HospitalInspections.org

Based on record review, document review and interviews it was revealed the facility failed to report and investigate allegations of harassment for one (1) out of one (1) patient who reported verbal harassment (patient # 1). This failure has the potential to negatively impact all patients receiving care at the facility.

1. A review of patient #1's medical record was conducted. On 11/12/19 at 2:04 p.m. it is noted in her record by the social worker, "Patient stated staff had been rude to her and stated they told her to 'shut up, sit down and eat your lunch.' She was very distraught over this." There was no other mention of this in her record.

2. A review was conducted of policy titled "Abuse, Neglect, Exploitation of Patients and Reporting" adopted on 05/2017. The policy states in part ... "E. Guidelines for All Facilities #7 Reporting/Responding: As a condition of employment, any person having reasonable cause to suspect that an BARH patient has suffered abuse, neglect, harassment or exploitation shall immediately report the incident to their supervisor or House Supervisor. The Community Chief Nursing Officer (CCNO) and administrator on-call should also be notified."

3. An interview was conducted with the lead social worker on the Geriatric Behavioral Health Unit on 11/19/19 at 11:24 a.m. Regarding patient #1 reporting the staff was rude she stated," I got her up and walked her out onto the unit for her to identify the staff member. The patient was unable to identify which staff member or give a viable description of anyone. So, in this incidence, since she couldn't point anyone out, I did not tell anyone. I couldn't prove it so I did not fill out a report."

3. In an interview with the manager of Behavioral Health on 11/19/19 at 2:18 p.m. she stated, "If a complaint is brought to anyone's attention whether they know exactly what happened or which staff member was involved, I would expect an incident report to be filed and notification to the supervisor so an investigation can be conducted."

4. An interview was conducted with the CCNO on 11/20/19 at 9:30 a.m. She stated, regarding patient #1's complaint, "It should not be the social worker's final decision if the event is escalated. She should have discussed the allegations with her supervisor so an investigation could be done."

Based on record review, document review and interviews it was revealed the facility failed to document appropriate assessments after the initiation of restraints at intervals determined by hospital policy for four (4) out of five (5) restraint records reviewed, patient #2, #27, #28 and #29. This failure has the potential to impact all patients receiving care at the facility.

1. A review of patient #2's medical record revealed the patient was placed in violent behavior restraints at 3:23 p.m. Re-assessment documentation is not complete as per policy during the duration of the restraint episode, every fifteen (15) minutes and every two (2) hours, ending 10/29/19 at 6:29 p.m.

2. A review of patient #27's medical record revealed the patient was placed in violent behavior restraints at 4:43 p.m. Re-assessment documentation is not complete as per policy during the duration of the restraint episode, every fifteen (15) minutes and every two (2) hours.

3. A review of patient #28's medical record revealed the patient was placed in violent behavior restraints at 2:35 p.m. Re-assessment documentation is not complete as per policy during the duration of the restraint episode, every fifteen (15) minutes and every two (2) hours, ending 10/31/19 at 8:45 p.m.

4. A review of patient #29's medical record revealed the patient was placed in violent behavior restraints at 12:00 a.m. Re-assessment documentation is not complete as per policy during the duration of the restraint episode, every fifteen (15) minutes and every two (2) hours.

5. A review of policy titled "Restraints and Seclusion" under heading "Procedure: Application of Restraint for Violent/Self-Destructive Behavior, section Assessment, Intervention, and Documentation:" states in part ... "The patient is assessed to assure the patient rights, dignity and well-being is protected during the use of restraints or seclusion as appropriate to the type restraint and seclusion and patient needs, the following observation procedures will be followed and documented at the time intervals described below. The condition of the restrained patient must be monitored at intervals not greater than 15 (fifteen) minutes to ensure that the violent or self-destructive behavior does not jeopardize the immediate physical safety of the patient, staff or others."

6. An interview was conducted with the Director of the Emergency Department on 11/20/19 at 9:30 a.m. He verified there was no additional restraint documentation available in the medical records for patients #2, #27, #28 or #29.

Based on clinical record reviews, review of a document and interviews it was revealed five (5) out of five (5) patients who were treated in the emergency room and had restraints (patients #2, #27, #28, #29 and #30) did not receive face-to-face assessments within one hour of initiation of restraints.

Findings include:

1. A review of five (5) emergency department (ED) records for patients who were restrained revealed five (5) did not have a face-to-face assessment within one hour after initiation of the restraint. These included patients #2, #27, #28, #29 and #30.

2. A review of an untitled document used to audit restraint charts in the emergency department revealed the face-to-face requirement is not audited on the charts for completion.

3. An interview conducted with the Director of the ED on 11/20/19 at 9:30 a.m. revealed he verified the patients listed above did not have face-to-face assessments done after the restraints were applied. The Director of the ED revealed chart audits for face-to-face assessments are not done.

Based on clinical record reviews, review of documents and interviews it was revealed four (4) out of four (4) patients who were treated in the emergency room and had violent behavior restraints (patients #2, #27, #28 and #29) did not receive face-to-face assessments within one hour of initiation of restraints.

Findings include:

1. A review of four (4) emergency department (ED) records for patients who had violent behavior restraints revealed four (4) did not have a face-to-face assessment within one hour after initiation of the restraint. These included patients #2, #27, #28 and #29.

2. A review of a document titled "Restraints and Seclusion," adopted 8/2019, revealed it stated in part: "The attending physician, other LIP (licensed independent practitioner) for the care of the patient, or a trained Registered Nurse or a trained physician assistant evaluates the patient in person within one hour of the initiation of the restraint or seclusion used for management of violent or self-destructive behavior that jeopardizes the physical safety of the patient, staff or others."

A review of an untitled document used to audit restraint charts in the ED revealed the face-to-face requirement is not audited on the charts for completion.

3. An interview conducted with the Director of the ED on 11/20/19 at 9:30 a.m. revealed he verified the patients listed above did not have face-to-face assessments done after the restraints were applied. The Director of the ED revealed chart audits for face-to-face assessments are not done.

Based on record review, document review and interviews it was revealed the facility failed to document appropriate assessments after the initiation of restraints for four (4) out of five (5) restraint records reviewed, patient #2, #27, #28 and #29. This failure has the potential to impact all patients receiving care at the facility.

1. A review of patient #2's medical record revealed the patient was placed in violent behavior restraints at 3:23 p.m. Re-assessment documentation is not complete as per policy during the duration of the restraint episode, every fifteen (15) minutes and every two (2) hours, ending 10/29/19 at 6:29 p.m.

2. A review of patient #27's medical record revealed the patient was placed in violent behavior restraints at 4:43 p.m. Re-assessment documentation is not complete as per policy during the duration of the restraint episode, every fifteen (15) minutes and every two (2) hours.

3. A review of patient #28's medical record revealed the patient was placed in violent behavior restraints at 2:35 p.m. Re-assessment documentation is not complete as per policy during the duration of the restraint episode, every fifteen (15) minutes and every two (2) hours, ending 10/31/19 at 8:45 p.m.

4. A review of patient #29's medical record revealed the patient was placed in violent behavior restraints at 12:00 a.m. Re-assessment documentation is not complete as per policy during the duration of the restraint episode, every fifteen (15) minutes and every two (2) hours.

5. A review of policy titled "Restraints and Seclusion" under heading "Procedure: Application of Restraint for Violent/Self-Destructive Behavior, section Assessment, Intervention, and Documentation:" states in part: ... "The patient is assessed to assure the patient rights, dignity and well-being is protected during the use of restraints or seclusion as appropriate to the type restraint and seclusion and patient needs, the following observation procedures will be followed and documented at the time intervals described below. The condition of the restrained patient must be monitored at intervals not greater than 15 (fifteen) minutes to ensure that the violent or self-destructive behavior does not jeopardize the immediate physical safety of the patient, staff or others."

6. An interview was conducted with the Director of the ED on 11/20/19 at 9:30 a.m. He verified there was no additional restraint documentation available in the medical records for patients #2, #27, #28 or #29.