HospitalInspections.org

Based on interview, documentation in 1 of 1 medical record reviewed of a patient who was involved in a patient to patient altercation (Patient 2), and review of policies and procedures, it was determined that the hospital failed to fully implement policies and procedures related to the identification, investigation, and response to patient incidents to ensure patient protection from abuse, neglect, or mistreatment.
* There was no incident report and investigation, and medical record documentation was incomplete secondary to a patient to patient altercation for Patient 2 and the other patient involved in the altercation as required by hospital policies.

Findings include:

1. The policy and procedure titled "Abuse and Neglect of Patients", dated as last reviewed "2/21/17." It reflected that "Cedar Hills promotes respect, dignity, and safety to all its patients and their rights. Therefore, allegations of patient abuse or neglect will be investigated...Within ten (10) working days of receiving the allegation, the Patient Advocate shall submit to Administration a final report of the investigation and action taken."

2. The policy and procedure titled "Incident Reporting", dated as last revised "4/2015," was reviewed. The policy reflected that an "Occurrence [Incident]" was defined as "that which is not consistent with the routine care of a patient and/or the desired operations of the facility. The results of this event require or could have required...unexpected medical intervention, unexpected intensity of care, or causes or had the potential to cause an unexpected physical or mental impairment."

The policy required that "Any facility employee or staff member who discovers, is directly involved in or responding to an event/occurrence is to complete or direct the completion of a Healthcare Peer Review (HPR) form...The HPR is to be completed at the time of the event...The Nurse Charge of Shift on duty at time of event is notified of any HPR incident, reviews HPR for completeness, making suggestions or additions as necessary from nursing perspective...The event is documented in the medical record by the person most closely associated with the event and includes...A concise statement of the facts of the event...Clinical condition of patient...Names, times of notification of physician, supervisory personnel, family members as necessary...The Nurse Charge of Shift ensures the following information is obtained prior to forwarding completed HPR to the Risk Manager...Information on form is complete...Appropriate persons were notified (i.e., Attending Physician, Department Supervisor, and Risk Manager, CEO or designee)...Patient was examined and received immediate medical attention as needed...Intervention and appropriate actions taken for prevention or protection of patient/facility...The completed form is forwarded to the Risk Manager within 72 hours..."

3. The policy and procedure titled "Rights and Responsibilities of Patients", dated as last reviewed "1/05/17," was reviewed. It reflected that "Cedar Hills policy is to preserve the patient's basic human rights during the provision of services as well as ensure that the behavior of patients and their family/friends is reasonable and responsible. Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation."

4. The medical record of Patient 2 was reviewed and reflected the patient was admitted on 04/19/2017 at 1320.

A Daily Nurse Progress Note was recorded by an RN on 04/28/2017 at 1955. The documentation reflected "Pt is intrusive [with] others...encouraged to focus on [his/her] care and getting well."

A Daily Nurse Progress Note was recorded by an RN on 04/29/2017 at 1609. The documentation reflected "Pt came up [to] the nurses station around 1456 reporting that a patient push (sic) a table towards [him/her] hitting [his/her] toes. Pt denies pain. Pt state (sic) [he/she] will just go to [his/her] room to get away from the patient a little bit. Pt denies any other area of [his/her] body that was hit other than [his/her] toes in [his/her] left foot...Pt currently out [in] courtyard with the MHT..."

A Group Therapy Progress Note was recorded by a QMHT on 04/29/2017 at 1624. The documentation reflected "Pt was alert and attentive in group, participated in group discussions, and responded appropriately to other members. Pt was involved in a minor altercation with another group member, but was not the aggressor." The notes included no other information about the event.

A Daily Nurse Progress Note was recorded by an RN on 04/29/2017 at 1658. The documentation reflected "...Patient reported [his/her] left knee is painful with pain scale 6/10. Pt reported [he/she] had a history of knee injury. Pt reported when the coffee table was pushed by another pt it hits [his/her] toes in an angle that it hurts [his/her] knee...Pt received Naproxen 250mg [by mouth] at 1647 for pain. Pt was advised to inform staff if the pain is getting worse. Pt was advised to inform staff anytime [he/she] feel unsafe."

A Daily Nurse Progress Note was recorded by an RN on 04/29/2017 at 1755. The documentation reflected "This RN reported [to physician] at this time that the pt reported knee pain on [his/her] left foot with pain scale 6/10."

A Physician Medical Consultation note dated 04/29/2017 reflected "...this afternoon, [patient] was in a group and [he/she] was keeping [his/her] feet on the coffee table and one of the other patient (sic) did not like it and pull (sic) the table out and then [his/her] foot fell down on the floor and [he/she] said since then, [he/she] feels some pain in the lateral side of the left knee...able to walk on [his/her] legs without difficulty and there is no swelling and bruises noted...left knee pain maybe (sic) secondary to the very mild sprain."

The record reflected the patient was discharged on 05/02/2017.

The documentation was unclear and was not consistent with the requirements of the hospital policies and procedures. For example, it did not clearly reflect the time of the event. It did not include if there were precipitating factors or behaviors to the event. It did not clearly reflect which staff member(s) were present, interacted, observed, evaluated or provided care to the patient at the time of the event. It did not reflect that the charge nurse was notified of the event.

5. During interview on 12/08/2017 at 1525 Patient 2's medical record was reviewed with the Director of PI and Compliance. He/she confirmed the medical record reflected that the patient reported left foot and knee pain after he/she was involved in an altercation with another patient. The Director of PI and Compliance stated there was no investigation and no incident report for the event, including for Patient 2 or the other patient involved.

6. An interview was conducted on 12/08/2017 at 1640 with the RN who was on duty on 04/29/2017. The RN stated that Patient 2 reported that another patient pushed a table against his/her left foot and toes. The RN stated Patient 2 was "upset" and complained of pain to his/her left foot and toes. The RN could not remember who the other patient was that was involved in the altercation. In regards to if the RN completed an incident report of the event, he/she stated "I don't think so."

7. An interview was conducted on 12/08/2017 at 1600 with the QMHT who was on duty on 04/29/2017. He/she stated that Patient 2 was in the group room sitting on a sofa with his/her legs elevated on a table. He/she stated that another patient became irritable and pushed the table out from under Patient 2's legs. He/she stated "I don't recall if [Patient 2] got hurt." He/she could not remember who the other patient was. The QMHP stated he/she could not remember if he/she reported the event to the charge nurse. He/she stated "I believe I told the nurse that they weren't getting along. I don't remember any other details." In regards to if the QMHP completed an incident report of the event, he/she stated "I did not."

Based on interview, review of documentation in 1 of 1 medical record of a patient who had a skin condition (Patient 2), and review of policies and procedures, it was determined that the RN failed to supervise and evaluate the nursing care for each patient in accordance with hospital policies and procedures in the areas of:
* Admission skin assessments;
* Conformance with physician's orders; and
* Monitoring of patient skin conditions.

Findings include:

1. The policy and procedure titled "Assessment of Patients, IP", dated as last revised "3/10/2017," was reviewed. It reflected that "All patients admitted to Cedar Hills Hospital will receive a thorough assessment and evaluation. Results of assessments are reviewed and integrated by the multidisciplinary treatment team to prioritize problems within the Interdisciplinary Treatment Plan...A comprehensive nursing assessment is performed by a Registered Nurse within eight hours of admission...the nursing assessment will include the following information...a skin check prior to admitting to the unit."

2. The policy and procedure titled "Daily Progress Notes/Re-assessment of Patients, IP", dated as last revised "11/09/16," was reviewed. It reflected that "It is the policy of Cedar Hills Hospital to assess patients at time of admission, when transitioning to another level of care and at time of discharge...Reassessment is conducted by Registered Nurse daily at a minimum. Additionally, reassessment occurs in the following circumstances...If there is a change in the patient's condition...As indicated by the patient's condition...the treatment team reassesses the patient in relation to progress toward treatment plan goal...reassessments are documented on the Interdisciplinary Treatment Plan Update form.
3. The policy and procedure titled "Skin Check/Body Search, IP", dated as last reviewed "11/15/2016," was reviewed. It reflected that "...Patients admitted to Cedar Hills are to have...an unclothed physical examination to ascertain the presences/absence of injuries, wounds, infections, scars...the licensed staff will be assessing, and documenting, the patient's current skin condition, assessing specifically for open wounds, bruising, rashes..."

4. The record of Patient 2 was reviewed and reflected the patient was admitted on 04/19/2017 at 1320.

The "Body/Skin Check" section on the Inpatient Nursing Admission Assessment dated 04/19/2017 at 1800 was not completed and was blank. There was no other documentation reflecting an admission skin check was completed.

The record reflected an untimed physician order for a "finger dressing BID" and "Med consult for nail infection" dated 04/28/2017.
The record reflected the physician orders for the finger dressing changes were not carried out. There was no nurse documentation of any dressing changes at all on 04/28/2017, 04/29/2017, 04/30/2017, 05/01/2017 and 05/02/2017.

The patient's Multidisciplinary Master Treatment Plan and Master Treatment Plan Update forms did not include a skin alteration or skin infection as a problem, and did not include any interventions for a skin alteration or skin infection.

There were no RN assessments or interventions for the patient's "nail infection." The only RN note addressing the patient's "nail infection" in the medical record was on 04/28/2017 at 1955 and it reflected only "Pt. is fixated on [his/her] infected finger on [right] 4th finger Educated on [Physician] tx orders and explained that [Physician] will be following up but it may not be a daily visit."

The record reflected the patient was discharged on 05/02/2017 at 1456. There was no final RN assessment of the patient's "nail infection" prior to discharge.

5. The findings above were confirmed during a review of the medical record with an RN on 12/08/2017 at 1640. The RN stated that there should have been an admission skin check completed and there was not. He/she stated "There should have been documentation of specific signs and symptoms of infection such as pus and temperature charted in the progress notes twice a day after every dressing change." He/she stated the care plan should have been updated to reflect the patient's finger skin condition and he/she confirmed it was not.