HospitalInspections.org

Based on patient record review and interview the hospital failed to provide resolution of grievance for one (Patient #7) of one who filed a grievance.

This failed practice had the likelihood to place all patients at risk of poor resolution of grievance. Thereby, creating an unsafe environment and patient fear. (See Tag 0118)

Based on patient record review and interview the hospital failed to ensure protection of privacy for one (Patient #16) of 18 Patients.

This failed practice had the likelihood to place patients at increased risk for poor quality of care. (See Tag 0142)

Based on patient record review, review of Risk Incident Report - Confidential Report of Occurrence, and interview the hospital failed to ensure one (Patient #16) of 18 patients received care in a safe setting.

This failed practice had the likelihood to place patients at increased risk of injury or harm. (See Tag 0144)

Based on record review and interview the hospital failed to provide resolution of grievance for one (Patient #7) of one Patients who filed a grievance.

This failed practice had the likelihood to place all patients at risk of poor resolution of grievance. Thereby, creating an unsafe environment and patient fear.

Findings:

Patient #7

A review of a document titled "Risk Incident Report-Confidential Report Occurrence" Showed on 05/31/19 Patient #7 requested to call the police and after "the nurse and tech got" Pt #7 to "calm down" he/she agreed to speak with administration, and the therapist to discuss the incident with Patient #7, "before initiating grievance." There was no documentation of follow up by the therapist or any staff, and no additional documentation of patient discussion, or documentation of Patient #7 declination or refusal to pursue the requested grievance.

On 06/28/19 at 1:15 pm Staff B reviewed the Risk Incident Report for Patient #7 and the clinical record and stated there was no follow up.

Based on record review and interview the hospital failed to ensure protection of privacy for one (Patient #16) of 18 Patients.

This failed practice had the likelihood to place patients at increased risk for poor quality of care.

Findings:

Patient #16

A Review of a document titled Risk Incident Report - Confidential Report of Occurrence" dated 06/21/19 showed at 8:40 pm Patient #16 was found in the patient room on bed with a towel wrapped around his/her neck. The "Nurse Reassessment Shift Note" dated 06/21/19 showed Patient #16 was placed on line of sight and the mattress was placed in the hallway, and at 12:30 am the patient was asleep on the mattress in the hallway.

On 06/28/19 at 1:20 pm Staff B reviewed the patient record and Risk Incident report for Patient #16 and stated the patient and their mattress should not have been on the floor in the hallway.

Based on patient record review, review of Risk Incident Report - Confidential Report of Occurrence, and and interview the hospital failed to ensure one (Patient #16) of 18 patients who received care in a safe setting.

This failed practice had the likelihood to place patients at increased risk of injury or harm.

Findings:

Patient #16

A review of the "Risk Incident Report - Confidential Report of Occurrence" showed patient #16 was choking themselves on 06/19/19 and was placed on line of sight. On 06/21/19 Patient #16 was found on the bed with a towel wrapped around their neck. There was a documented order to place the patient on line of sight. There was no documentation to show a change to discontinue or decrease monitoring by line of sight. There was no changes documented in the Nurse Reassessment Shift note, or in the Mental Health Tech Shift note dated 06/21/19. There was no documentation to show patient was within line of sight for staff on 06/21/19.

On 06/28/19 at 1:20 pm Staff B reviewed the Nurse Reassessment Shift notes and Risk Incident Report and stated no updates were made to reflect line of sight for Patient #16.

NRI Unit

On 06/28/19 at 1:45 pm during a tour of the Neurologic Rehabiltation institute "NRI" Unit the quiet room was observed to be empty and the interior of the door had three dime sized holes in the door (one on the top left side quarter of the door and two on the lower bottom quarter of the door).

On 06/28/19 at 1:45 pm the surveyor pointed to the three holes in the door. Staff B stated new quick release handles had been placed on the door and a work order would be completed.

Based on record review and interview the hospital failed to ensure the nursing staff provided coordination and report of symptom complaints for one (Patient #12) of 18 patients.

This failed practice had the likelihood to place all patients at risk of unresolved symptom management, and therapeutic intervention. Thereby resulting in poor quality of care.


Findings:

Patient #12

A review of the patient record showed, on 06/12/19 at 3:34 am, patient #12 notified the nurse about blood in urine. The nurse documented frank red blood on toilet paper, and told the patient to notify staff of anymore blood. A patient record dated 06/12/19 at 4:35 am showed the patient was given Valium due to being anxious about blood tinged toilet paper when wiping. On 06/12/19 at 3:00 PM the nurse documented the patient remained concerned and reported a little blood throughout the day. On 06/12/19 at 3:15 pm the nurse documented patient #12 was "still bleeding a little"; on 06/13/19 at 12:05 am the nurse documented patient was anxious and worried about the vaginal bleeding. On 06/13/19 3:15 pm Patient #12 complained of "still bleeding." On 06/15/19 Patient reported a request of hormone medication for "sweating, hotflashes, & coldness at other times." There was no documentation to show the nursing staff contacted or notified the physician of the patient bleeding or patient concerns about bleeding until 06/17/19, (five days after the initial patient report).


On 06/28/19 at 1:10 pm Staff B stated the nursing staff should have reported the bleeding and patient concerns to the physician.

Based on patient record review and interview the hospital failed to ensure the patient plans of treatment were updated with changes in care for two (Patient #15, and #16) of 18 patients.

This failed practice had the potential to result in the patient receiving treatment that is not current with orders and thereby delay therapeutic treatment and receipt of quality of care.


Findings:

Patient #15

A review of the Mental Health tech noted documented on 06/21/19 at 3:00 pm showed Patient #15 was angry with peers and did not follow redirection. There was no documentation to show the nurse was notified in the Mental Health tech note or the Nurse Reassessment note.

A physician order dated 06/24/19 showed a new order to increase Suboxone for Patient #15. The treatment plan dated 06/19/19 showed a goal to discontinue Suboxone. There was no documentation to update or change the treatment plan and goal for Patient # 15 regarding the Suboxone medication increase.

Patient #16

A review of the patient record showed no plan of treatment update for Patient #16 related to level of supervision changes after the patient attempted to choke themselves on 06/24/19 and was in the bed with a towel wrapped around their neck. The treatment plan dated 06/19/19 showed no increased 1:1 or line of sight monitoring.

A review of patient record showed on 06/24/19 Patient #16 was placed in the hallway on a mattress. There was no documented changes to the treatment plan for Patient #16.


On 06/28/19 at 1:20 pm Staff B stated the update to patient monitoring and changes in care would be noted on the treatment plan and there was no update on the treatment plans of Patient #15 and #16.

Based on patient record review and interview the hospital failed to ensure completion and documentation of the medical history and physical exam (H&P) within 24 hours of admission for six (Patient #1, 2, 7, 10, 15, and 17) of 18 patients.

This failed practice had the likelihood of patients to be placed at risk of having incomplete records. Thereby, affecting the quality of patient care; as the patient record provides communication of patient care in a sequential manner to promote timely assessment and intervention.

Findings:

A review of Policy Number 5415 showed medical record entry time frames to include "History & Physician entry of records within 24 hours, Psychiatric Evaluation within 24 hours of admission."

A review of Patient Records Showed:
Patient #1 Admitted to the hospital on 03/16/19 the Physician signature for the H&P was dated 03/21/19 (five days after admission).

Patient #2 Admitted to the hospital on 06/09/19 the Physician signature for the H&P was dated 06/11/19 (two days after admission).

Patient #7 Admitted to the hospital on 06/07/19 the Physician signature for the H&P was dated 06/10/19 (three days after admission).

Patient #10 Admitted to the hospital on 06/07/19 the Physician signature for the H&P was dated 06/10/19 (two days after admission).

Patient #15 Admitted to the hospital on 06/17/19 the Physician signature for the H&P was dated 06/19/19 (two days after admission).

Patient #17 Admitted to the hospital on 03/02/19 the Psychiatrist signature for the H&P was dated 03/04/19 (two days after admission).

On 06/28/19 at 2:00 pm Staff B stated it was Policy for the H&P to be signed within 24 hours.