HospitalInspections.org

A. Based on document review, observation and interviews, it was determined that for 2 of 2 patient with orders for 1:1 monitoring (Pt. #1 and #3) the Hospital failed to protect and promote each patients right to care in a safe setting.

The cumulative effect of these systemic practices resulted in the harm of 1 patient (Pt. #1) and a potential for harm for 1 patient (Pt. #3) as well as 15 other patients on census at the time of the survey. As a result, 42 CFR 482.13, the Condition of Participation for Patient Rights was not met.

Findings include:

1. The Hospital failed to ensure the patient was monitored on 1:1 observation precautions in accordance with policy in order to maintain patient safety. See deficiency cited at A 144 A.

2. The Hospital failed to ensure all potentially harmful items were removed from patient's room. See deficiency cited at A 144 B.

3. The Hospital failed to ensure annual training and competencies on precautions observation for all staff on the Behavioral Medicine Unit. See deficiency cited at A144 C.

4. The Hospital failed to ensure restraint orders specified the type, length of time and purpose or reason for the restraint as required by policy. See deficiency cited at A168.

5. The Hospital failed to ensure a 1 hour face to face evaluation was conducted after initiation of restraints. See deficiency cited at A178.

A. Based on document review and staff interview, it was determined that for 1 of 2 (Pt. #1) records reviewed of patients with an order for a 1:1-sitter, the Hospital failed to ensure the patient was monitored on 1:1 observation precautions in accordance with policy, in order to maintain patient safety.

Findings include:

1. The Hospital policy titled, "Precaution" (revised 2/7/11), reviewed on 3/12/14 at approximately 11:00 AM, required, "A staff member who has been in-serviced and tested on precautions...will be within arm's reach of the patient on 1:1 observation at all times including in the shower and the bathroom. 1. Never leave the patient alone...Precaution: One to One (1:1); frequency of monitoring: Continuous...."

2. The clinical record of Pt. #1 was reviewed on 3/12/14 at approximately 10:00 AM. Pt. #1 was a 23 year old male admitted on 3/4/14 at 3:47 AM with a diagnosis of schizoaffective disorder, bipolar type. The nursing admission note dated 3/4/14 at 5:30 AM indicated "Pt begins threatening to hurt all staff...pushes..swinging at staff, affect is hostile, mood is labile...pt is monitored with 1:1 sitter." A physician's order dated 3/4/14 at 3:30 PM required, "1:1 sitter for safety."

The progress notes indicated that 1:1 observation was initiated by the nurse on admission prior to receiving the physician's order. The precaution observation sheets which required documentation every 15 minutes, lacked documentation to evidence Pt. #1 was on 1:1 monitoring from 3/4/14 at 3:30 PM (time of physician's order) until 3/5/14 at 6:45 AM.

A nursing progress note on 3/4/14 at 11:10 PM indicated the following occurred: "Pt walked into room of other patients then began threatening the patients in that room and taking their clothing, then upon 2 staff persons attempts to redirect patient, the patient began grabbing, hitting and biting the 2 staff, code gray was called...."

The record further included a resident's note on 3/5/14 at 3:40 AM which indicated, "Pt. seen and examined today... Exam ...Right eye swollen, unable to open eye, mild laceration ...on right cheek, dry blood on the cheeks ...."

3. The charge nurse on duty (E #1) during the incident was interviewed by telephone on 3/12/14 at approximately 1:00 PM. E #1 stated he did not see the entire incident on 3/4/14 although it was reported that Pt. #1 was in his room at first then went to another room threatening the patients in the room, and one of the patients in the room came to the nursing station to ask staff to get Pt. #1 out of their room. E #1 stated that Pt. #1 was on 1:1 observation, however could not say if staff was actively monitoring Pt. #1 on a 1:1 at the time of the incident.

4. The VP of Patient Care Services (E #6) and the VP of Quality and Compliance (E #7) were interviewed on 3/14/14 at approximately 3:30 PM. E #6 and #7 stated that during the course of the investigation it was found that the staff assigned to monitor Pt. #1 on 1:1 was at the nursing station, giving report at the change of shift, leaving Pt. #1 unmonitored, contrary to stated practice and policy.

5. The findings were discussed with E #6 and 7 during the above interview who stated that it is hospital practice for the nurse to give report to the incoming staff and the [offgoing] 1:1 sitter remains with the patient at arms length. The [offgoing] 1:1 sitter then provides any additional information to the incoming 1:1 sitter at the hand off.


B. Based on document review, observation and staff interview, it was determined that for 1 of 1 (Pt. #3) on 1:1 sitter monitoring on the 4 South Unit, the Hospital failed to ensure all potentially harmful items were removed from the patient's room as required by policy. This posed a potential risk of harm for all 16 patients on census on the 4 South Unit.

Findings include:

1. The Hospital policy titled, "Precaution" (revised 2/7/11), reviewed on 3/12/14 at approximately 11:00 AM, required, "A staff member who has been in-serviced and tested on precautions...will be within arm's reach of the patient on 1:1 observation at all times including in the shower and the bathroom. 3 Remove any potentially harmful items from patients room...."

2. The clinical record of Pt. #3 was reviewed on 3/13/14. Pt. #2 was a 30 year old female admitted on 3/9/14 with a diagnosis of schizoaffective disorder. The clinical record included an order for 1:1 sitter for safety.

3. During an observational tour on the 4 South Behavioral Unit, a chair in Pt. #3's room, (room 445), contained a piece of clear plastic bag approximately 5 by 18 inches, that was visible to the hallway and accessible to Pt. #3 and 15 other patients in the unit.

4. The VP of Patient Care Services (E #6) was interviewed on 3/13/14 at approximately 10:30 AM. E #6 stated that the plastic bag should have been completely removed from the chair.


C. Based on document reviews, stated practice and interview, it was determined that for 2 of 6 (E #2 and #9) Nurse technicians on the Behavioral Medicine Unit, the Hospital failed to ensure annual training and competencies on precautions observation.

Findings include:

1. The Hospital policy titled, "Precaution" (revised 2/7/11), reviewed on 3/12/14 at approximately 11:00 AM, required, "A staff member who has been in-serviced and tested on precautions...will be within arm's reach of the patient on 1:1 observation at all times including in the shower and the bathroom. 1. Never leave the patient alone...Precaution: One to One (1:1); frequency of monitoring: Continuous...."

2. The Vice President of Nursing Services (E #6) stated during an interview on 3/13/14 at approximately 3:30 PM, that it is the Hospital's practice to determine competency of Behavioral Medicine staff on all precautions observation including 1:1 monitoring, annually.

3. The personnel files of 6 Nurse Technicians assigned to the Behavioral Medicine Unit were reviewed on 3/14/14 and 3/18/14. E #2's and E #9's files lacked current competencies for precautions observation, including 1:1. E #2's and E #9's files lacked documentation of annual competencies for precautions observation, since 4/11/12 (1 year and 11 months).

4. The above findings were discussed with the VP of Patient Care Services and the VP of Quality and Compliance, during an interview on 3/14/14, at approximately 4:00 PM, who stated that precautions observation competencies should be done on an annual basis.

A. Based on document review and staff interview, it was determined that for 1 of 4 (Pt. #1) records reviewed for restraint usage, the Hospital failed to ensure restraint orders specified the type, length of time and purpose or reason for the restraint as required by policy.

Findings include:

1. The Hospital policy titled, "Restraint/Seclusion Policy" (revised 2/2009) reviewed on 3/13/14 at approximately 9:00 AM required, "Policy: Behavioral Management: 8. The restraint order must specify: Date and time ordered, type of restraints, length of time that restraints are authorized, purpose or reason for restraint...."

2. The clinical record of Pt. #1 was reviewed on 3/12/14 at approximately 10:00 AM. Pt. #1 was a 23 year old male admitted on 3/4/14 at 3:47 AM with a diagnosis of schizoaffective disorder, bipolar type. The clinical record contained the following incomplete restraint orders:

*3/4/14 at 5:30 AM, and 7:30 AM, each for two hours, however the orders lacked the type of restraints and/or whether restraints were for full or alternate limbs.

*3/4/14 at 9:25 AM and 11:30 AM, restraints were ordered as "therapeutic restraints" and lacked the type of restraints, length of time that restraints were authorized and purpose or reasoning for the restraints.

*3/4/14 at 11:10 PM, and 3/5/14 at 1:10 AM, 3:10 AM, and 5:10 AM, lacked whether full or alternate limbs were to be restrained and the reason for the restraints.

3. The above findings were discussed with the VP of Patient Care Services during an interview on 3/13/14 at approximately 12:00 PM, who acknowledged the orders were not complete.

Based on document review and staff interview, it was determined that for 2 of 4 (Pt. #1 and #2 ) clinical records reviewed for patients with orders for restraints, the Hospital failed to ensure a 1 hour face to face evaluation was conducted after initiation of restraints.

Findings include:

1. The Hospital policy titled, "Restraint/Seclusion Policy" (revised 2/2009) reviewed on 3/13/14 at approximately 9:00 AM required, "Policy: Behavioral Management:7. Within one (1) hour of restraint/seclusion application for the management of violent or self-destructive behavior, the trained practitioner (MD, PA, RN, APN) must conduct a face-to face-evaluation...."

2. The clinical record of Pt. #1 was reviewed on 3/12/14 at approximately 10:00 AM. Pt. #1 was a 23 year old male admitted on 3/4/14 at 3:47 AM with a diagnosis of schizoaffective disorder, bipolar type. The clinical record included orders for restraints on 3/4/14 at 5:30 AM (and reordered at 7:30 AM, 9:25 AM, 11:30 AM), at 2:30 PM and at 11:10 PM; and on 3/5/14 at 1:10 AM (reordered at 3:10 AM, and 5:10 AM). The record indicated Pt. #1 was restrained as ordered, however the record lacked the 1 hour face to face evaluation after Pt. #1 was restrained at the various times.

3. The clinical record for Pt. #2 was reviewed on 3/13/14 at approximately 10:30 AM. Pt. #2 was a 42 year old female, admitted on 3/6/14 with a diagnosis of schizoaffective disorder. The record contained orders for restraints on 3/7/14 at 9:40 PM and 11:00 PM with documentation of Pt. #2 being restrained from 3/7/14 at 9:00 PM to 3/8/14 at 1:00 AM. However the record lacked the 1 hour face to face evaluation after Pt. #1 was restrained.

4. The above findings were discussed with the VP of Patient Care Services, during an interview on 3/13/14 at approximately 12:00 PM, who acknowledged that the face to face evaluation was lacking in the record.