9/13/20. A physician documented at 3:51 PM that surgery and psychiatry consults were requested and that the patient was a 2 PC (Two Physician Certification) admission to facilitate surgery the following day on 9/14/20.

Nursing documentation at 4:45 PM, while the patient was in an inpatient unit revealed she became very agitated and ripped her intravenous access (IV) out. Security was called and the patient left the unit against medical advice (AMA) but refused to sign an AMA form. The patient returned to the unit escorted by a nursing supervisor and was placed a 1:1 constant observation to prevent her from leaving the hospital. The patient became agitated and combative at 7:00 PM after the 1:1 constant observation was implemented. A Code White was called (A code that is activated when a crime is being committed or when a patient, visitor or staff pose a risk of danger to themselves or others) at 7:09 PM. Attempts were made to restrain the patient and she was medicated for agitation with Ativan 2mg IM (Intramuscular injection) at 7:30PM and Benadryl 50 mg IM at 7:45 PM. The patient remained agitated and combative after the medications were administered.

The psychiatrist documented on 9/13/2020 at 8:48 PM that an emergency transfer to another hospital's psychiatric unit was being effected that night because of the patient's "extremely combative behavior on the unit, she was throwing objects at staff, ripped off her IV line and splashed the blood on the face of a nurse."

The policy titled "Code White Response" which was last reviewed on 11/19 states, "the hospitalist will respond to all Code Whites to facilitate medical intervention if required."

There was no documented evidence that a member of the medical staff responded to the Code White to evaluate the patient and facilitate any medical intervention required.

During an interview conducted on 10/19/2020 at 12:55 PM with Staff B, a Security Officer who responded to the code, he stated the patient was placed in soft restraints which she removed. She was then placed in four (4) point leather restraints. Staff B reported that the police were called to the facility because the patient had assaulted a Patient Care Assistant (PCA) and a Registered Nurse (RN) during the incident.

During an interview on 10/19/20 at 11:40 AM with Staff D, Nursing Supervisor, she stated the patient was arrested by police on the inpatient unit but was not taken into custody because she received a telephone call at approximately 8:30 PM on 9/13/20 from another area hospital that reported the patient was in their Emergency Department.

As per interview with Staff H, Psychiatrist on 10/19/2020 at 3:20 PM, he conducted a virtual telehealth consultation on the patient the night of 9/13/20. The patient's nurse told him afterwards that the patient was going to be transferred to another facility. Staff H acknowledged he did not reassess the patient.

This finding was shared with Staff A, the Chief Operating Officer on 10/19/2020 at approximately 5:05 PM.
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Based on medical record review, document review and interview, in one (1) of 12 medical records reviewed, it was determined that staff failed to consult the attending physician as soon as possible when a patient was placed in physical restraints (Patient #1).

Findings include:

Review of the policy titled "Restraint and Safety" which was last revised 5/19 states, "the physician assesses the patient and documents the restraint type/clinical justification on a printed Physician Restraint Order sheet."

Review of medical record for Patient #1 revealed a 22-year-old patient who was admitted on 9/13/20 to an inpatient unit for surgery and treatment of a worsening left thigh infected wound. The patient had a previous history of alcohol (ETOH) abuse and Bipolar Disorder-Depression type. At 7:00 PM, the patient became agitated as she was prevented from leaving the inpatient unit with her boyfriend. A "Code White" was called. Attempts were made by staff to restrain the patient and she was medicated for agitation with Ativan and Benadryl.

There was no documentation in the medical record that a physician was informed of the use of restraints on the patient and there was no written order for the application of the restraints.

This finding was shared with Staff A, the Chief Operating Officer at approximately 4:55 PM on 10/19/2020.
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Based on medical record review, document review and interview, in one (1) of 12 medical records reviewed, it was determined the staff failed to ensure that a patient who was placed in restraints received a face-to-face evaluation within one hour of the intervention (Patient #1).

Findings include:

Review of medical record for Patient #1 revealed the patient became agitated and combative on 9/13/2020 at approximately 7:00 PM and a Code White (A code that is activated when a crime is being committed or when a patient, visitor or staff pose a risk of danger to themselves or others) was called.

Review of the form titled "Code White Incident Report," noted the code was activated at 7:09 PM on 9/13/2020 for Patient #1 who was physically aggressive and disruptive.

During an interview with Staff B, a security officer on 10/19/2020 at 12:55 PM, he stated he responded to the Code White and observed the patient hitting and kicking staff, yelling and attempting to leave the unit. He stated the patient was first placed in soft restraints and when she removed the soft restraints, 4-point leather restraints were applied.

During an interview with Staff D, a nursing supervisor on 10/19/2020 at 11:40 AM, she stated the patient left the unit at approximately 8:00 PM on 9/13/20.

There was no documented evidence of a face to face assessment of the patient by a physician. The medical record did not indicate when the soft restraints were applied and removed and the patient's medical and behavioral response to the soft restraints. In addition, there was no documentation of when the patient was placed in leather restraints, how the restraints were applied, when they were removed, and her response to the application of the leather restraints.

These findings were shared with Staff A, the Chief Operating Officer on 10/19/2020 at 5:00 PM.
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Based on medical record review, document review and interview, in one (1) of eight (8) medical records reviewed, it was determined the staff failed to provide the recipient facility with all necessary medical information of a patient who was transferred from its facility (Patient #1).

Findings include:

Review of facility policy titled "Transfer and Discharge of Patient" which was last revised 7/19, states "Physician's order for transfer to another Acute Care or a Tertiary Care facility, to include mode of transportation. If patient being transferred due to mental health condition, ensure that any legal papers & appropriate paperwork is completed prior to transfer. The primary RN or Case Manager will verify by phone from receiving facility, either through the transfer center or registration that a bed is available and that the facility has accepted the patient and that the patient may be transferred." The policy also states that a copy of the patient's record must be sent to the recipient facility.

Review of medical record for Patient #1 identified a 22-year old female who was admitted through the Emergency Department (ED) on 9/13/2020 for treatment of an abscess wound to her left thigh. While in the impatient unit, the patient was placed on 1:1 observation because she had eloped from the unit. On 9/13/20 at 7:00 PM, the patient again attempted to elope from the unit, she became combative, she threatened and assaulted staff. The Police was called. At 10:34 PM, the nurse documented that the police arrived on the unit and transferred the patient to another hospital. The psychiatrist documented on 9/13/2020 at 8:48 PM that an emergency transfer to another hospital's psychiatric unit was being effected that night because of the patient's "extremely combative behavior on the unit, she was throwing objects at staff, ripped off her IV line and splashed blood on the face of a nurse."

There was no documented evidence that the receiving facility was contacted and accepted the patient. The patient's medical information including the patient's current course of illness and treatment was not provided to the recipient facility at the time she was transferred from the hospital.

On 10/19/20 at 11:40 AM, during interview with Staff D, Nursing Supervisor, she acknowledged findings and reported that the receiving hospital called to request the patient's medical information.

These findings were shared with Staff A, Chief Operating Officer on 9/19/2020 at 5:00 PM.