HospitalInspections.org

Based on hospital policy reviews, medical record reviews, hospital employed police report, and interviews with staff, the Emergency Department (ED) nursing staff failed to provide nursing supervision in a manner to ensure a patient injury was assessed and evaluated for 1 of 1 patients who sustained an injury during a restrictive intervention (Patient #2) and by failing to follow hospital policy for skin assessment and pressure ulcer managment for 1 of 10 patients (#1).

The findings include:

1. Review of current hospital policy "Restraints Security Alert/Violent/Self -Destructive Behavior Restraints and Seclusion; Chemical Restraints" last revised 02/2019 revealed "...Documentation of patint care during a restraint episode is done on the Violent Restraint Documentation Flowsheet... iii. Any injuries to the patient..."

Review of hospital employed police report filed by Officer #2 revealed, at 1745 on Sunday 3-31-19 "called to BHS (Behavioral Health Services) for Patient #2 spitting on RN #1's shoe... (Patient was in his room upon officers arrival) RN #2 asked Patient #2 to sit on the bed so medication can be given. Patient #2 started towards the bed ...then became irate, starting cursing and spit in RN #2 face... Officer #3 placed Patient #2 on the bed to restrain him... Pt #2 continued to punch, kick yell and curse...Patient #2 nose was accidentally struck and began to bleed...shortly after Patient #2 was struck we were able to get Patient #2 in 4 point restraints and restrain him to the bed..."

Closed record review of Patient #2 revealed a 28 year old male who presented to the Hospital's ED on 03/29/2019 at 1142 under involuntary commitment petition (IVC). Review revealed a past medical history (PMH) of Schizophrenia, Post Traumatic Stress Disorder (PTSD), and Personality Disorder. Review of the ED Provider Notes on 03/29/2019 at 1218 revealed "Patient was brought to the emergency department by police officers who stated he was drunk, was found setting a fire in the backyard, and had allegedly threatened to shoot his parents with a gun. The patient emphatically denies this latter allegation, stating that neither he nor his parents own a gun. He does admit to heavy drinking. Reportedly the patient's parents are on the process of obtaining an involuntary commitment order for him..." Review of ED Provider Notes at 1333 revealed " Further information obtained from the patient's mother who initiated the IVC petition...that he came to her house today angry and banging on her door, the patient has not been compliant with his psychiatric medications and that he has been getting progressively delusional and psychotic. In her opinion he appeared to be responding to internal stimuli. He is reportedly not sleeping or bathing. He was most recently admitted to Cherry in November 2018 and stayed for 2-3 months. Review of Behavioral Health Assessment Team progress notes on 03/29/2019 at 1413 revealed "Assessment: history of schizophrenia and bipolar disorder, who presents for evaluation of worsening psychosis and ETOH (alcohol) use...Pt (patient) denies SI, HI (Suicidal ideation, Homicidal ideation) and perceptual disturbances. Pt said he only burned a small amount of pinestraw and it was not a major fire...Pt states he takes his medication.. denies feeling depressed or anxious...Hx (history) of assault on medical personnel and law enforcement officer...Appearance is disheveled and unkept. Insight is minimal and judgement impaired..Mood and affect are guarded...Pt has not exhibited any aggressive/assaultive behaviors while in the ED... Pt to remain on IVC and will be referred for inpatient psychiatric treatment once he is medically cleared...The patient is at acutely elevated risk of suicide/dangerousness to self/others and further worsening psychiatric condition..." Review of ED Notes on 03/30/2019 at 1228 revealed "Pt with intermittent loud outbursts and screaming racial statements. Patient also hitting his hands as if he was punching someone..." and at 2207 "Pt verbally aggressive, loud, shouting racial slurs in room, pt laying on bed." Review of ED Notes on 03/31/2019 at 0354 revealed "Pt laying on bed, awake, intermittently shouting in room." Review of record revealed Patient #2 was compliant with daily medications ordered. Review of ED Notes on 03/31/2019 at 1806 revealed "1740H: Patient get agitated and states "My dad kill my mom and I don't have any part of it". Patient is pacing in the hallway 1745H: Patient when out to his room and talk about his left in Carolina Beach [sic] ... All of a sudden Patient becomes verbally aggressive and spit on me and hit me on my leg and shoes. Patient went back to his room. Informed (named) Team Leader, (named) Charge Nurse and attending doctor. Security Alert called... 1747 Charge Nurse (named) prepared medication for PRN (as needed) as per ordered in MAR (Medication Administration Record). Patient is in the room and all of a sudden Patient spit on (named) charge nurse in the face. Hospital Security hold the patient and placed the patient in bed. 1750H: PRN medication administered IM (intramuscularly) while Hospital Security holding patient. Patient was placed on the 4 point restraint [sic] due to danger to self and others. Patient kick the hospital security [sic] and verbally abusive to all health care personnel and threatening to harm us." Review revealed no documentation of signs of injury during the restraint episode. Review revealed Patient #2 remained in 4 point restraints until 2330 and legs were released and at 0000 on 04/01/2019 the patient was released from all restraints. Review of IVC paperwork revealed the IVC was discontinued on 04/01/2019 at 1041 due to the telephone consultation with MD #2. Review of the IVC discontinuation documents revealed "...pts assaultive behavior seems to be more criminal in nature instead of psychosis... " The patient was discharged to jail at 1127 on 04/01/2019.

Interview on 04/09/2019 at 1620 with RN #1 revealed he was Patient #2's primary nurse on 03/31/2019. Interview revealed Patient #2 approached the nurses station to inquire about his disposition. Interview revealed RN #1 advised the patient he was waiting on placement. Interview revealed the patient became verbally abusive and spit on RN #1's shoe then returned to his room. Interview revealed he told Officer #1 and the charge nurse about the incident and stated a "Security Alert" was announced. Interview revealed approximately 6-7 staff members were present at that time to help administer PRN medications to Patient #2. Interview revealed Patient #2 spit on RN #2 in the face. Interview revealed security intervened by placing the patient on the bed in a hold while on his back. Interview revealed Patient #2 had a bloody nose after the "altercation" with hospital security. Interview confirmed he did not document the patient injury nor notified the attending physician.

Interview on 04/10/2019 at 1035 with Officer #2 revealed he was working on 03/31/2019 and was notified by radio to come to the BH (Behavioral Health ) ED. Interview revealed he was made aware of an assault on a nurse by Patient #2 spitting on his shoe. Interview revealed Patient #2 was in his room. Interview revealed Patient #2 became verbally aggressive and irate, spitting on the floor after staff arrival. Interview revealed the patient spit on RN #2 and Officer #3. Interview revealed while attempting to physically restrain the patient, he was kicked. Interview revealed while restraining Patient #2 "we saw blood". Interview revealed he was unsure how the injury occurred, "possibly hit with my elbow". Interview revealed after the patient obtained his nose injury, he stated "I give". Interview revealed the patient stopped resisting at that point and laid still while staff proceeded to place the patient in 4 point restraints.

Interview on 04/10/2019 at 1115 with RN #2 revealed she was called to report to BHED. Interview revealed when she arrived Patient #2 was "screaming from his room." Interview revealed RN #1 had medications in his hand. Interview revealed 3 security and 3 nursing staff were present to show a "presence of force" regarding the patient's behavior. Interview revealed she made the patient aware she was there to give him some medications. Interview revealed Patient #2 was yelling, screaming and cursing. Interview revealed the patient stated he wanted the medication and as she approached him, he spit in her face. Interview revealed she removed herself from the room to clean herself. Interview revealed when she returned to the room, the patient had blood on his face. Interview revealed the patient was restrained on his back by Officers #1, #2 and #3 and the medication was administered. Interview revealed injury sustained to a patient should have been documented and alert the provider of the injury. Interview confirmed there was no documentation of an injury during the restraint episode nor was the provider notified.

Interview on 04/11/2019 at 1145 with MD #1 revealed he signed off the one hour face to face assessment post restraint which was filled out by RN#1. Interview revealed if he signed the form he would have looked at the patient. Interview revealed he was not made aware of any patient injury or could he recall one.

Interview with MD #3 revealed he was the discharging physician. Intervew revealed he did assess the patient prior to discharge but failed to document the assessment. Interview revealed he could not recall a patient injury.











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2. Review of the facility policy titled "Assessment of Patient, Nursing..." with revision date of 08/2018 revealed "...Procedure: A. Scope of Assessment: 1. Registered nurses assess and reassess patient needs for nursing care....The initial assessment includes...general health status and a complete physical assessment...."

Review of the facility policy titled "Skin Breakdown Prevention Measures" with revision date of 09/2018 revealed "...A. Patients will be assessed for the risk of skin impairment on admission, every 24 hours and prn (as needed) using the Braden Risk Assessment Tool....B. patients will be placed in groupings based on the Braden Risk Assesment score: 1. Low Risk (15-18) 2. Moderate Risk (13-14). 3. High Risk (12 and under)....D..Moderate Risk patients should have the same interventions as the low risk patient. If the patient has a pressure ulcer refer to the Pressure Ulcer policy E. High-risk patients should have the same interventions as the Moderate Risk patient however; the high-risk patient....will be evaluated for a specialty bed, refer to the pressure ulcer policy...."

Review of the facility policy titled "Pressure Injuries, Treatment and Management of" with revision date of 01/2018 revealed "...The staff nurse will follow the guidelines below for treatment and management of a Stage 1 or Stage 2 pressure injuries. When deemed necessary, the staff nurse should consult with the physician and/or the Wound, Ostomy, Continence Nurse.....B. The Wound, Ostomy, and Continence Nurse or designee should be consulted for Stage 3 or Stage 4 pressure injuries or deterioration of a pressure injury...G. If a pressure injury is identified on admission or occurs during the hospital stay, a (report) will be generated and forwarded to the Event Manager for Pressure Injuries and the Quality Department. .H. Assessment: The RN assesses the following on admission and once each week ideally on the 7a-7p shift unless the dressing change is ordered less frequently in which case this assessment is completed with the ordered dressing change: a. Size of the ulcer measured in centimeters to include length, width, and depth. b. Undermining or tunneling including location and length in centimeters. c. Stage of the pressure injuries. d. General description of the wound bed, color and necrotic tissue in percentages of each. e. Color, temperature, induration, maceration, and any other abnormalities of skin surrounding ulcer f. Drainage-including amount, color, consistencey and odor 2. The RN assesses at least every shift: a. Location of the injury b. Condition of the dressing, if appropriate.....J. Documentation: 1. Documentation with each daily assessment assessment should include: a. Location of the injury b. Size of the injury measured in centimeters to inclue length, width and depth c. Undermining or tunneling including location and length in centimeters 2. Documentation with each assessment completed every shift and/or with each dressing change should include: a. Stage of the pressure injury b. General description of the wound bed, color and necrotic tissue in percentage of each c. Drainage-including amount, color, consistency and odor d. Color, temperature, induration, maceration, and any other abnormalities of skin surroundin injury...."

Review of a closed medical record for Patient #1 revealed an 83 year old female admitted on 02/28/2019 at 1026 for "rattling cough" with diagnosis of Flu and UTI (urinary tract infection). Review of admission nursing notes revealed no documentation of a skin assessment. Review of nurses documentation on 03/01/2019 at 2000 (34 hours after admission) revealed "Stage 2 (pressure ulcer) Coccyx/Sacrum. Orientation: Inner left/right..." Review of nurses notes dated 03/02/2019 at 1940 revealed a Braden score of 12. Review revealed no documentation of a referral for a specialty bed for a low Braden score of 12. Review of the record revealed the patient was incontinent of urine and required incontinence care. Review of documentation of skin assessment dated 03/03/2019 at 1420 revealed "Dressing Status: Clean, Dry; Changed...Dressing Moist Gauze; ABD." Further review revealed no documentation of measurements, including length, width, or depth, stage of wound, or drainage of wound. Review of documentation of "wounds on sacral area" dated 03/04/2019 at 0840 and 1435 revealed "Dressing Status: Clean, Dry; Changed....Dressing: Moist Gauze; ABD." Review of documentation of a skin assesment dated 03/05/2019 at 2030 revealed "skin integrity: stage 2 to coccyx-wound to buttock. Dressing CD&I (clean, dry and intact) not removed. Further review revealed no documentation of measurements, including length, width, or depth, stage of wound, or drainage of wound before discharge.

Interview on 04/10/2019 at 2036 with the assigned admission nurse revealed the skin assessment was left blank. Interview revealed there was no documentation or measurements of the pressure ulcers on the skin at admission. Interview revealed the patient had pressure ulcers on admission and became worse during hospital stay, remembering the patient.

Interview on 04/10/2019 at 1035 with a nursing manager revealed the nursing staff should have documented skin assessment on admission, with dressing changes and on discharge. Interview revealed the hospital policy was not followed.

Interview on 04/10/2019 at 1530 with a wound nurse revealed there are concerns that the policy was not followed. Interview revealed skin assessment should be performed on admission, with dressing changes and on discharge. Interview revealed a wound care nurse referral should have been ordered based on a Braden score and pressure ulcer on admission. Interview revealed a referral to the wound nurse was not received during this hospital stay.

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