HospitalInspections.org

Based on policy review, document review, record review, hospital video recording review, and interview, the hospital failed to promote and protect all patient rights and ensure staff were trained to handle difficult patient behaviors and all patients were protected from abuse and physical harm and all patients received care in a safe setting.

The findings included:

1. The hospital failed to ensure falls were investigated and measures to prevent falls were implemented.
Refer to A144

2. The hospital failed to ensure that all patients were protected from abuse, neglect, and physical harm.
Refer to A145

3. The hospital failed to ensure staff were adequately trained and deemed competent to safely manage disruptive and assaultive behavior.

Refer to A194

Based on policy review, record review, incident report review, and interview, the hospital failed to ensure falls were investigated and measures to prevent falls were implemented for 1 of 2 (Patient #2) patients with falls.

The findings included:

1. Review of the "FALLS PRECAUTIONS & INTERVENTIONS" policy revealed, " ...The patient's have the right to a safe environment ...implement an interdisciplinary approach to fall precautions ..."

2. Medical record review revealed Patient #2 was admitted to the hospital on 10/6/17 with diagnoses of Dementia with Behaviors, Psychosis, Anxiety, and Mood Disorder.

Review of the "DAILY NURSING FLOWSHEET" dated 10/14/17, revealed Patient #2 was at a moderate fall risk. Moderate fall risk precautions included the use of a bed alarm.

3. Review of a "Critical Incident Report" dated 10/28/17 at 3:50 PM for Patient #2 revealed, " ...Injury S/P [status/post] fall ...Bed alarm did not go off ...Leadership Section: Did this Critical Incident Involve an internal/external investigation ...[internal circled] yes [checked] ..." Further review of the Critical Incident Report revealed that a nurse from the Emergency Room (ER) called the hospital and said Patient #2's nose was not broken but he did have sutures in his lip and would be returning to the hospital.

Review of a nurse's note dated 10/28/17 at 7:48 PM revealed, "...Returned from hospital...check bed alarm to ensure it was functioning...".

There were no new interventions implemented to prevent falls for Patient #2 upon his return from the ER.

There was no documentation of the internal investigation for the fall on 10/28/17 at 3:50 PM.

Review of a nurse's note dated 10/29/17 at 9:00 AM revealed, "...1st CT [computed tomography] scan done on 10/28/17 at 5:25 PM showed nasal bone fx [fracture] minimal displacement even though [named ER nurse] told me no fractures in ER report..."

In an interview, in the Chief Executive Officer's (CEO) office, on 11/15/17 at 9:51 AM, the CEO verified that bed alarm function monitoring is not documented.

4. Review of a "Critical Incident Report" dated 10/28/17 at 8:08 PM for Patient #2 revealed, "...Pt [patient] just returned to facility from hosp [hospital] s/p fall [symbol for with] stitches to lip...bed alarm sounded...found on floor @ foot of bed approximately 3 mins [minutes] [symbol for after] PCT [psychiatric care technician] left room...bleeding from nose and mouth...blood and clots...unable to stop bleeding [symbol for after]...sent to hospital per EMS [emergency medical services..."

Further review of the "Critical Incident Report" revealed, "...Leadership Section: Did this Critical Incident involve an internal [circled]/external investigation...yes [checked]...Upon investigation pt is ambulatory, Dx [diagnosis] Dementia [symbol for with] behaviors, psychosis. Pt wanders halls day and nights. PCT's were near, RN [registered nurse] responded immediately..."

In an interview, in the Chief Executive Officer's (CEO) office, on 11/15/17 at 9:52 AM, the CEO verified that the hospital was unable to provide the complete internal investigation for the fall on 10/28/17 at 8:08 PM.

5. Patient #2 did not return to the hospital and was discharged on 10/30/17.

Based on policy review, record review, hospital investigation review, hospital video recording review, and interview, the facility failed to ensure that all patients were protected from abuse, neglect and physical harm for 1 of 4 (Patient #1) sampled patients.

The findings included:

1. Review of the "ABUSE AND NEGLECT INVESTIGATION AND REPORTING" policy revealed, " ...Any suspicion of abuse or neglect shall be immediately reported to the Program Director, who will, initiate the internal investigation by conducting interviews ...review video footage ..."

2. Medical record review revealed Patient #1 was admitted to the hospital on 11/1/17 with diagnoses of Dementia with Behaviors, Hypertension, and Hyperlipidemia.

Review of the "NURSE'S PROGRESS NOTES" dated 11/2/17 at 12:05 AM revealed, " ...Pt [Patient] wandered in Rm [room] 9A and woke up pt by shaking him ...staff attempted to remove pt. from room pt. became verbally and physically aggressive and pulled away from staff and fell to the floor and hit back of head ..."

Observations of the hospital video camera footage dated 11/1/17 beginning at approximately 11:57 PM revealed, Patient #1 walked down the hallway to the exit door to the courtyard. She then turned and walked back up the hallway and entered a patient room. Psychiatric Care Technician (PCT) #1 then walked down the hall with a clipboard in her hand and entered the same patient room. There was no audio and there was no video in the patient rooms. Patient #1 and PCT #1 then re-entered the hallway struggling with each other. PCT #1 then pulled on Patient #1's arms and on both jacket sleeves as Patient #1 was attempted to get away from PCT #1. They both re-entered the patient room and when they reappeared, PCT #1 shoved Patient #1 to the floor in the hallway. Patient #1 landed on her right side with her back to the camera. PCT #2 then walked down the hall towards PCT #1 and Patient #1. PCT #1 entered the patient room again and when she came back into the hallway, she and PCT #2 walked away without checking on Patient #1. Patient #1 then got up off the floor and entered another patient room, then PCT #2 returned and Patient #1 followed her up the hall. As Patient #1 walked up the hall, she held her right hand to the right side of her head then she took her hand down and looked at it as if there was something on her hand..

3. Review of the written statement from PCT #2 dated 11/3/17 revealed, " ...I admittedly did nothing to intervene or assist the patient due to being shocked at what I just saw ...Once all was calm I verbally told the charge nurse [Registered Nurse (RN) #1] what I had seen and how it would appear once staff watched the video footage.

Review of the written statement from RN #1 dated 11/6/17 revealed, " ...PCT [named PCT #2] had told me that [named PCT #1] had walked past [named Patient #1] with her note pad as if she didn't care that she had fell ..."

4. In an interview, in the Chief Executive Officer's (CEO) office, on 11/15/17 at 11:21 AM, the CEO verified that she had been notified that Patient #1 had a fall during the night on 11/1/17. The fall was discussed in the morning meeting but the video footage was not reviewed until mid-afternoon on 11/2/17 when the Social Worker was made aware that Patient #1 did not really fall but she might have been pushed by staff. The CEO verified that video footage is not routinely reviewed for falls. The CEO verified that there is no documentation informing the physician that Patient #1 was involved in an altercation with a staff member.

Based on policy review, medical record review, hospital video recording review, personnel file review, and interview, the hospital failed to ensure 1 of 42 (Psychiatric Care Technician (PCT) #1) staff were adequately trained and deemed competent to safely manage disruptive and assaultive behavior.

The findings included:

1. Review of the "RESTRAINT USE" policy revealed, " ...All patients have the right to be free from physical or mental abuse ...have the right to be free from restraint, of any form ...Implements restraints using hospital authorized and approved techniques for physical holding ..."

2. Medical record review revealed Patient #1 was admitted to the hospital on 11/1/17 with diagnoses of Dementia with Behaviors, Hypertension, and Hyperlipidemia. Review of the "NURSE'S PROGRESS NOTES" dated 11/2/17 at 12:05 AM revealed, " ...Pt [Patient] wandered in Rm [room] 9A and woke up pt by shaking him ...staff attempted to remove pt. from room pt. became verbally and physically aggressive and pulled away from staff and fell to the floor and hit back of head ..."

3. Review of the hospital investigation revealed, " ...Upon investigation of fall incident: At 3:30 PM on 11/2/17 ...were notified that there was "more to the fall than what had been originally report"[reported]...the camera footage ...inappropriately placing patient ...in a physical hold and pulling patient out of another patient's room by her clothing ...mishandled the patient physically ..."

4. Observations of the hospital video camera footage dated 11/1/17 beginning at approximately 11:57 PM revealed, Patient #1 walked down the hallway to the exit door to the courtyard. She then turned and walked back up the hallway and entered a patient room. Psychiatric Care Technician (PCT) #1 then walked down the hall with a clipboard in her hand and entered the same patient room. There was no audio and there was no video in the patient rooms. Patient #1 and PCT #1 then re-entered the hallway struggling with each other. PCT #1 pulled on Patient #1's arms and on both jacket sleeves as Patient #1 attempted to get away from PCT #1. They both re-entered the patient room and when they reappeared, PCT #1 shoved Patient #1 to the floor in the hallway. Patient #1 landed on her right side with her back to the camera. PCT #2 was then seen walking down the hall towards PCT #1 and Patient #1. PCT #1 entered the patient room again and when she came back into the hallway, she and PCT #2 walked away without checking on Patient #1. Patient #1 then got up off the floor and entered another patient room, then PCT #2 returned and Patient #1 followed her up the hall. As Patient #1 walked up hall, she was held her right hand to the right side of her head then she took her hand down and looked at it as if there was something on her hand..

5. There was no documentation that PCT #1 had been trained in Nonviolent Crisis Intervention (CPI).

6. In an interview, in the Chief Executive Officer's (CEO) office, on 11/13/17 at 11:18 AM, the CEO verified that staff are required to be trained in CPI and that PCT #1 had not been trained.

7. In a telephone interview on 11/16/17 at 9:44 AM, PCT #1 verified that she had worked at the hospital 5 months and had not been trained in CPI.