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Based on review of facility documents and staff interview, it was determined the facility failed to protect patient's rights as per facility policy, in two of 10 patients (Patient (P)1 and P4).

Reference:

482.13(c)(2) - Care In Safe Setting

482.13(e) - Use of Restraint or Seclusion

Based on review of facility documents and staff interview, it was determined the facility failed to ensure staff reported safety events, as per facility policy, in two of 10 patients (Patient (P) 1 and P2).

Reference:

482.23(b)(6) - Supervision of Contract Staff

Based on staff interview, medical record review, and review of facility documents, it was determined the facility failed to provide care in a safe setting for one of one medical records reviewed (Patient (P)1).

Findings include:

Facility policy titled "Occupational Exposure to Bloodborne Pathogens: Exposure Control Plan" with an effective date of 3/16/22, states " ...Procedure: ... 2. Appropriate Engineering Controls: ...o. Sharps will be disposed of into an approved puncture resistant biohazard container ..."

On 2/27/25 at 1:15 PM, a review of P1's medical record was conducted and revealed the following:

On 1/17/25 at 12:11 PM, P1 arrived to the Emergency Department (ED) with a chief complaint of abdominal pain with associated behavior changes.

At 8:45 PM, Staff (S)45, Registered Nurse (RN), documented "Mother approached Nurses' station saying pt (patient) "just-head butted me." Verbal order obtained by Admitting Physician for IM (intramuscular) Ativan. [S49, Physician] to come to bedside for evaluation."

At 8:52 PM, IM Ativan was administered to P1's left deltoid by S44, RN.

On 2/28/25 at 10:44 AM, an interview was conducted with S45. S45 stated he/she was the charge nurse in the Pediatric ED on 1/17/25 when the IM Ativan was administered to P1. When questioned regarding the administration of the IM Ativan, S45 recalled that S44 had administered the medication. S45 stated that after the injection was administered, P1's mother found a bent needle, used to administer the IM Ativan in P1's room, and brought the needle to the nursing station and gave it to S45.

On 2/28/25 at 11:24 AM, an interview was conducted with S44. When questioned regarding the administration of the IM Ativan, S44 stated that P1 was very strong and hard to keep still. S44 stated there were four to six security officers in P1's room and they were having a hard time holding P1 down so that S44 could administer the IM Ativan. S44 stated that P1 was screaming and spitting. S44 stated he/she gave the IM Ativan in P1's arm and during the injection, P1 broke free from security and pushed himself upright into a sitting position and the needle became bent but remained intact. S44 stated he/she then threw the needle behind P1's bed to get it out of the way because there was no sharps container for disposal of needles in P1's room since it was a safe room.

On 2/28/25 at 12:26 PM, an interview was conducted with S47, RN. S47 stated that after P1 was transferred to Gagnon 3 (a medical/surgical unit) on 1/18/25, staff had to remove everything, such as mirrors, from the walls, in P1's room, in order to make the room safe for P1.

Based on medical record review, staff interviews, and review of facility documents, it was determined the facility failed to order and document the use of restraints, as per facility policy, for one of three medical records reviewed (Patient (P)4).
Findings include:
Facility policy titled "Restraints and Seclusion" effective 01/24/2025, stated, " ...Violent/Self Destructive Restraints: Patients demonstrating violent/self-destructive behavior, as evidenced by escalating agitation, combative behavior, attempts to harm themselves or others ...1. Application of Restraints for Violent/Self-Destructive Behavior: ...f. Application of two (2) points must include one (1) ankle and one (1) wrist or diagonal and opposing sides ONLY. Two (2) points cannot be applied to both wrists or both ankles or to a wrist and ankle on the same side ... Monitoring and Documentation: ...i. Assessment for clinical status and reevaluation of the need for restraints at least every thirty (30) minutes or more frequently for the Violent/Self-destructive patient.
On 02/27/25 at 12:58 PM, a review of Patient (P) 4's medical record revealed the following:
On 01/20/25 at 1:14 PM, P4 presented to the Emergency Department (ED) for an evaluation of an unwitnessed fall.

At 04:20 PM, Violent or Self-Destructive Restraints were ordered by S10, ED Physician Assistant. The restraint order contained the following documentation: "...Clinical Justification: Agitation escalating; Other ...(patient safety for lab work) ...Restraint Monitoring Every 30 Minutes ...Continuous Observation: Yes ...Restraint Type Soft Restraint R (right) Wrist (V): Start; Soft Restraint L (left) Wrist (V): Start."

When referencing the restraint order for continuous observation, no order could be found for one-to-one (1:1) observation. While reviewing P4's flowsheet, no documentation for 1:1 observation was completed.

While reviewing P4's restraints flowsheet, the following was documented by S8, ED Registered Nurse (RN). "Soft Restraint R (right) [and] L (left) Wrist (V); 04:20 PM - Start; 05:00 PM - Continued; 05:30 PM - Continued; 06:20 PM - Continued."

The next documentation on the restraints flowsheet was at 11:00 PM by S9, ED RN, in which he/she wrote, "not in restraints upon receiving patient."
On 02/28/25 at 10:40 AM, an interview was conducted with S6, ED Nurse Manager, and S7, ED Clinical Specialist. S6 and S7 confirmed the restraint order was placed incorrectly. S6 stated "if violent restraints are ordered, we never use soft restraints. Violent restraints must also be on opposite appendages. Violent restraints cannot be placed on two wrists or two ankles if they are ordered as two-point restraints such as this order." S7 stated "as for the restraints flowsheet, we reviewed it and are unable to determine what occurred between 06:20 PM and 11:00 PM as the nurse caring for [P4] stopped documentation at 06:20 PM."

Based on review of facility documents and staff interview, it was determined the facility failed to ensure staff reported safety events, as per facility policy, in two of 10 patients (Patient (P) 1 and P2).

Findings include:

Facility Policy titled, "Event Reporting" last reviewed 9/1/2023 stated, " ...Definitions: Actual Event: Any unusual or unexpected event or condition that is not consistent with the routine safe delivery of patient care or facility operations that reaches the patient or visitor ...Procedure: Reporting: 1. Any Near Miss, Actual Event, Preventable Event, Serious Preventable Adverse Event, or Serious Reportable Event will be reported through [facility name] electronic event reporting process. The rule of thumb is: 'When in doubt, fill it out.' 2. The individual with the most knowledge regarding the circumstances of the event should complete the report ...Investigation/Follow-up: 1. Every reported Near Miss or Actual Event will be reviewed by the unit/department Manager or designee who is responsible for: a. Ensuring the accuracy and level of detail of the information submitted; b. Investigating the event in timely manner, including meeting with all persons with relevant knowledge, if reasonably possible ...c. Documenting the investigation in the electronic reporting system; d. Developing corrective action, where appropriate ..."

On 2/27/25 at 1:15 PM, a review of P1's medical record was conducted and revealed the following:

On 1/17/25 at 12:11 PM, P1 arrived the Emergency Department (ED) with chief complaint of abdominal pain with associated behavior changes.

At 8:45 PM, Staff (S)45, Registered Nurse (RN), documented "Mother approached Nurses' station saying pt (patient) "just-head butted me". Verbal order obtained by Admitting Physician for IM (intramuscular) Ativan. [S49, Physician] to come to bedside for evaluation."

At 8:52 PM, IM Ativan administered to P1's left deltoid by S44, RN.

On 2/28/25 at 10:44 AM, an interview was conducted with S45. S45 stated he/she was the charge nurse in the Pediatric ED on 1/17/25 when the IM Ativan was administered to P1. When questioned regarding the administration of the IM Ativan, S45 recalled that S44 had administered the medication. S45 stated that after the injection was administered, P1's mother found a bent needle, used to administer the IM Ativan in P1's room, and brought the needle to the nursing station and gave it to S45.

On 2/28/25 at 11:24 AM, an interview was conducted with S44. When questioned regarding the administration of the IM Ativan, S44 stated that P1 was very strong and hard to keep still. S44 stated there were four to six security officers in P1's room and they were having a hard time holding P1 down so that S44 could administer the IM Ativan. S44 stated P1 was screaming and spitting. S44 stated he/she gave the IM Ativan in P1's arm and during the injection, P1 broke free from security and pushed himself upright into a sitting position and the needle became bent but remained intact. S44 stated he/she then threw the needle behind P1's bed to get it out of the way because there was no sharps container for disposal of needles in P1's room since it was a safe room.

On 2/28/25 at 12:26 PM, an interview was conducted with S47, RN. S47 stated that after P1 was transferred to Gagnon 3 (a medical/surgical unit) on 1/18/25, staff had to remove everything, such as mirrors, from the walls in P1's room, in order to make the room safe for P1.

On 2/28/25 at 2:10 PM, S2, Director of Risk Management, and S4, Risk Manager, confirmed there was no record of an event report being filed by the nursing staff for the incident involving the bent needle during the administration of IM Ativan for P1 on 1/17/25.


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On 2/27/25 at 10:10 AM, a review of P2's medical record was conducted and revealed the following:

P2 was admitted to the facility on 2/6/25 for a procedure to be performed by Staff (S) 48, Surgeon. Post surgical procedure, P2 was admitted to the Pediatric Intensive Care Unit (PICU). The PICU was the location of the alleged incident between S48 and P2.

On 2/26/25 at 1:47 PM, an interview was conducted with S30, Assistant Nurse Manager (ANM) - PICU. S30 explained that the incident involving S48 and P2 occurred approximately 2 ½ weeks prior. According to S30, the incident was relayed to him/her by S24, RN. S30 explained that S24 was told the following by P2's mother: P2 said to S48, "Are you going to give me a kiss goodbye?" S48 then gave P2 a kiss on the lips and left the room. S30 reported that he/she encouraged S24 to enter an anonymous report. According to S30, S24 stated that P2's mother did not want the incident reported. S30 explained that he/she met with P2's mother frequently throughout the hospitalization and she never reported the incident to him/her.

On 2/27/25 at 11:47 AM, a telephone interview was conducted with S24. S24 explained that he/she was not in the room when S48 allegedly kissed P2. According to S24, during bedside handoff between S24 and S26, RN, P2's mother shared that P2 said to S48, "I like you; can I have a hug?" S48 gave P2 a hug. P2 then asked S48, "Where's my goodbye kiss?" According to S24, P2's mother explained that S48 kissed P2 on the lips like an "old Italian man." S24 stated that P2's mother reported that S48 previously kissed P2 on the head, but never on the lips. S24 reported that P2's mother felt the kiss was bizarre and was more concerned for infection. S24 explained that P2's mother wiped P2's face after the kiss, as the patient is neutropenic. S24 reported the incident in passing to his/her ANM, S30. S24 explained that he/she feels that he/she followed protocols by reporting the incident to the ANM. According to S24, P2's mother stated she did not want to get anyone in trouble.

On 2/27/25 at 12:40 PM, a telephone interview was conducted with S26. S26 reported that P2's mother relayed the incident to S24 and S26 during bedside handoff. According to S26, P2's mother nonchalantly mentioned that S48 kissed P2 on the lips. According to S26, P2's mother was laughing and giggling while relaying the incident. S26 reported that he/she did not see when S48 entered P2's room. He/she stated that both S26 and S24 were not sure what to do with the information, because neither saw the incident. P2 was asleep when the story was relayed to them, and the mother did not seem concerned. S26 explained that S24 stated he/she would tell "someone."

On 2/28/25 at 11:01 AM, a telephone interview was conducted with S30. According to S30, if staff wanted to report something inappropriate that occurred, they would follow the facility's policy which escalates the matter to the Manager and the Risk Manager. S30 explained these parties would provide a recommendation on what action is to be taken, likely reporting to Corporate Compliance. When asked if S30 feels the incident with P2 should have been escalated, S30 explained "It is a gray area and overall, I do not think so." According to S30, the nurse came to him/her despite P2's mother not wanting "anyone to get in trouble." S30 reported that he/she met with P2 and his/her mother frequently, since the incident occurred. S30 explained he/she made it clear as to what his/her role is on the unit. S30 reported that he/she did not outwardly ask if this specific incident occurred, but he/she made it clear to the mother that he/she can be trusted. According to S30, the patient and the mother never reported the situation. S30 stated, "I have no concerns for the patient or the mother's well-being." S30 explained that a staff member can report an incident of inappropriate staff behavior by entering an event report, contacting Risk Management, utilizing the Corporate Compliance number, or escalating it to the Manager. According to S30, in certain situations, the staff will directly call Risk Management and consult them for guidance. S30 stated, "I did not consult Risk Management in this situation. I did not feel the need to consult them as I had spoken with the mother multiple times, and she never mentioned it."

On 2/28/25 at 12:10 PM, an interview was conducted with S1, Risk Manager, and S4. S1 and S4 explained that if an incident occurred with a patient by a staff member, an event report should be submitted. According to S1 and S4, the Event Reporting Policy would be the policy staff and leaders should follow in this situation. They explained that risk management triages the events and directs them to the appropriate department for investigation. S1 and S4 explained that staff and leaders can always call Risk Management for guidance, and that this happens often.

On 2/28/25 at 1:45 PM, an interview was conducted with S1, S2, and S4 and they agreed that it was difficult to say what policy staff should have followed in this situation. S2 stated, "Everything is so subjective regarding whether this was inappropriate. All staff involved did not feel it was inappropriate." S1 reported that the pediatric staff consult him/her frequently on issues. According to S1, no staff involved called regarding this issue.