HospitalInspections.org

43881

Based on observation of a surveillance video, review of medical records, and staff interview, it has been determined that the hospital failed to meet the Condition of Participation §482.13 related to Patient Rights, due to the hospital's failure to complete physician ordered patient safety checks and ensure that employees complete the required education pertaining to patient de-escalation.

Findings are as follows:

1. The hospital failed to ensure that patient safety checks are completed per the physician's order and hospital policy for 3 of 4 patients, Patient ID #'s 1, 2, and 3 (Refer to A 144).

2. The hospital failed to ensure that staff are trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraints or seclusion per the hospital's policy for 18 of 23 Security Guards and 1 of 7 Nursing personnel. Employee ID's C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, and U (Refer to A 196).

43881

Based on policy review, surveillance video review, and staff interview, the hospital failed to ensure patients receive care in a safe setting for 3 of 4 patients reviewed relative to physician ordered safety checks, Patient ID #s 1, 2, and 3.

Findings are as follows:

1. The hospital's policy for "Checks Procedure for Patient Assessment Services" effective 8/3/2022 states in part,
"A. Purpose.
The purpose of the Checks Procedure is to define the safety steps related to the Categories of Observation Hospital Policy in Patient Assessment Services (PAS) ...

C. Policy.
It is the policy of ...Hospital to provide a safe and therapeutic environment at all times ...
...F. Procedure:
...1) The triage nurse in PAS completes triage ...
...ii. The patient is added to the checks board on 15 min checks ...
...Steps:
...4) The staff member is responsible for recording their visual observation of all patients according to the level of observation ordered using the key provided on the checks sheet.

5) Each round of checks is recorded on the checks sheet concurrently as the patient is visually observed ...
...8) When the patient is in the bathrooms or showers:
i. The assigned staff will call the patient's name and expect a prompt verbal response from the patient to ensure safety.
ii. If no response is heard, staff must visually observe the patient before moving on with the checks process ..."

Record review revealed that Patient ID #1 presented to the hospital's Patient Assessment Services department in September of 2022 "seeking... detox."

Review of Patient ID #1's "Initial Psychiatric Evaluation" from 9/26/2022 revealed that upon assessment, the evaluator noticed "red marks" on Patient ID #1's neck. The evaluator stated in her note that Patient ID #1, "admitted that when [she/he] had taken several minutes in the bathroom prior to ...meeting, [she/he] had wrapped a johnny [hospital gown] around [his/her] neck and attempted to hang [himself/herself] using one of the plastic sockets/light switches ..."

Record review of a document titled, " ...Checks Assignment for PAS Day Shift 7am - 3pm" dated 9/26/2022, revealed that Patient ID #1 was on a 15-minute observation level which began at 12:45 PM in PAS and ended by 3:00 PM on the same day.

This document revealed that Patient ID #1 was marked off as "in PAS" on 9/26/2022 at the following times:
- 12:45 PM
- 1:00 PM
- 1:15 PM
- 1:30 PM
- 1:45 PM
- 2:00 PM
- 2:15 PM
- 2:30 PM
- 2:45 PM

During a surveyor interview on 10/6/2022 at 2:30 PM with Employee A, Intake Coordinator, she revealed that she was assigned to complete safety checks of patients on 9/26/2022 and during rounds, she observed Patient ID #1 sitting by the bathroom. She stated that she observed Patient ID #1 enter the bathroom sometime between 2:00 PM and 3:00 PM prior to shift change. Employee A stated that she and another staff member knocked on the bathroom door at different times and heard a response by Patient ID #1.

Review of the hospital's surveillance video footage titled, "PAS Lock Waiting Room" from 9/26/2022 revealed that Patient ID #1 was in the bathroom for approximately 23 minutes before a staff member approached the bathroom door to ensure his/her safety.

During a surveyor interview on 10/7/2022 with the Director of Risk Management, she was made aware that Employee A was not observed in the hospital's surveillance video footage of the PAS waiting area knocking on the bathroom door to check on Patient ID #1 as she had stated. The Director of Risk Management was unable to provide evidence that a 15-minute safety check was performed on Patient ID #1 as ordered during the time she/he was in the bathroom and allegedly attempted to hang himself/herself using a hospital gown and a "plastic socket/light switch" in the bathroom.

2. The hospital's policy for "Checks Procedure" effective 7/18/2022 states in part,
" ...III. Policy. It is the policy of [Hospital's Name] to provide a safe and therapeutic environment at all times
IV. Definitions ...
...A. SP means Special Precautions ...
...C. Steps:
...5. The staff member is responsible for recording their visual observation of all patients according to the level of observation ordered

6. Each round of checks is recorded on the checks sheet concurrently as the patient is visually observed ...
...iv. If a patient is on SPs-The checks person must visually observe the patient at the time of checks ...

2a. Record review for Patient ID #1 revealed a "Shift Progress Note" dated 10/2/2022 Which stated in part that at approximately 10:55 AM during observation checks, Patient ID #1 " ...was found slouched over by the doorway in [his/her] assigned room with one end of a hospital johnny tied around [his/her] neck and the other fastened to a light switch from which [she/he] had removed the cover. Pt [patient] was lowered to the floor and johnny was removed while additional staff were summoned. Upon immediate assessment pt was noted to have erythema [redness] across the front of [his/her] neck ..."

Further review of this progress note revealed that Patient ID #1 endorsed neck pain after the incident, and she/he was transferred out to another hospital for an evaluation.

Record review for Patient ID #1 revealed that on the day of the above-mentioned incident, an order to be observed every 5 minutes was in place which had been initiated on 9/30/2022.

Review of the hospital's surveillance video footage titled, "Riverview Hallway 1" revealed that on 10/2/2022 between 10:00 AM and 11:00 AM, Employee B, Mental Health Worker, who was assigned to complete safety checks of patients, failed to visually observe Patient ID #1 every 5 minutes as ordered for a period of 14-minutes in which no observations were performed by employee B.

Further review of this video footage revealed that on another occasion on 10/2/2022 between 10:00 AM and 11:00 AM, Employee B, who was still assigned to complete safety checks of patients, failed to visually observe Patient ID #1 every 5 minutes as ordered for approximately a 12 minute period. It was at this time after the 12-minute period that Employee B found Patient ID #1 attempting to strangulate himself/herself with a hospital gown fastened to a light switch.

2b. Record review for Patient ID #2 revealed an order for him/her to be observed every 5 minutes with special precautions initiated on 10/2/2022 at 7:34 AM.

Review of the hospital's surveillance video footage titled, "Riverview Hallway 1" revealed that on 10/2/2022 between 10:15 AM and 11:00 AM, Employee B failed to visually observe Patient ID #2 every 5 minutes as ordered for a period of 14-minutes in which no observations were performed by employee B.

2c. Record review for Patient ID #3 revealed an order for him/her to be observed every 5 minutes initiated on 9/20/2022 at 8:29 PM.

Review of the hospital's surveillance video footage titled, "Riverview Hallway 1" revealed that on 10/2/2022 between 10:00 AM and 11:00 AM, Employee B failed to visually observe Patient ID #3 every 5 minutes as ordered for a period of 13-minutes in which no observations were performed by employee B.

During a surveyor interview on 10/7/2022 with the Director of Risk Management she acknowledged that based on video surveillance footage, Employee B failed to visually observe Patient ID #s 1, 2, and 3 according to their ordered observation level and hospital policy.

Based on policy review, record review, and staff interview it has been determined that the hospital failed to ensure that staff are trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraints or seclusion as part of orientation and subsequently on a periodic basis for 18 of 23 hospital Security Guards and 1 of 7 Nursing staff, Employees C, D, E, F, G, H, I, J, K , L, M, N, O, P, Q, R, S, T, and U.

Findings are as follows:

The hospital's policy for "Restraint and Seclusion" effective 9/17/2019 states in part,

"I. Purpose. The purpose of this Restraint and Seclusion policy... is to assure the safety of patients and staff, and to ensure compliance with all applicable regulations, when restraint and seclusion become necessary during patient care...

...Training of Staff:

All nursing and security staff is required to attend education and training, which emphasizes de-escalation techniques and the safe use of restraint and seclusion procedures and to demonstrate competence in these techniques and procedures (as well as the hospital's policies and procedures relating to restraint and seclusion) during orientation before they participate in any use of restraint or seclusion and annually thereafter..."

Review of personnel education and training records for Security Guards and Nursing staff revealed the following:

Employee C, Security Guard, was hired on 8/3/2020. This employee's record failed to reveal evidence that de-escalation training was completed upon orientation and annually per hospital policy.

Employee D, Security Guard, was hired on 9/1/2014. This employee's record failed to reveal evidence that de-escalation training was completed upon orientation and annually per hospital policy.

Employee E, Security Guard, was hired on 6/3/2010. This employee's record failed to reveal evidence that de-escalation training was completed upon orientation and annually per hospital policy.

Employee F, Security Guard, was hired on 9/12/2016. This employee's record failed to reveal evidence that de-escalation training was completed upon orientation and annually per hospital policy.

Employee G, Security Guard, last completed his de-escalation training on 11/23/2020. This employee's record failed to reveal evidence that de-escalation training was completed annually thereafter per hospital policy.

Employee H, Security Guard, last completed his de-escalation training on 11/23/2020. This employee's record failed to reveal evidence that de-escalation training was completed annually thereafter per hospital policy.

Employee I, Security Guard, last completed his de-escalation training on 10/24/2019. This employee's record failed to reveal evidence that de-escalation training was completed annually thereafter per hospital policy.

Employee J, Security Guard, last completed his de-escalation training on 7/19/2019. This employee's record failed to reveal evidence that de-escalation training was completed annually thereafter per hospital policy.

Employee K, Security Guard, was hired on 8/31/2020. This employee's record failed to reveal evidence that de-escalation training was completed upon orientation and annually per hospital policy.

Employee L, Security Guard, last completed his de-escalation training on 2/20/2020. This employee's record failed to reveal evidence that de-escalation training was completed annually thereafter per hospital policy.

Employee M, Security Guard, last completed his de-escalation training on 7/21/2021. This employee's record failed to reveal evidence that de-escalation training was completed annually thereafter per hospital policy.

Employee N, Security Guard, was hired on 6/26/1995. This employee's record failed to reveal evidence that de-escalation training was completed upon orientation and annually per hospital policy.

Employee O, Security Guard, last completed her de-escalation training on 7/21/2021. This employee's record failed to reveal evidence that de-escalation training was completed annually thereafter per hospital policy.

Employee P, Security Guard, was hired on 8/31/1989. This employee's record failed to reveal evidence that de-escalation training was completed upon orientation and annually per hospital policy.

Employee Q, Security Guard, last completed his de-escalation training on 11/21/2019. This employee's record failed to reveal evidence that de-escalation training was completed annually thereafter per hospital policy.

Employee R, Security Guard, last completed his de-escalation training on 10/4/2018. This employee's record failed to reveal evidence that de-escalation training was completed annually thereafter per hospital policy.

Employee S, Security Guard, last completed his de-escalation training on 7/21/2021. This employee's record failed to reveal evidence that de-escalation training was completed annually thereafter per hospital policy.

Employee T, Security Guard, was hired on 1/20/2014. This employee's record failed to reveal evidence that de-escalation training was completed upon orientation and annually per hospital policy.

Employee U, Nursing Director of Riverview 3, last completed her de-escalation training on 2/24/2021. This employee's record failed to reveal evidence that de-escalation training was completed annually thereafter per hospital policy.

During a surveyor interview on 10/7/2022 at 12:52 PM with the System Director of Security he indicated that it is the expectation that all Security Guards complete de-escalation training upon orientation and annually thereafter.

During a surveyor interview on 10/7/2022 with the Director of Risk Management, she acknowledged that Employee U, did not complete her annual de-escalation training and that it is also the expectation of nursing staff to complete this training upon orientation and annually thereafter.