HospitalInspections.org

Based on observation, interview and record review, the facility failed to ensure the provision of care in a safe setting by preventing an assault of one mentally impaired patient by another mentally impaired patient within the Behavioral Health department for 2 of 5 sampled patients (#1 & 2).

Findings:

A review of the medical record of patient #1 was performed. The patient was admitted to the ILOC (Intensive Level of Care) unit of the Behavioral Health department on 2/13/10 after s/he had ingested nails. There was no evidence in the record of any propensity towards a violence or aggression to others, either prior to admission or, while a patient, prior to 3/25/10.

A review of the medical record of patient #2 was performed. S/he was seen by a physician in the ER (Emergency Room) on 3/25/10 at 1:34 PM. A Baker Act was initiated in the ER by the ER physician. The Admitting diagnosis was stated as: "Psychotic D/O NOS." Behavioral unit admission orders for the ILOC were issued at 3:30 PM.

A review of staffing on the ILOC unit for the evening of 3/25/10 revealed that on the 3-7 PM shift there were one registered nurse (RN) and two mental health technicians (MHTs).

Patient #2 arrived on the unit at 6:15 PM on 3/25/10. A review of the "15 Minute Observation Check Sheet" revealed that patient #2 was in the Activity Room from 6:45-9 PM on 3/25/10. Except for the first 45 minutes, all of the location notations during this time frame were made by one of the mental health techs. A nurse's note of 3/25/10 at 7:33 PM read, "15 minute safety checks initiated . . . ."

Observation revealed that the unit consisted of a single hallway, separated from the remainder of the Behavioral Health department by two doors which required employee badges to open. Near the distal end of the unit was an activity room on one side of the hall. On the other side of the hall, across from the activity room, was the nurse's station and an adjacent supply room which held patient care supplies. Patient rooms were on either side of the hall, more proximal to the door that the nurse's station and activity room. It was observed that access to a coffee machine would require a person to go through these doors and swipe their badges.

A nurse's note on 3/25/10 at 10:41 PM by the unit's RN read, "Patient was separated from another peer tonight. The peers stated that this patient had reached out and grabbed his/her hair unprovacatively. Patient was asked to explain what happened that led to the incident, but [s/he] smiled and was saying things unrelated to the incident and pointing at other patients. [S/he] was observed to have a skin tear on both hands with bright red blood. [His/her] hands were cleaned with normal saline and covered with Tegaderm. Other peers stated that [s/he] might have hit this patient on the head. Patient was checked for bruises and contusions and none was observed. [S/he] denies any pain of discomfort even to touch. There were no other bruises or noted except for the skin tear. Vital signs were: BP (blood pressure)140/70 mmgh, P (pulse): 66; R (respirations): 18; T (temperature): 98.2. Will continue observations."

A review of a written statement which had been written by this nurse on 3/25/10, obtained by the Department of Children and Families (DCF) and forwarded to AHCA (Agency for HealthCare Administration) revealed the following: "Writer heard a call out of the activity room and quickly exited the nursing station into the activity room. I observed the patient (#2) sitting and patient (#1) standing against [him/her] and both (patients') hands waving in the air in a defensive maneuvers. Writer took the risk of getting in between both (patients), without any backing, as I observed I was the only staff there, to safely separate both patients. Patient (#1) was asked what happened, [s/he] said patient (#2) reached out and grabbed [his/her] hair. [S/he] said [s/he] hit [him/her] on the head, and later said [s/he] may have also hit the wall or the chair, trying to release from [his/her] hold . . . .Patient (#2) was asked what happened, [s/he] smiled and said things unrelated to incident and was pointing at other patients . . . .[Patient] (#2's) skin tear on both hands bled minimally and was cleansed and covered with Tegaderm . . . .Patient (#1's) hand (right knuckle) was swollen and bruised, and [s/he] was given ice pack and encouraged to calm down." The swollen right hand of patient #1 was evidence that the patient's right hand had impacted with something.

An interview of the RN was conducted on 4/13/10 at 1:28 PM. She stated that the approximate time of the incident was at 8:35 PM.

A review of a written statement which had been written by "B" MHT on 3/27/10, obtained by the DCF and forwarded to AHCA revealed the following: "Around 8 PM or 8:15 PM all the pt (patients) were eating snack and asked for coffee so I went told (the nurse) & (MHT) "A" I was going to ... to get a pot of coffee. When I walked back on the unit 5 min later (patient #1) was walking down the hall [his/her] hair was all messed up. [S/he] told me that (patient #2) had pulled [his/her] hair and yanked [him/her] out of the chair and that [s/he] punched (patient #2) in the head in self-defense. (Patient #1's) hand (right) was swollen and bruised."

An interview was conducted with MHT "B" on 4/12/10 at 10:05 AM. Regarding the statement of her having left the unit to get coffee, she confirmed this. She said she was off the unit for a time period of approximately two minutes or less. As for the veracity of the written statement which AHCA received from DCF, she confirmed it.

An interview was conducted with MHT "A" on 4/12/10 at 3:39 PM. His account of the incident is as follows. He said that at approximately 8-8:15 PM (later text reveals this to be an error, off by fifteen minutes), she notified the nurse that he was preparing to go on break by going into the supply room, where his locker was. He had told the nurse in the nurse's station that he was planning on going and she said "OK". The door was closed while he was in there. He then heard the nurse call for him, due to the incident. He was in the supply room for no more than three minutes. When he came out, he noticed the nurse was with (patient #2) in the hallway and that (patient #1) was in the activity room, but soon exited it.

A nurse's note regarding patient #2 at 12 AM on 3/26/10, entered at 1:08 AM on 3/26/10 read, "Up in [his/her] room. Confused and disoriented. Patient states 'I took a beating in my face' and initially reports facial discomfort, then almost immediately denies it."

A request was made for any computerized data created by employee badge swipes at the entrance to the unit surrounding the reported time of the incident. This request was made to ascertain who entered and exited the unit near the time of the incident and the times of such movement. The results revealed that MHT "B" had left the unit at 8:26 PM and returned at 8:28 PM. This corresponded to the reported time of the incident. Therefore, the incident between patients #1" and "2" took place at some point during the two minute absence of MHT "B".

Both patients #1 and #2 asserted that patient #2 had been hit in the head on 3/25/10.