HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the change of a patient's adult brief occurred in a private setting for one (Patient #10) of 14 patients.

This failed practice has the likelihood to result in patient with feelings of shame, embarrassment and disrespect, and a loss of therapeutic trust in hospital staff, thereby hindering progression toward goals. (See Tag 0143)

Based on observation, record review and interview, the hospital failed to ensure a ligature-free environment for one (ID unit) of five patient units.

This failed practice has the likelihood to result in patient injury or death. (See Tag 0144)

Based on observation, record review and interview, the hospital failed to ensure:
1. Staff intervened to prevent patient abuse or neglect for one (Patient #10) of 14 patients.
2. Staff reported patient abuse or neglect to the hospital for one (Patient #10) of 14 patients.
3. Staff treated patients with dignity and respect for one (Patient #11) of 14 patients.

This failed practice has the likelihood to result in patient and staff perception of a culture that tolerates patient abuse or neglect. (See Tag 0145)

Based on record review and interview, the hospital failed to ensure the change of a patient's adult brief occurred in a private setting for one (Patient #10) of 14 patients.

This failed practice has the likelihood to result in patient with feelings of shame, embarrassment and disrespect, and a loss of therapeutic trust in hospital staff, thereby hindering progression toward goals.

Review of a policy titled "Patient Rights & Responsibilities" read in part, "All employees and members of the Medical Staff are responsible for ensuring that patients' rights are respected and honored throughout the course of care ....Rolling Hills Hospital employees and members of the Medical Staff shall: ...Treat the patient in a dignified and respectful manner that supports his or her dignity ....Respect the patient's right to personal privacy ....Respect and ensure the patient's right to an environment that preserves dignity and contributes to a positive self-image."

Patient #10

On 11/01/21 Staff H stated the following:
1. He or she saw Staff J and Staff K change the patient's brief in the ID unit dayroom.
2. There were patients present in the dayroom at the time.
3. The patient was not covered by a blanket.
4. This occurred last week.

On 11/03/21 Staff J stated the following:
1. He or she changed the patient's pull-up in the ID unit dayroom.
2. He or she should not have done that because the patient could have been exposed to other patients, made to feel self-conscious, or made fun of.
3. He or she worked a shift on 10/28/21.

On 11/03/21 Staff K stated the following:
1. He or she assisted in changing the patient's brief in the ID unit dayroom.
2. He or she pulled the brief onto the patient while Staff J held the patient above the geri-chair.
3. There were more than ten patients in the ID unit dayroom at the time.
4. This occurred on 10/28/21.

Based on observation, record review and interview, the hospital failed to ensure a ligature-free environment for one (ID unit) of five patient units.

This failed practice has the likelihood to result in patient injury or death.

Review of a policy titled "Contraband" read in part, "Contraband is classified as: Any clothing or accessories that might be a hazard to self or others ( ...shoestrings ...) ...To ensure a safe environment ...Each patient is asked to relinquish contraband upon admission ..."

On 11/04/21 at 11:18 AM, camera footage of the ID unit was reviewed. Patient #14 was observed in the dayroom putting on tennis shoes and tying the shoelaces in the presence of at least eleven other patients on 10/28/21 at approximately 9:21 AM.

On 11/04/21 Staff L reviewed the 10/28/21 9:21 AM camera footage and stated the following:
1. The patient should not have had shoestrings on the unit.
2. The shoestrings could have been wrapped around a patient or staff's neck to strangle them.

Based on observation, record review and interview, the hospital failed to ensure:
1. Staff intervened to prevent patient abuse or neglect for one (Patient #10) of 14 patients.
2. Staff reported patient abuse or neglect to the hospital for one (Patient #10) of 14 patients.
3. Staff treated patients with dignity and respect for one (Patient #11) of 14 patients.

This failed practice has the likelihood to result in patient and staff perception of a culture that tolerates patient abuse or neglect.

Review of a policy titled "Standards of Nursing Practice" read in part, "The nurse will: Act as the patients advocate when necessary to facilitate the achievement of health."

Review of a policy titled "Abuse: Patient" read in part, "Appropriate reporting occurs when suspicion arises that a patient may have been or is at risk for abuse, exploitation or neglect. Staff is to immediately report suspected or alleged abuse, neglect, or exploitation to the CEO/designee ....This includes patient abuse that may occur while hospitalized."

Review of a policy titled "Patient Rights & Responsibilities" read in part, "Rolling Hills Hospital employees and members of the Medical Staff shall: ...Treat the patient in a dignified and respectful manner that supports his or her dignity.

Prevent Abuse or Neglect

On 11/01/21 Staff H stated the following:
1. He or she saw Staff J and Staff K change Patient #10's brief in the ID unit dayroom in the presence of other patients.
2. He or she knew they were to be a patient advocate, but did not know if he or she could address staff.

On 11/03/21 Staff K stated the following:
1. He or she assisted in changing Patient #10's brief in the ID unit dayroom on 10/28/21 in the presence of other patients.
2. He or she did not attempt to prevent this from happening and should have.

Report Abuse or Neglect

On 11/01/21 Staff H stated the following:
1. He or she saw Staff J and Staff K change Patient #10's brief in the ID unit dayroom in the presence of other patients.
2. He or she did not know to whom to report such matters.
3. He or she received no facility orientation addressing the patient abuse process.
4. Upon discovering matters could be reported to the Director of Nursing, he or she still had not reported the incident involving Patient #10 that occurred last week.

On 11/03/21 Staff K stated the following:
1. He or she assisted in changing Patient #10's brief in the ID unit dayroom on 10/28/21 in the presence of other patients.
2. We were told we have to report patient abuse, but we weren't taught to whom to report it. Should I have addressed the incident with hospital leadership?
3. In the past, if staff complained, they were made to feel like they should not have. He or she was afraid of losing their job.

Patient Dignity

On 11/02/21 at approximately 12:00 PM, camera footage of the ID unit was reviewed. Staff J was observed picking Patient #11 up off the floor and forcefully placing the patient into a wheelchair on 10/28/21 at approximately 11:16 AM. Staff J released the grip on the patient prior to the patient's hips making contact with the wheelchair, causing the patient to drop, with momentum, onto the seat of the wheelchair.

On 11/02/21 Staff B reviewed the 10/28/21 11:16 AM camera footage and stated Staff J appeared a little agitated and should have set the patient down easier into the wheelchair.

Based on observation, record review and interview, the hospital failed to ensure execution of fall precautions for one (Patient #11) of 14 patients.

This failed practice has the likelihood to result in patient injury and delayed psychiatric improvement.

Review of a policy titled "Special Precautions" read in part, "It is the policy of the Nursing Department to provide special precautions when deemed necessary according to Doctor's order. These include ...Fall ...To maintain a safe and therapeutic environment for patients and staff."

Patient #11

On 11/02/21 at approximately 12:00 PM, camera footage of the ID unit was reviewed. The following was observed:
1. Patient #11 fell forward out of a wheelchair onto the dayroom floor on 10/28/21 at approximately 11:16 AM.
2. Patient #11 sat with a collapsed torso over an arm of the wheelchair and over his or her lap prior to the fall while staff walked by and did not intervene.

Review of the Intake Assessment dated 10/19/21 12:08 PM read in part, "has harness to keep in chair and will try to lean out of it."

Review of the High Risk Notification Form dated 10/19/21 5:10 PM read in part, "Self-Injury, patient has been leaning out of wheelchair."

Review of the Admission Order dated 10/19/21 9:00 PM showed a diagnosis of epileptic catatonia and an order for fall precautions.

Review of the Interdisciplinary Treatment Plan Medical Problem Sheet initiated 10/20/21 showed a fall precaution of "Monitor for fatigue."

Review of the day shift Nursing Assessment dated 10/28/21 at approximately 9:00 AM (time illegible) showed documentation of no fall precautions.

Review of the Practitioner Order Sheet dated 10/28/21 6:05 PM showed an order for a non-emergent transfer to an ER for lethargy and decreased respirations after a fall.

On 11/04/21 Staff M reviewed the medical record for Patient #11 and stated the following:
1. It was obvious staff were not watching the patient or the patient would not have fallen.
2. The patient should have been kept by the nurses' station where staff could have seen repositioning was needed.
3. Fall precautions should have been documented on the day shift Nursing Assessment. The nurse mis-documented.
4. If a patient fell, injury or not, we would put the patient on 1:1 level of observation because the previous fall precautions were ineffective. That was not done for this patient.

Based on observation, record review and interview, the hospital failed to ensure staff wore masks for one (Rolling Hills Hospital) of one hospitals.

This failed practice has the likelihood to place patients at risk of contracting Covid-19.

Review of a policy titled "Masking Policy and Procedure" read in part, "All individuals who enter Rolling Hills Hospital, including staff ...will be asked to wear facial coverings/masks to reduce the spread of the Covid-19 virus ...The practice of universal masking includes: Wearing the facial covering/mask as directed to cover the mouth and nose ...Strict avoidance of manipulation/touching the mask to reduce the risk of contamination and self-inoculation ..."

On 11/02/21 at 12:32 PM, camera footage of the ID unit was reviewed. In the dayroom and in the presence of ten patients, Staff K was observed with no mask on while Staff N was observed wearing a mask not covering the nose on 10/28/21 at approximately 11:28 AM.

On 11/03/21 Staff I was observed to repeatedly pull mask away from contact with his or her face while in the hospital.

On 11/03/21 Staff J was observed to repeatedly pull mask down under his or her nose while in the hospital.

On 11/02/21 Staff B reviewed the 10/28/21 11:28 AM camera footage and stated staff are expected to wear a mask over the mouth and nose when in the building regardless of being around patients.