HospitalInspections.org

Based on observation, record review, and interview, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient's rights as evidenced by:
Failure of the hospital to provide supervision as ordered by the physician for 1 current patient on 1:1 observation level (Patient #1), 1 current patient on LOS observation level (Patient #2) and 18 current random patients on routine observation levels (Patients #R1-R18).

This resulted in an Immediate Jeopardy Situation. S1Administrator was notified on 9/18/2024 at 4:00 p.m.
The hospital provided the following plan of removal for the Immediate Jeopardy situation:
Eliminate Line of Sight observation status from policy. Medical director approval on 9/19/2024 and Board approval completion dated by 9/20/2024.
Retrain/Inservice per NSG 034 Levels of Observation policy for 1:1 9/18/2024.
Establish 1:1 Accounting Log and inservice starting 09/18/2024. This will ensure the 1:1 are assigned timely an ensure q12hr assessment/reassessment and no excessive 1:1 utilization.
Establish Nurse and MHT Assignment Sheet to be utilized every shift every day, 9/18/2024. This will establish direct patient accountability between nurse and MHT.
We anticipate all staff will be inserviced by 9/27/2024. However, as the direct caregivers work assigned shifts, they will be inserviced and caught up to speed relative to this training or they will not work.

Root Cause Analysis: the direct oversight by nursing leadership has neglected the routine rounding and evaluation of the q15 observations sheets performed by the MHT. The nurses became reliant upon the MHT performing these duties but failed to routinely audit the MHT knowledge in real-time of each patient exact whereabouts at all times.
Immediate Corrective Actions: created 1:1 Accounting Log, created Nurse/MHT Assignment sheets, Inservice for q15 retraining, 1:1 accounting log, Nurse/MHT Assignment sheets
Short Term Corrective Measures: 1:1 accounting sheets will identify the patient that is currently on 1:1 and have the charge nurse sign the acknowledgement sheet, get the initials of the nurse assigned to said patient on 1:1 and time the nurse assessment for continued observation status if warranted. This will create a more proactive approach, at least 3 times a day, to acknowledge that the patient in fact still warrants such strenuous observation status. Nurse/MHT assignment sheets will memorialize and create top of mind awareness of which nurse is assigned to what MHT, therefore the nurse will have more proactive accountability to the q15 observation indexing. We will revise the NSG 034 Nursing Levels of Observation policy to remove line of sight as a status. Patients will either be routine observation or 1:1 per doctor's order.
Monitoring and Ongoing Compliance: In order for the jeopardizing circumstance not to reoccur, routine audits will be performed. Nurse assigned the specific patient will routinely audit through the shift the q15. The process will be vertically audited beyond that. The Nurse/MHT assignment sheets will be audited by the DON. The 1:1 accounting logs will be audited by the Compliance Manager.

On 09/19/2024 at 12:45 p.m., the Immediate Jeopardy Situation was lifted but there was not enough evidence to determine sustainability of compliance for the Condition of Patient Rights to be cleared therefore the deficiency remains at a Condition level (See findings in A0144);

Based on observation, record review, and interview, the hospital failed to ensure patients receive care in a safe setting as evidenced by:
1) Failure of the hospital to provide supervision as ordered by the physician for 1 current patient on 1:1 observation level (Patient #1), 1 current patient on LOS observation level (Patient #2) and 18 current random patients on routine observation levels (Patients #R1-R18);
2) Failure of the hospital to provide supervision as ordered by the physician for 1 discharged patient who was sexually violated, while on ordered 1:1 observation level (Patient #3) and
3) Failure to ensure 1 patient did not have access to items considered contraband (Patient #4)
Findings:

1. On 09/18/2024 at 1:35 p.m., observation on the "Grey Hall" revealed S2BHT was standing outside Patient #1's door. Interview with S2BHT at that time revealed the patient was on 1:1 observation level. The surveyor asked S2BHT what 1:1 observation level meant and the tech stated that the patient was to be watched at all times. The surveyor asked if the tech could see the patient in his room if the tech was standing outside the room in the hallway and the S2BHT stated no. At that time, the surveyor entered Patient #1's room and observed him awake sitting on the bed. The bed was unable to be visualized from the doorway of the room.

Further interview with S2BHT at that time revealed there were 9 other patients on the hall, but S2BHT was the only tech on the hall at the time due to the other tech being off the hall. S2BHT stated there was also another patient on the hall on LOS observations (Patient #2). S2BHT stated the patient was in his room. The surveyor asked if that patient could be seen from the hallway, and S2BHT stated no. At that time, the surveyor entered Patient #2's room and the patient was walking around the room. There was no supervision of the patient by any staff at that time.

On 09/18/2024 at 1:45 p.m., observation reveals S2BHT walking down the hall passing out snacks to the patients on the hall. Patient #1 (1:1) was observed in his room and unable to be visualized from the hallway.

On 09/18/2024 at 1:50 p.m., observation of the Close Observation logs for Patient #2 (LOS level) and Patients #R1-R8 (every 15 minute observation level) revealed the last documentation on the logs was at 1:15 p.m. (35 minutes since the patients had been observed by staff). At that time, S2BHT revealed that the other tech on the hall was responsible for documenting on the Close Observation logs for all patients except Patient #1 (1:1 patient). S2BHT confirmed the logs should be signed off by staff every 15 minutes, indicating that the patient was observed. S2BHT confirmed that the logs were not current and that the last documented observation of the other patients was at 1:15 p.m. (35 minutes earlier).

On 09/18/2024 at 1:55 p.m., observation of the "Blue Hall" with S1Administrator revealed all patients were off the hall, either outside or seeing the physician. Observation of a clipboard on a table in the hall revealed all 10 patients Close Observation logs were on the clipboard. Review of the logs for Patients #R11-R20 revealed the last documented observation was at 1:15 p.m. (40 minutes earlier). At that time, S1Administrator confirmed the Close Observation logs should be current and up to date. S1Administrator further confirmed that there was no documented evidence that the patients were being observed per physician orders.

On 09/18/2024 at 2:45 p.m., observations on the "Grey Hall" revealed that S2BHT was standing outside of Patient #1's (1:1 observation level) room talking to another tech. The surveyor asked why the tech was not observing the patient in his room and S2BHT stated that he likes to give the patient "a little space and comfort". The surveyor asked why the patient was on 1:1 observation level and S2BHT stated it was because the patient was aggressive.

On 09/18/2024 at 3:25 p.m., observations on the "Grey Hall" revealed a new shift of techs was on the hall. Observation revealed S3BHT was standing outside of Patient #1's room assisting with obtaining vital signs on another patient. The surveyor asked if Patient #1 was still on 1:1 observation level and S3BHT stated yes. The surveyor asked what that meant and S3BHT stated it meant to watch the patient at all times. The surveyor asked S3BHT if he could see the patient while he was standing in the hall and he stated no. Further observations at that time revealed Patient #2 (LOS level) was ambulating in the day room with no staff supervision.

Review of the medical record for Patient #1 revealed an admit date of 09/13/2024 with chief complaint of being homicidal and suicidal. Review of the physician progress note on 09/14/2024 revealed the patient is aggressive and unable to direct on the unit. The patient is spitting on staff, broke the window out in his room, and charged at staff. On 09/14/2024 at 5:50 a.m., the physician wrote an order to place patient in active suicide and 1:1 for aggression and threats.

Review of the medical record for Patient #2 revealed an admit date of 09/17/2024 with a diagnosis of paranoid schizophrenia. On 09/18/2024 at 2:30 p.m., interview with S4RN confirmed that the patient was on LOS observation level.

On 09/18/2024 at 3:50 p.m., S1Administrator confirmed that patients on 1:1 monitoring levels should be observed at all times and within arm's length of staff. S1Administrator also confirmed that patients on LOS observations should be in constant visual at all times. He further confirmed that all Close Observation logs should be current and signed off by staff every 15 minutes, indicating observation was performed. S1Administrator agreed that the lack of ordered observations placed the above patients at risk for serious injury, serious harm, serious impairment or death.


2. Review of the medical record for Patient #3 revealed an admit date of 09/02/2024. Diagnoses included bipolar disorder and recent manic episode with psychosis.

Review of physician progress note dated 09/07/2024 revealed the patient was having increased agitation and aggression with hypersexual behaviors. The patient was ordered 1:1 observation level at this time.

Review of physician progress note dated 09/12/2024 revealed patient remains 1:1 due to assault on staff member.

Review of physician progress note dated 09/15/2024 revealed staff report defiant on unit. Remains 1:1 and attacked a tech earlier this week. Patient sat on another patient's lap and allowed him to touch her inappropriately.

Review of the LDH Hospital Abuse/Neglect Initial Report form dated 09/15/2024 at 8:45 a.m. revealed in part that the patient grabbed another patient's hand and forced it down the front of her pants approaching her pubic area. The report further stated this is not alleged; this in fact happened as evidenced by both victim and aggressor's acknowledgement of such. The initial actions taken stated that the patient's courtyard privileges were immediately revoked. The report stated Patient #3 was on 1:1 observation level, starting on 09/07/2024, and remained on 1:1 until her discharge on 09/16/2024. The report further stated that the tech stated the patient needed to get some air and took the patient to the outside common area where the incident took place.

On 09/18/2024 at 3:50 p.m., interview with S1Administrator confirmed that there was no investigation performed to determine how this sexual incident with Patient #1 occurred, since the patient was on 1:1 observation level. S1Administrator further confirmed there was no new interventions put in place, no increased monitoring of 1:1 patients and no further training conducted to the staff to ensure incidents like this one would not occur again. S1Administrator confirmed that that the lack of ordered 1:1 observations by the staff allowed Patient #1 to be sexually violated by another patient.

3. Review of the medical record for Patient #4 revealed an admit date of 09/12/2024 at 11:37 a.m. The patient was transferred from another facility due to paranoid and aggressive behaviors. Review of the admission nurses notes dated 09/12/2024 at 11:37 a.m. revealed that the patient would be on routine (every 15 minute) observations.

Review of an incident report dated 09/12/2024 at 7:10 p.m. revealed that another patient reported that Patient #3 was standing in his window asking the other patient to raise up her shirt. A male tech went into Patient #3's room to pull him from the window and the patient fought back swinging at the tech. The report further states that the patient hit the tech with an object and punctured the tech's forearm with the object.

Review of nurses notes dated 09/12/2024 at 7:15 p.m. revealed that the patient was observed by a tech to be masturbating in front of his bedroom window attempting to induce the patient on another hall (windows face each other) to pull up her shirt. The tech went into Patient #4's room and the patient tried to stab the tech with an unknown object. There was an altercation between the patient and the tech. The patient now complains of left shoulder pain and was sent to the ER for evaluation. The tech has two puncture wounds on his inside right forearm.

There was no documented evidence in the record that the patient nor his room was searched to locate the object that was used to injure the tech.

On 09/19/2024 at 12:30 p.m., interview with S5DON revealed that she was unsure what type of object that Patient #4 used to stab the tech. She stated that they assumed it was a plastic fork because there were four puncture wounds on the tech's arm. When asked if there had been any investigation to determine what object was used to injure the tech, S5DON stated no.

On 09/19/2024 at 12:45 p.m., interview with S4RN revealed that she was working the evening that the incident occurred with Patient #4. When asked what Patient #4 used to stab the tech, S4RN stated that the patient was holding a small golf pencil when she walked into the room and that she assumed that was what was used. When asked if the patient or the room was searched for any other contraband after this incident, S4RN stated no.

On 09/19/2024 at 1:55 p.m., interview with S1Administrator confirmed that a thorough investigation was not performed after this incident with Patient #4 to determine what the patient had used or how he had obtained it. When asked if the hospital had reviewed the process for searching patients upon admit for contraband after this incident, S1Administrator stated no. When asked if any new interventions or processes had been put in place after this incident with Patient #4, S1Administrator stated no.

Based on record review and interview, the hospital failed to ensure the hospital wide QAPI program's performance improvement program implemented preventive actions. This deficient practice is evidenced by the lack of an implemented preventive action plan following incidents involving patient observation levels and contraband.
Findings:

1. Review of the medical record for Patient #3 revealed an admit date of 09/02/2024. Diagnoses included bipolar disorder and recent manic episode with psychosis.

Review of physician progress note dated 09/07/2024 revealed the patient was having increased agitation and aggression with hypersexual behaviors. The patient was ordered 1:1 observation level at this time.

Review of physician progress note dated 09/12/2024 revealed patient remains 1:1 due to assault on staff member.

Review of physician progress note dated 09/15/2024 revealed staff report defiant on unit. Remains 1:1 and attacked a tech earlier this week. Patient sat on another patient's lap and allowed him to touch her inappropriately.

Review of the LDH Hospital Abuse/Neglect Initial Report form dated 09/15/2024 at 8:45 a.m. revealed in part that the patient grabbed another patient's hand and forced it down the front of her pants approaching her pubic area. The report further stated this is not alleged; this in fact happened as evidenced by both victim and aggressor's acknowledgement of such. The initial actions taken stated that the patient's courtyard privileges were immediately revoked. The report stated Patient #3 was on 1:1 observation level, starting on 09/07/2024, and remained on 1:1 until her discharge on 09/16/2024. The report further stated that the tech stated the patient needed to get some air and took the patient to the outside common area where the incident took place.

On 09/18/2024 at 3:50 p.m., interview with S1Administrator confirmed that there was no investigation performed to determine how this sexual incident with Patient #1 occurred, since the patient was on 1:1 observation level. S1Administrator further confirmed there was no new interventions put in place, no increased monitoring of 1:1 patients and no further training conducted to the staff to ensure incidents like this one would not occur again. S1Administrator confirmed that that the lack of ordered 1:1 observations by the staff allowed Patient #1 to be sexually violated by another patient.

Observations during the survey on 09/18/2024 revealed Patient #1 was not observed at 1:1 observation level and Patient #2 was not observed at LOS observation level, as ordered by the physician.

2. Review of the medical record for Patient #4 revealed an admit date of 09/12/2024 at 11:37 a.m. The patient was transferred from another facility due to paranoid and aggressive behaviors. Review of the admission nurses notes dated 09/12/2024 at 11:37 a.m. revealed that the patient would be on routine (every 15 minute) observations.

Review of an incident report dated 09/12/2024 at 7:10 p.m. revealed that another patient reported that Patient #3 was standing in his window asking the other patient to raise up her shirt. A male tech went into Patient #3's room to pull him from the window and the patient fought back swinging at the tech. The report further states that the patient hit the tech with an object and punctured the tech's forearm with the object.

Review of nurses notes dated 09/12/2024 at 7:15 p.m. revealed that the patient was observed by a tech to be masturbating in front of his bedroom window attempting to induce the patient on another hall (windows face each other) to pull up her shirt. The tech went into Patient #4's room and the patient tried to stab the tech with an unknown object. There was an altercation between the patient and the tech. The patient now complains of left shoulder pain and was sent to the ER for evaluation. The tech has two puncture wounds on his inside right forearm.

There was no documented evidence in the record that the patient nor his room was searched to locate the object that was used to injure the tech.

On 09/19/2024 at 12:30 p.m., interview with S5DON revealed that she was unsure what type of object that Patient #4 used to stab the tech. She stated that they assumed it was a plastic fork because there were four puncture wounds on the tech's arm. When asked if there had been any investigation to determine what object was used to injure the tech, S5DON stated no.

On 09/19/2024 at 12:45 p.m., interview with S4RN revealed that she was working the evening that the incident occurred with Patient #4. When asked what Patient #4 used to stab the tech, S4RN stated that the patient was holding a small golf pencil when she walked into the room and that she assumed that was what was used. When asked if the patient or the room was searched for any other contraband after this incident, S4RN stated no.

On 09/19/2024 at 1:55 p.m., interview with S1Administrator confirmed that a thorough investigation was not performed after this incident with Patient #4 to determine what the patient had used or how he had obtained it. When asked if the hospital had reviewed the process for searching patients upon admit for contraband after this incident, S1Administrator stated no. When asked if any new interventions or processes had been put in place after this incident with Patient #4, S1Administrator stated no.