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Tag No.: A0115
The Condition of Participation for Patient Rights has not been met.
1. For one of three sampled patients reviewed for neglect (Patient #42), the hospital failed to ensure the Nursing Supervisor and Physician were notified of the patient's behavior that spanned over multiple hours, which resulted in significant injuries to both legs and the patient required surgery. The hospital also failed to ensure that a staff member placed on administrative leave during an investigation was removed from patient care.
2. For one of three patients sampled for alleged mistreatment from staff (Patient #44) the hospital failed to ensure the patient was provided with care in a dignified manner.
Please see A145
Tag No.: A0145
Based on clinical record review, staff interviews, review of hospital documentation, and interviews, for one of three sampled patients reviewed for neglect, the hospital failed to ensure the Nursing Supervisor and Physician were notified of the patient's behavior that spanned over multiple hours, which resulted in significant injuries to both legs and the patient required surgery. The hospital also failed to ensure that a staff member placed on administrative leave during an investigation was removed from patient care. The finding includes:
Patient #42 presented at the Emergency Department (ED) on 1/18/21 with delusions, hallucinations, altered mental status, insomnia and paranoia and was admitted to the behavioral health unit. Further review of the admitting History and Physical (H&P) dated 1/18/21 identified that the patient had been in the ED three previous times within a week for sleep deprivation, confusion, delusions, combativeness, aggression and severe agitation.
Nurse's notes dated 1/26/21 at 6:27 PM identified that Patient #42 was thought blocking, confused and intrusive, refused 5:00 PM Propanolol and all nighttime (HS) medications. The note identifed the patient repeatedly pressed the end button on the phone, and refused dinner and snack.
Review of a safety check sheet dated 1/27/21 at 6:00 PM through 1/28/21 at 7:00 AM (13 hours) identified Patient #42's location every 15 minutes was in the bathroom.
Nurse's notes dated 1/27/21 at 5:02 AM identified that Patient #42 was very anxious, agitated, paranoid and crawling on the floor. MD was made aware of behaviors and ordered Haldol 2.5 milligrams (mg) intramuscular (IM), Ativan 1 mg IM, and 1 mg of Cogentin IM. Medications were administered and the patient continued to be very anxious and agitated. The MD was updated and ordered Ativan 1 mg IM and the patient was assisted to bed.
Nurse's notes dated 1/29/21 at 2:00 PM (an addendum note for 1/27/21) identified at 9:40 PM the nurse checked on Patient #42 who was in the bathroom shower, sitting on a bench, calm and diaphoretic. The note identified help was offered but the patient refused. The note identified at approximately 11:18 PM a recheck was done and the patient was not diaphoretic, was half kneeling on a pillow on the floor, shirt was off, and accepted a water pitcher from the nurse. The note identified that the patient was encouraged to get into bed but the patient refused.
Nurse's notes dated 1/27/21 at 11:19 PM identified Patient #42 stayed in room most of shift, was extremely paranoid and thought blocking, not really talking, refused all medications, care, vital signs, food and assessments. The note further identified the patient was half kneeling on a pillow on the shower floors in the patient's room, naked. Additionally, the note identified a pitcher of water was provided, encouraged to get out of shower and into bed, help offered and was refused. The patient remained on the shower floor, positioned on pillow. The note lacked documentation that the patient was assessed or that the RN Supervisor or MD was made aware of the behaviors and refusals for care.
Nurse's notes dated 1/28/21 at 6:35 AM identified that Patient #42 spent the whole night on the bathroom floor positioned on pillow, patient refused to get out of bathroom, behavior continues to be bizarre, refusing to leave bathroom despite several requests and interactions. The note further identified no safety concerns during shift. The note lacked documentation that the patient was assessed or that the RN Supervisor or MD was made aware.
Nurse's notes authored by RN #7, dated 1/29/21 at 1:06 PM (addendum note for night of 1/27/21) identified that at 12:30 AM, Patient #42 was noted on the shower floor, in a kneeling position with a pillow under the legs. The patient was then noted to stand for approximately 5 minutes then sat on toilet, privacy was provided. At 1:30 AM (One hour later) the patient was still on the toilet. The writer asked the patient if he/she was finished and was told "wait", the nurse left the room. At 2:15 AM the patient was found on the shower floor in the same kneeling position as earlier in the shift. Nurse's note identified that the nurse discussed the importance of getting sleep, encouraged to go back to bed but the patient remained in the shower. Between 3:00 AM and 4:00 AM the note identified the nurse checked on the patient and was still on the shower floor in a kneeling position with a pillow underneath, the patient was encouraged to go to bed but refused. At 5:00 AM the patient was observed in the shower on the floor, was calm, encouraged to go to bed and refused. At 6:00 AM there was no change in assessment. At 7:00 AM the nurse's note identified being called to patient's room by NA to assist with getting patient out of bathroom, had difficulty standing and required the assistance of 2 people. The note identified the patient's bilateral feet were discolored, pale and blueish. The patient was assisted back to bed, a set of vital signs were taken and report was given to the oncoming nurse.
RN #7 neglected to assess the patient's legs during the time the patient remained in the kneeling position for most of the shift, failed to notifiy the RN Supervisor and/or MD that the patient refused direction, care, and remained in the kneeling position on the floor for most of the 11:00 PM to 7:00 AM shift.
Review of the clinical record dated 1/28/21 at 12:40 PM noted that during rounds around 8:30 AM, Patient #42 appeared to be severely dehydrated, with weakness and cold and clammy skin. The patients blood glucose was 204, blood pressure 100/53 and heart rate 124 with sinus tachycardia on a STAT EKG. The note identified the Hospitalist was notified at 8:47 AM and was at the patient's bedside immediately.
Review of the Hospitalist H&P dated 1/28/21 at 1:02 PM identified that Patient #42 was sitting in the bathroom for a prolonged period of time refusing to come out. The note identified this morning the patient was slightly lethargic and had swollen legs as well as decreased perfusion to the feet. The note identified extreme swelling of the bilateral legs with diminished perfusion to the feet. The patient appeared confused, answered questions, appeared to be quite weak, and the neurological exam was non-focal. Blood tests were run and identified severe Rhabdomyolysis with hyperkalemia and acute kidney injury as well as an elevated D-dimer. The patient was transferred to the ICU and started on IV fluids, received Kayexalate and underwent several radiological studies including a chest x-ray and arterial venous dopplers. The H&P note further identified edema, tight calves, patchy areas of skin ecchymosis, and cooler feet. Additionally, the note identified venous doppler was not able to notice any flow in the veins below the knees.
Interview with MD #2 on 8/9/21 at 11:45 AM stated that he was made aware of what happened that morning and went to see the patient. MD #2 stated that Patient #42 had diminished pulses, pain in bilateral legs and the patient could not move the legs, and MD # 2 stated that he called for a consult. MD #2 stated that it was not okay to leave a patient on a hard surface and he wished she (the nurse) had called someone.
Interview with MD #3 on 8/10/21 at 10:09 AM stated that he was called to the behavioral health unit to assess Patient #42. MD #3 stated that it was reported to him that the patient was sitting on the floor and toilet for long periods of time. MD #3 stated he assessed the patient and noted the patient had swollen legs, decreased perfusion to the feet, was confused and weak. MD #3 stated that he ordered lab work and it was determined the patient had rhabdomylosis, hyperkalemia and acute kidney injury and was transferred to the ICU. MD #3 stated that being in the same position for long periods of time could have cause the Rhabdomylosis.
Review of a Vascular consultation note dated 1/28/21 at 3:34 PM noted Patient #42 had tingling to the bottom of bilateral feet, pain in the lower extremities below each knee and (patient) states cannot move either lower extremity below the knee. The note further identified the patient would be taken to the operating room (OR) for bilateral fasciotomy this evening.
Interview with the Director of Behavioral Health/Associate Chief Nursing Officer, on 8/9/21 at 11:00 AM stated that she was made aware of the incident with Patient #42 immediately after it occurred and a full investigation was implemented. The Director stated that RN #7 was placed on administrative leave while the investigation was conducted. The Director stated that the clinical record was reviewed and was noted that no assessments were conducted on the patient by the RN's for 11 hours, there were no steps taken to get the patient out of the bathroom like calling an Early Response Team or a "Dr. Strong code", and the RN Supervisor or MD on call was not notified of what was going on with the patient. The Director stated that if the nurse was assessing the patient throughout the night while in the bathroom then it would be okay for the patient to remain in the bathroom. The Director further stated that RN #7 was terminated after the investigation was concluded.
Interview with APRN #1 on 8/9/21 at 11:50 AM stated that when she came in on the morning of 1/28/21, she pulled Patient #42's chart and identified the patient had spent the night in the bathroom. APRN #1 stated she went to assess the patient and observed the patient in bed, weak, looked dehydrated and was cold. APRN #1 stated that she asked MD #2 to come assess the patient and it was at that time they called for a medical MD. The APRN stated that prior to this incident, the patient would be walking in the halls but started with some bizarre behaviors like crawling on the floor and refusing medications, and the behavior of being in a closed space was not normal for the patient. APRN #1 stated that she would have expected nursing staff to reach out to the on-call MD to inform them of the behaviors.
Interview with RN #8 on 8/9/21 at 1:05 PM stated that on 1/27/21 Patient #42 had increased paranoia and that it was not reported to her that the patient was staying in the bathroom until 9:40 PM. RN #8 stated that when she saw the patient, the patient was standing, then sat down. RN #8 stated that she brought the patient a pitcher of water, helped the patient dress and was able to bring the patient out of the bathroom at that time. RN #8 stated that she again checked on the patient around 10:15 PM and the patient was again in the bathroom kneeling/sitting on a pillow with the legs half tucked under the buttocks. RN #8 stated that she reported off to the oncoming shift that the patient was in the bathroom, most of the shift and that the patient was kneeling on a pillow.
Interview with NA #1 on 8/9/21 at 1:50 PM stated that when he came in on 1/28/21 at 7:00 AM he made rounds on the patients and saw that Patient #42 was in the bathroom in the shower area sitting on his/her legs directly on the floor of the shower. NA #1 stated that he spoke to the patient and the patient opened their eyes but did not respond so he called for a nurse. NA #1 stated that the 11:00-7:00 shift nurse (RN #7) and another staff member came to the bathroom. NA #1 stated that the patient could not stand on their own, and he observed the patients legs and they were very gray in color and cold to touch. NA #1 stated that he and the other staff lifted the patient up by under the arms and legs and transferred him/her into the bed. NA #1 stated that he only observed the RN (RN #7) ask for staff to get vital signs.
Interview with NA #2 on 8/10/21 at 10:20 AM stated when she came in around 6:00 PM on 1/27/21 she was assigned to do safety checks every fifteen minutes on the patients and when she saw Patient #42, the patient was more quiet than usual. NA #2 stated that she reported to the charge nurse (RN # 8) that the patient was in the bathroom and would not come out and was told by the nurse she would talk to the patient. NA #2 stated that throughout her shift the patient kept going in and out of the bathroom and that she reported this to the oncoming staff.
Interview with NA #3 on 8/11/21 at 7:45 AM stated that when she came in on 1/27/21 at 11:00 PM she saw Patient #42 in the bathroom with her legs bent to the side and with buttocks on a pillow. NA #3 stated she was able to get the patient out of the bathroom around 2:15 AM, but at 2:45 AM the patient was back in the bathroom for the rest of her shift, legs bent to side and buttocks on a pillow. NA #3 stated that she reported this to RN #7 and she recalls that the nurse came to the room, but can't recall how many times. NA #3 stated that when the day shift came in she assisted getting the patient out of the bathroom because the patient could not stand/walk.
Interview with RN Manager #3 on 8/11/21 at 2:00 PM stated that after he found out that Patient #42 was transferred to the ICU he began investigating what happened. RN Manager #3 stated that he identified that the patient was in the bathroom from approximately 2:15 AM until 7:00 AM when the day shift arrived and the patient was unable to stand and walk. Nurse Manager #3 stated that he reviewed the clinical record and identified that RN #7 did not assess the patient throughout the night or notify the RN Supervisor or MD on-call regarding the patients behavior. The Nurse Manager stated he spoke to the Chief Nursing Officer at the time of the incident and RN #7 was placed on administrative leave pending investigation.
Nurse Manager #3 stated that RN #7 was crossed off the schedule and told not to report to work. Nurse Manager #3 stated that he did not communicate with the weekend supervisor that RN #7 was placed on administrative leave pending an investigation. Review of RN #7's time sheet punches on 8/11/21 with a Human Resources Representstive identified that RN #7 worked on 1/29/21 and 1/30/21 on the 11-7 shift. Nurse Manager #3 stated that he was not aware that RN #7 worked after she was put on administrative leave until today (8/11/21) when it was identified by the surveyor. Manager #3 identified that RN #7 should not have worked while on administrative leave.
Several attempts were made to contact RN #7 but were unsuccessful.
The hospital implimented an immediate action plan that included staff education on patient behaviors, conducting assessments, initiating interventions, and notification to the supervisor and/or physician. RN #7 was placed on administrative leave and then terminated. Leadership reviewed and initiated a check list for any employee on administrative leave.
16648
Based on review of the clinical record, review of hospital documentation, interviews, and the hospital's code of conduct, for one of three patients sampled for alleged mistreatment from staff (Patient #44) the hospital failed to ensure the patient was provided with care in a dignified manner. The finding includes:
Patient #44 was admitted to the hospital from home on 4/8/2021 due to alcohol withdrawal and observed seizures. The admission History and Physical identified Patient #44 reported anxiety, depression, was alert and oriented.
Interview and review of grievance documentation with the Director of Patient Experience on 8/10/2021 at 10:30 AM identified Patient #44 reported to the unit charge nurse that NA #4 was rude and had provided poor care. The unit Manager was notified and initiated an investigation.
The investigation identified that on 4/14/2021, Patient #44 called for assistance to the bathroom and on two occasions was incontinent of bladder as a result of the delay in staff response to the calls. NA #4 entered the patient's room after each occasion and was angry and rude to the Patient because she had to change the bedding. Patient #44 called for assistance a third time, had to wait and was incontinent again. NA #4 entered the room, scolded the patient for wetting the bed, roughly removed the soiled bedding and the patient's hospital gown. NA #4 left the Patient naked in the bed stating he/she would have to wait for a hospital gown because the NA was busy. While reporting the incident, Patient #44 was anxious, crying and felt afraid.
NA #4 was immediately removed from the unit and placed on administrative leave pending the conclusion of the investigation.
In an interview on 8/10/2021 at 1:00 PM, Nurse Manager #10 indicated that NA #4 received written disciplinary action for not providing care in accordance with Patient Rights and the hospitals Code of Conduct. Before returning to work, NA#4 was provided with education and had supervision on the unit once she returned.
The Hospital's Code of Conduct directs staff to to deliver patient care that is safe, efficient, and effective. The hospital's main concern is the well being, comfort and dignity of all Patients. All Patients have the right to receive care that is without abuse, neglect, or intimidation.
Tag No.: A0385
The Condition of Participation for Nursing Services has not been met.
1. The hospital failed to ensure the Nursing Supervisor and Physician were notified of the patient's behavior that spanned over multiple hours, which resulted in significant injuries to both legs and the patient required surgery. Refer to A395
2. The hospital failed to revise the plan of care after one patient (#42) was exhibiting behaviors that resulted in harm to the patient. Refer to A396
Tag No.: A0395
Based on clinical record review, review of hospital documentation, and staff interviews, for one of three sampled patients reviewed for behaviors (Patient #42), the hospital failed to ensure nursing staff notified the Nursing Supervisor and physician when the patient displayed ongoing behaviors, refused care, refused medications, and was not directable. The hospital faied to ensure the patient was asessed when noted to remain seated on the floor for several hours resulting in bilateral leg injuries. The finding includes:
Patient #42 presented at the Emergency Department (ED) on 1/18/21 with delusions, hallucinations, altered mental status, insomnia and paranoia and was admitted to the behavioral health unit. Further review of the admitting History and Physical (H&P) dated 1/18/21 identified that the patient had been in the ED three previous times within a week for sleep deprivation, confusion, delusions, combativeness, aggression and severe agitation.
Nurse's notes dated 1/26/21 at 6:27 PM identified that Patient #42 was thought blocking, confused and intrusive, refused 5:00 PM Propanolol and all nighttime (HS) medications. The note identifed the patient repeatedly pressed the end button on the phone, and refused dinner and snack.
Review of a safety check sheet dated 1/27/21 at 6:00 PM through 1/28/21 at 7:00 AM (13 hours) identified Patient #42's location every 15 minutes was in the bathroom.
Nurse's notes dated 1/27/21 at 5:02 AM, Patient #42 was very anxious, agitated, paranoid and crawling on the floor. MD was made aware of behaviors and ordered Haldol 2.5 milligrams (mg) intramuscular (IM), Ativan 1 mg IM, and 1 mg of Cogentin IM. Medications were administered and the patient continued to be very anxious and agitated. The MD was updated, Ativan 1 mg IM was ordered and administered, the patient was assisted back to bed.
Nurse's notes dated 1/29/21 at 2:00 PM (an addendum note for 1/27/21) identified at 9:40 PM the nurse checked on Patient #42 who was in the bathroom shower, sitting on a bench, calm and diaphoretic. The note identified help was offered but the patient refused. The note identified at approximately 11:18 PM a recheck was done and the patient was not diaphoretic, was half kneeling on a pillow on the floor, shirt was off and accepted a water pitcher from the nurse. The note identified that the patient was encouraged to get into bed but the patient refused.
Nurse's notes dated 1/27/21 at 11:19 PM identified Patient #42 stayed in room most of shift, was extremely paranoid and thought blocking, not really talking, refused all medications, care, vital signs, food and assessments. The note further identified the patient was sitting in the shower in the patient's room, naked and half kneeling on a pillow on the floor. Additionally, the note identified a pitcher of water was provided, encouraged to get out of shower and into bed, help offered and was refused. The patient remained on the shower floor, positioned on pillow. The note lacked documentation that the patient was assessed or that the RN Supervisor or MD was made aware of the behaviors and refusals for care.
Nurse's notes dated 1/28/21 at 6:35 AM identified that Patient #42 spent the whole night on the bathroom floor positioning self on pillow, patient refused to get out of bathroom, behavior continues to be bizarre, refusing to leave bathroom despite several requests and interactions. The note further identified no safety concerns during shift. The note lacked documentation that the patient was assessed or that the RN Supervisor or MD was made aware.
Nurse's notes authored by RN #7 dated 1/29/21 at 1:06 PM (addendum note for night of 1/27/21) identified that at 12:30 AM, Patient #42 was noted on the shower floor, in a kneeling position with a pillow under the legs. The patient was then noted to stand for approximately 5 minutes then sat on toilet, privacy was provided. At 1:30 AM (one hour later) the patient was still on the toilet. The writer asked the patient if he/she was finished and was told "wait", the nurse left the room. At 2:15 AM the patient was found on the shower floor in the same kneeling position as earlier in the shift. Nurse's note identified that the nurse discussed the importance of getting sleep, encouraged to go back to bed but the patient remained in the shower. Between 3:00 AM and 4:00 AM the note identified the nurse checked on the patient and was still on the shower floor in a kneeling position with a pillow underneath, the patient was encouraged to go to bed but refused. At 5:00 AM the patient was observed in the shower on the floor, was calm, encouraged to go to bed and refused. The nurses note identified at 6:00 AM there was no change in assessment. At 7:00 AM the nurse's note identified being called to patient's room by a NA to assist with getting patient out of bathroom, had difficulty standing and required the assistance of 2 people. The note identified the patient's bilateral feet were discolored, pale and blueish. The patient was assisted back to bed, a set of vital signs were taken and report was given to the oncoming nurse.
RN #7 neglected to assess the patient's legs during the time the patient remained on the floor in the kneeling position for most of the shift and failed to notifiy the RN Supervisor and/or MD that the patient refused direction, care, and remained in the kneeling position on the floor for most of the 11:00 PM to 7:00 AM shift.
Review of the clinical record dated 1/28/21 at 12:40 PM noted that during rounds around 8:30 AM, Patient #42 appeared to be severely dehydrated, with weakness and cold and clammy skin. The patients blood glucose was 204, blood pressure 100/53 and heart rate 124 with sinus tachycardia on a STAT EKG. The note identified the Hospitalist was notified at 8:47 AM and was at the patient's bedside immediately.
Review of the Hospitalist H&P dated 1/28/21 at 1:02 PM identified that Patient #42 was sitting in the bathroom for a prolonged period of time refusing to come out. The note identified this morning the patient was slightly lethargic and had swollen legs as well as decreased perfusion to the feet. The note identified extreme swelling of the bilateral legs with diminished perfusion to the feet. The patient appeared confused, answered questions, appeared to be quite weak, and the neurological exam was non-focal. Blood tests were run and identified severe Rhabdomyolysis with hyperkalemia and acute kidney injury as well as an elevated D-dimer. The patient was transferred to the ICU and started on IV fluids, received Kayexalate and underwent several radiological studies including a chest x-ray and arterial venous dopplers. The H&P note further identified edema, tight calves, patchy areas of skin ecchymosis, and cooler feet. Additionally, the note identified venous doppler was not able to notice any flow in the veins below the knees.
Review of a Vascular consultation note dated 1/28/21 at 3:34 PM noted Patient #42 had tingling to the bottom of bilateral feet, pain in the lower extremities below each knee and (patient) states cannot move either lower extremity below the knee. The note further identified the patient was taken to the operating room (OR) for bilateral fasciotomy.
Interview with the Director of Behavioral Health/Associate Chief Nursing Officer on 8/9/21 at 11:00 AM stated that she was made aware of the incident with Patient #42 immediately after it occurred and a full investigation was implemented. The Director stated that RN #7 was placed on administrative leave while the investigation was conducted. The Director stated that the clinical record was reviewed and was noted that no assessments were conducted on the patient by the RN's for 11 hours, there were no steps taken to get the patient out of the bathroom like calling an Early Response Team or a "Dr. Strong code", and the RN Supervisor or MD on call was not notified of what was going on with the patient. The Director stated that if the nurse was assessing the patient throughout the night while in the bathroom then it would be okay for the patient to remain in the bathroom. The Director further stated that RN #7 was terminated after the investigation was concluded.
Interview with MD #2 on 8/9/21 at 11:45 AM stated that he was made aware of what happened that morning and went to see the patient. MD #2 stated that Patient #42 had diminished pulses, pain in bilateral legs and the patient could not move the legs, and MD # 2 stated that he called for a consult. MD #2 stated that it was not okay to leave a patient on a hard surface and he wished she (the nurse) had called someone.
Interview with APRN #1 on 8/9/21 at 11:50 AM stated that when she came in on the morning of 1/28/21, she pulled Patient #42's chart and identified the patient had spent the night in the bathroom. APRN #1 stated she went to assess the patient and observed the patient in bed, weak, looked dehydrated and was cold. APRN #1 stated that she asked MD #2 to come assess the patient and it was at that time they called for a medical MD. The APRN stated that prior to this incident, the patient would be walking in the halls but started with some bizarre behaviors like crawling on the floor and refusing medications, and the behavior of being in a closed space was not normal for the patient. APRN #1 stated that she would have expected nursing staff to reach out to the on-call MD to inform them of the behaviors.
Interview with RN #8 on 8/9/21 at 1:05 PM stated that on 1/27/21 Patient #42 had increased paranoia and that it was not reported to her that the patient was staying in the bathroom until 9:40 PM. RN #8 stated that when she saw the patient, the patient was standing, then sat down. RN #8 stated that she brought the patient a pitcher of water, helped the patient dress and was able to bring the patient out of the bathroom at that time. RN #8 stated that she again checked on the patient around 10:15 PM and the patient was again in the bathroom kneeling/sitting on a pillow with the legs half tucked under the buttocks. RN #8 stated that she reported off to the oncoming shift that the patient was in the bathroom, but not that she had been in and out of there most of the shift or that she was kneeling on a pillow.
Interview with NA #1 on 8/9/21 at 1:50 PM stated that when he came in on 1/28/21 at 7:00 AM he made rounds on the patients and saw that Patient #42 was in the bathroom in the shower area sitting on his/her legs directly on the floor of the shower. NA #1 stated that he spoke to the patient and the patient opened their eyes but did not respond so he called for a nurse. NA #1 stated that the 11:00-7:00 shift nurse (RN #7) and another staff member came to the bathroom. NA #1 stated that the patient could not stand on their own, and he observed the patients legs and they were very gray in color and cold to touch. NA #1 stated that he and the other staff lifted the patient up by under the arms and legs and transferred him/her into the bed. NA #1 stated that he only observed the RN (RN #7) ask for staff to get vital signs.
Interview with MD #3 on 8/10/21 at 10:09 AM stated that he was called to the behavioral health unit to assess Patient #42. MD #3 stated that it was reported to him that the patient was sitting on the floor and toilet for long period of time. MD #3 stated he assessed the patient and noted the patient had swollen legs, decreased perfusion to the feet, was confused and weak. MD #3 stated that he ordered lab work and it was determined the patient had rhabdomylosis, hyperkalemia and acute kidney injury and was transferred to the ICU. MD #3 stated that being in the same position for long periods of time could have cause the Rhabdomylosis.
Interview with NA #2 on 8/10/21 at 10:20 AM stated when she came in around 6:00 PM on 1/27/21 she was assigned to do safety checks every fifteen minutes on the patients and when she saw Patient #42, the patient was more quiet than usual. NA #2 stated that she reported to the charge nurse (RN # 8) that the patient was in the bathroom and would not come out and was told by the nurse she would talk to the patient. NA #2 stated that throughout her shift the patient kept going in and out of the bathroom and that she reported this to the oncoming staff.
Interview with NA #3 on 8/11/21 at 7:45 AM stated that when she came in on 1/27/21 at 11:00 PM she saw Patient #42 in the bathroom with her legs bent to the side and with buttocks on a pillow. NA #3 stated she was able to get the patient out of the bathroom around 2:15 AM, but at 2:45 AM the patient was back in the bathroom for the rest of her shift, seated on the floor, legs bent to side and buttocks on a pillow. NA #3 stated that she reported this to RN #7 and she recalls that the nurse came to the room, but can't recall how many times. NA #3 stated that when the day shift came in she assisted getting the patient out of the bathroom because the patient could not stand/walk.
Interview with RN Manager #3 on 8/11/21 at 2:00 PM stated that after he found out that Patient #42 was transferred to the ICU he began investigating what happened. RN Manager #3 stated that he identified that the patient was in the bathroom from approximately 2:15 AM until 7:00 AM when the day shift arrived and the patient was unable to stand and walk. Nurse Manager #3 stated that he reviewed the clinical record and identified that RN #7 did not assess the patient throughout the night or notify the RN Supervisor or MD on-call regarding the patients behavior. The Nurse Manager stated he spoke to the Chief Nursing Officer at the time of the incident and RN #7 was placed on administrative leave pending investigation.
Several attempts were made to contact RN #7 but were unsuccessful.
Tag No.: A0396
Based on clinical record review and staff interview for 1 of 3 sampled patients who exhibited behaviors (Patient #42), the hospital failed to revise the plan of care after the patient was exhibiting behaviors. The finding includes:
Patient #42 presented at the Emergency Department (ED) on 1/18/21 with delusions, hallucinations, altered mental status, insomnia and paranoia and was admitted to the behavioral health unit. Further review of the admitting History and Physical (H&P) dated 1/18/21 identified that the patient had been in the ED three previous times within a week for sleep deprivation, confusion, delusions, combativeness, aggression and severe agitation.
Review of the treatment plan dated 1/18/21 identified acute/chronic confusion with interventions that included to use treatment groups to learn effective communication skills, cooperate with treatment plan including milieu groups and activities and identify/practice healthy constructive coping skills.
Nurse's notes dated 1/26/21 at 6:27 PM identified Patient #42 was thought blocking, confused and intrusive, refused 5:00 PM Propanolol and all nighttime (HS) medications. The note identifed the patient repeatedly pressed the end button on phone, and refused dinner and snack.
Nurse's notes dated 1/27/21 at 5:02 AM identified Patient #42 was very anxious, agitated, hallucinating, paranoid and crawling on floor with blue bed pad, unable to follow directions and refused help. MD was made aware of behaviors and ordered Haldol 2.5 mg IM, Ativan 1 mg IM and 1 mg of Cogentin IM. Medications were administered and the patient continued to be very anxious and agitated. The MD was updated and ordered Ativan 1 mg IM and the patient was assisted to bed.
The treatment plan failed to identify nursing interventions for exhibited behaviors of crawling on the floor on 1/27/21.
Review of the clinical record on 8/13/21 with the Quality Improvement Manager identified the treatment plan should have been updated after the patient was exhibiting new behaviors.