HospitalInspections.org

Based on record review, observation, document review, and staff interview it was determined the facility failed to ensure a Registered Nurse (RN) was available and readily accessible on Unit A4, as all the RNs on the unit secured themself behind a closed door (See Tag A 395) and failed to follow policy for securing the medication room door (See Tag A 398), leaving patient #1 unattended in the nurse's station with access to the medication room. This failure has the potential to cause great harm or death to all the patients on the unit, and the staff. As a result of this failure, an Immediate Jeopardy (IJ) was identified and the facility was notified on 11/30/22 at 8:21 a.m. The facility submitted and implemented an acceptable plan to remove the IJ, which was verified by the State Survey Agency on 11/30/22 at 5:06 p.m.

The following interventions were implemented to resolve the IJ: Education of all licensed staff will be completed for securing the medication room door. Training will continue until 100% of all licensed staff are educated. A new protocol for conducting debriefing immediately following a code situation was implemented to identify if immediate action needs to be taken. RN #1 was suspended pending investigation. Supervision rounds will be performed every shift to ensure staff are following policies/procedures.

Based on record review, observation, document review, and staff interview it was determined the facility failed to ensure a Registered Nurse (RN) was available and readily accessible on Unit A4, as all the RNs on the unit secured themself behind a closed door, leaving patient #1 unattended in the nurse's station. This failure has the potential to cause great harm or death to all the patients on the unit, and the staff.

Findings includes:

A record review was conducted for patient #1. Patient #1 was transferred to the facility per court order on 09/19/22 with a diagnosis of Post-Traumatic Stress Disorder (PTSD). The patient has several incidents of violent behaviors involving staff and peers, requiring medications and physical holds. On 11/07/22 at approximately 7:38 p.m., it is noted by Orientee RN #1 in a "Psychiatric Emergencies" note, in part: "Comments: patient verbally threatening to kill staff and peers, threatened to smother peer in their sleep by putting a pillow on their head, patient threatened to sharpen an object and stab and cut staff and peers throats. Patient then told staff to watch and see, [Patient #1] proceeded to climb over the nursing station, launching at staff, staff was able to get to safety by shutting a door between them and the patient. Patient then began to destroy the nursing station by kicking and smashing two [2] computers, pulling phones out of the wall, and set the fire alarm."

An observation was conducted on 11/28/22 at 2:07 p.m. of the video review from 11/07/22 on Unit A4 with the Director of Human Resources (HR). The video revealed the following:

8:35:14 p.m. Three (3) staff at the nurse's station: RN #1, Orientee RN #1, Health Service Worker (HSW) #1. Patient #1 is standing in front of the divider and appears to be talking with staff.

8:38:16 p.m. RN #1 on the phone at the desk.

8:38:45 p.m. Patient #1 climbing over nursing station divider.

8:38:47 p.m. Patient #1 into nurse's station, RN #1 and Orientee RN #1 enter the charting room in the back of the nurse's station and close the door. Patient picking up keyboards, and computers, smashing them onto the floor.

8:39:31 p.m. Patient #1 in the nurse's station medication room, picking up items and smashing them onto the floor.

8:40:05 p.m. Patient #1 climbs back over divider onto day area of the unit.

8:40:10 p.m. Security Personnel #1 enters nurse's station.

8:40:33 p.m. RN #1 and Orientee RN #1 open door and enter into nurse's station.

A review was conducted of policy titled "Plan for the provision of Nursing care," last reviewed 07/23/19. The policy states in part: "I. Definitions A. Registered Professional Nurse (RN): According to the state of West Virginia Code and Legislative Rules for Registered Nurses: The practice of "registered professional nursing" shall mean the performance of compensation of any service requiring substantial specialized judgment and skill based on knowledge and application and principles of nursing derived from the biological, physical and social sciences, such as responsible supervision of a patient requiring skill in observation of symptoms and reactions and the accurate recording of the facts, or the supervision and teaching of other persons with respect to such principles of nursing, or in the administration of medications and treatments as prescribed by a licensed provider for a licensed dentist or the application of such nursing procedures as involves understanding of cause and effect in order to safeguard life and health of a patient and others."

A review was conducted of the CCG (Crisis Consultant Group) training (Verbal Crisis Prevention and Intervention Training) for RN #1 and Orientee RN #1. RN #1 completed the training on 03/31/22. Orientee RN #1 completed the training on 10/27/22.

A telephone interview was conducted with RN #1 on 11/28/22 at 7:37 p.m. Regarding the incident with patient #1, RN #1 stated, "I came in at 7 (7:00 p.m.) and I had an orientee with me. The patient was arguing with the health service worker. I tried to de-escalate and [patient #1] chased me into the nursing station. [Patient #1] hit me with a shoe while I was calling a code. [Patient #1] then calmed down afterwards. [Patient #1] came back up to the nurse's station and started yelling. [Patient #] said [patient #1] was going to kill us and slit our throats. [Patient #1] was just mad and didn't want to be here, wanted to go to jail and was going to kill someone to get there. I was not able to call anyone before we went into the charting room. The orientee was holding the door shut. We didn't call for help, we just stayed in the room. There were other staff on the floor, they had probably called for help. Security was there when we came out. Me and the supervisor called the physician. The physician ordered a two to one (2:1). The supervisor called the Nursing Director. No one has talked to me about this incident except for the supervisor that night. I was scared. [Patient #1] is only [ _ years old] and I'm fifty (50) years old. I had an orientee with me that couldn't do a hold, since they had not completed the training. I was thinking I was going to get hurt. The supervisor came to the floor and we talked about what happened throughout the night."

An interview was conducted with the Nursing Supervisor on 11/29/22 at 8:05 a.m. Regarding the incident with patient #1, the Nursing Supervisor stated, "I was notified that the patient jumped over the partition at the nurses. [Patient #1] got into the med [medication] room, broke computers and a telephone. I documented the damage and sent it to [Chief Nursing Executive (CNE)]. I don't know what had transpired prior to that happening. [CNE] wanted the doctor to come in and [CNE] wanted to get the patient properly medicated and evaluated. There were several calls back and forth between [CNE] and the physician. The patient always thinks [patient #1's] in charge and runs that unit. I don't know what I would have done in this situation. I never had to experience this patient one on one (1:1). I would definitely have kept eyes on the patient even if I had to try to move away from [patient #1]. I wouldn't have shut myself in a room where I couldn't see. I took pictures of the damage and sent it to [CNE]."

A telephone interview was conducted with HSW #1 on 11/29/22 at 7:05 p.m. Regarding the incident with patient #1, HSW #1 stated, "I was there when [patient #1] jumped over the nurse's station wall. I had to leave and wasn't allowed back on the unit. About thirty to thirty-five (30-35) minutes prior, I was punched in the face by [patient #1]. One (1) of the nurses was on orientation, so the RN grabbed [Orientee RN #1] and went into the room in the back of the nurse's station."

An interview was conducted with the CNE on 11/29/22 at 9:48 a.m. Regarding the incident with patient #1, the CNE stated, "I had been called about the incident that night. The next day I had a debriefing. We talked about what could have been done, maybe more verbal de-escalation for a different outcome. If there were two (2) people present, they could have done a CCG hold. The rest of the population was not in harm, as other staff were there on the unit. I discussed with the physician that night with this patient due to [patient #1's] diagnosis if we put [patient #1] on a two to one (2:1), it would provoke [patient #1] more. [Patient #1] was getting close to maxing out on medications. It's scary to feel that you don't have any alternatives. Part of it was fear, not knowing what to do by the nurse. A couple days later this patient even broke a security guard's nose for no reason. Right after the incident, we did a body check. We did an incident report and there was documentation from the nurse and the provider. We did a debriefing the next day. I reviewed the video and I spoke with a supervisor. I talked with the orientee RN that quit the next morning over the incident. I discussed with the LPN [Licensed Practical Nurse] about leaving the med room door unlocked. We had a nurse manager meeting and discussed what could have been done. I talked with the nurse. [RN #1] was scared and didn't know if [patient #1] had a weapon. The orientee should have had CCG training before being allowed to work on the unit."

An interview was conducted with the CNE on 11/29/22 at 2:00 p.m. When asked about RN #1 and Orientee RN #1 locking themselves in a room in the nurse's station, and no RN being present on the unit to protect the other staff and patients, the CNE stated, "I didn't even think of that until you just now mentioned it."

An interview was conducted with the Chief Medical Director on 11/29/22 at 3:35 p.m. The Medical Director agreed at the very least, RN #1 should be re-educated on CCG.

Based on observation, document review, and staff interview, it was determined the facility failed to secure the medication room per policy allowing patient #1 to access the medication room. This failure has the potential to cause great harm, and/or death to all patients on the unit.

Findings include:

An observation was conducted on 11/28/22 at 2:07 p.m. of the video review from 11/07/22 on Unit A4 with the Director of Human Resources (HR). The video revealed the following:

8:35:14 p.m. Three (3) staff at nurse's station: Registered Nurse (RN) #1, Orientee RN #1, Health Service Worker (HSW) #1. Patient #1 is standing in front of the divider and appears to be talking with staff.

8:38:16 p.m. RN #1 on the phone at the desk.

8:38:45 p.m. Patient #1 climbing over nursing station divider.

8:38:47 p.m. Patient #1 into nurse's station, RN #1 and Orientee RN #1 enter the charting room in the back of the nurse's station and close the door. Patient picking up keyboards, and computers, smashing them onto the floor.

8:39:31 p.m. Patient #1 in the nurse's station medication room, picking up items and smashing them onto the floor.

8:40:05 p.m. Patient #1 climbs back over divider onto day area of the unit.

8:40:10 p.m. Security Personnel #1 enters nurse's station.

8:40:33 p.m. RN #1 and Orientee RN #1 open door and enter into nurse's station.

A review was conducted of policy titled "Medication Administration," last effective 09/30/21. The policy states in part: "IV. Medication Room: ... The Medication Room IS TO BE KEPT LOCKED AT ALL TIMES. The only exception to this is when medications are being administered."

A telephone interview was conducted with Licensed Practical Nurse (LPN) #1 on 11/28/22 at 6:51 p.m. Regarding the incident with patient #1, LPN #1 stated in part, "I left the med [medication] room door open since the RNs were at the desk."

An interview was conducted with the Chief Nursing Executive (CNE) on 11/29/22 at 9:48 a.m. Regarding the incident with HSW #1, the CNE stated in part, "I discussed with the LPN about leaving the med room door unlocked."

An interview was conducted with the Quality Assurance Performance Improvement (QAPI ) Coordinator on 11/29/22 at 2:00 p.m. The QAPI Coordinator agreed the policy states to secure the medication room door at all times.