HospitalInspections.org

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Based on interview, record review, and document review the facility failed to ensure patient injuries, which resulted in medical interventions, were communicated to 1 patient (#6)'s parent/guardian, out of 6 records reviewed. This failed practice denied patient's parents/guardians the right to be notified and participate in care planning. Findings:

During an interview on 6/22/20 at 2:20 am, when asked under what circumstances a parent and/or guardian would be notified of a minor patient's emergency or injury, Licensed Nurse (LN) #1 stated for an emergency, staff would first call the medical doctor. The LN stated after the situation was stabilized they would notify the patient's parent and/or guardian. When asked what types of situations would be reported, LN #1 stated if the Patient required medical treatment, parents/guardians would be contacted. The LN stated he/she would not report superficial scratches.

Based on record review on 6/22-23/20 revealed Patient #6 was admitted to the facility with diagnoses that included Post Traumatic Stress Disorder and Obsessive Compulsive disorder. The Patient's guardian was his/her biological parent.

Review of "Nurse Daily Assessment/Progress Note [s]", dated 4/12/20; 5/18/20; 5/28/20; 6/3/20; and 6/19/20 revealed the Patient #6 was at risk for self-harm (intentional injury of soft tissue) and suicidal.

4/12/20

Review of a "Nurse Daily Assessment/Progress Note", dated 4/12/20, revealed "Nurses Note ... Order of a body check this evening showed superficial excoriations bilaterally on ventral [under] side of forearms (including 'Loser' near antecubital [inner elbow] space of left arm) and small superficial excoriations bilaterally ...phalanges [fingers] ... An ISC [in-system consult] was ordered today to assess SH [self-harm] from yesterday."

Review of a "Request for In-System Consult", ordered 4/12/20, revealed "Reason for consult...: Self harm cuts ... Assessment: 1) Abrasion bilateral forearm-self-metal piece 2 ...cellulitis [skin infection] (R) knee cap 3) chapped lips. Plan: 1) Soap [with] water 2) Vaseline hydration 3) daily shower topical antibiotics do not pick scabs". The consult was signed by a provider on 4/13/20.

There was no information Patient #6's parent and/or guardian was notified of the event.

5/18/20

Review of a "Nurse Daily Assessment/Progress Note", dated 5/18/20, revealed "Nurses Note ... [Patient #6] had an in-system consult today for an abrasion on [his/her] left wrist which was done with a piece of plastic..."

Review of a "Request for In-System Consult", ordered 5/21/20, revealed "Reason for consult...: Cut wound on arm. Patient reports [he/she] used plastic found on ground and now wound ...Assessment: Abrasion left wrist-cut with plastic piece. Plan: Daily Hygiene, Topical antibiotic BID [twice daily] X [for] 5 days, do not pick scabs."

There was no information Patient #6's parent and/or guardian was notified of the event.

5/28/20

Review of a "Nurse Daily Assessment/Progress Note", dated 5/28/20, revealed "Nurses Note ...Today it was discovered that [Patient #6] self-harmed yesterday on [his/her] wrist with laminate [he/she] pulled from the cabinets. [He/she] was placed in scrubs and 1:1 observations while away until seen by a provider..."

Review of a "Request for In-System Consult", ordered 5/28/20, revealed "Reason for consult ...Assess self-inflicted forearm injury ...Assessment: Open wound/cut to left forearm self-harm 'laminate from cabinet' ...Plan: Removed gauze dressing; cleansed site, applied ...closed wound with steri-strips; and applied paper tape to ends of steri-strips for durability ..." The consultant had signed the assessment on 5/28/20.

There was no information the parent and/or guardian had been notified of Patient #6's injuries.

6/3/2020

Review of a "Nurse Daily Assessment/Progress Note", dated 6/3/2020, revealed "Nurses Note ...During hygiene [Patient #6] entered [his/her] room and banged [his/her] head three times resulting in epistaxis [bloody nose], in system neuro consult ordered and 24 hr neuro checks [assessment of head injury] initiated ..."

Review of a "Request for In-System Consult", ordered 6/3/20, revealed "Reason for consult ...Hit head on wall and nose bleed ...Assessment: Head Trauma hit head against wall 'not very hard' ...Epistaxis, after hit head against wall. Pt. reports that the night before [he/she] picked [his/her] nose and it bled ...Neuro exam: unremarkable Note: dx [diagnosis] two concussions during 1 incident, December 2019. Plan: Continue neuro checks as ordered, Declined Tylenol, or Ibuprofen at present, offer PRN [as needed] Tylenol or Ibuprofen, NS [normal saline] Nasal Spray (oceans) as ordered." The consult was signed by a provider on 6/4/20.

There was no information Patient #6's parent and/or guardian was notified of the episode on 6/3/20.

6/19/20

Review of a "Nurse Daily Assessment/Progress Note", dated 6/19/2020, revealed "Nurses Note ...In the evening [Patient #6] paced the hall, preoccupied and trying to find screws and contraband on the unit to SH with. An in system consult was requested today to visualize SH wounds allegedly from yesterday."

Review of a "Request for In-System Consult", ordered 6/19/20, revealed "Reason for consult ...Wound Assessment ...Assessment: Abrasion bilateral forearms-fingernail gouge Plan: cleanse wound, topical antibiotic oint [ointment] Q HS [bedtime] X 5 days leave wound open to air handwashing". The consult was signed by a provider on 6/20/20.

There was no information Patient #6's parent and/or guardian was notified of the wounds.

Patient #5

Review of Patient #5's record, revealed a "Request for In-System Consult", dated 6/5/20, the back of the form had the section "Guardian/Parent ...was notified regarding results of consultation. The form was signed and dated by a LN.

During an interview on 6/23/20 at 6:30 pm, when asked about parental/guardian notification after an injury or event (such has head banging). Acute Program Director #2 and LN #3 stated it depended on the injury. Parents are generally notified of head banging, wall punching, and any type of consult that requires out of facility consultation. Both staff stated the incident could be documented anywhere in the medical record or could be reviewed by the therapist during the weekly family conference (conducted by video or telephonically).

During an interview on 6/23/20 at 7:30 pm, when asked if there was a policy on what needed to be reported, LN #4 stated there used to be a booklet, but the policies had since gone online.

During an interview on 6/23/20 at 7:30 pm, Acute Program Director #1 stated she was not aware the facility had different "Request for In-System Consult" forms in different areas of the hospital. One had the section, on the back of the form, for parental/guardian notification and the other form did not.

Review of the facility policy "Department: Provision of Care Title In-System Consults", approved 01/19, revealed no information about parental/guardian notification.

Review of the "North Star Patient Rights and Responsibilities", undated, revealed "Each person in the hospital has rights (or) privileges, which include, but are not limited to the following ...24. The right to be told of an unexpected outcome."
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Based on interview, record review, and policy review, the hospital failed to fully implement procedures related to the identification, investigation, and reporting patient self-harm incidents for 1 of 1 medical record reviewed (patient #6) who had episodes of self-arming behaviors that requited in-house medical consultation and treatment. This failed practice had the potential to limit patient protection and treatment from unsafe behaviors. Findings:

During an interview on 6/22/20 at 2:10 pm, Licensed Nurse #1 stated if there was a patient injury, that required a medical intervention, facility staff would to do a HPR (Healthcare Peer Review-Incident Report).

Review of Patient #6's medical record on 6/23/20 revealed from 4/12-/19/20, the Patient had engaged in 6 separate episodes of self harming measures that had necessitated an in-house consultation and subsequent medical intervention.

Review of the quality dashboard with the Quality Improvement and Risk Manager (QI/RM), on 6/23/20 at 1:30 pm revealed the department used reports from the HPRs to calculate cases for the quality metrics. The facility monitored episodes of patient self-harm as a quality measure.

During an interview on 6/23/20 at 1:45 pm, when asked Patient #6's episodes of self harm, from 4/12/20-6/19/20 had been reported, the QI/RM stated that the department had not received any HPRs for those episodes. During the interview the QI/RM stated that a minor injury, that required medical intervention, caused by self-harm would be considered a Level II (IV being the highest).

The QI/QM stated the HPR would trigger a physician and parent guardian notification. During the interview, she stated that sometimes she sometimes received the reports of self-harm from the maintenance repair requests.

Review of "North Star New Hire Orientation", revised 03/15/17, revealed staff were to complete an HPR for a "patient injury".

Review of the "North Star Behavioral Health Patient Rights and Responsibilities", undated, revealed "Each person in the hospital has the rights (or privileges), which include but are not limited to the following...The right to a clean and safe unit and hospital..."
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