HospitalInspections.org

Based on observation, interview, and record review, the facility failed to protect patient rights for a safe environment for 2 (#1, 2) of 10 patients and failed to renew restraint orders every four hours for 1 (#2) of 2 patients, resulting in the potential for harm to all patients.
Findings include:

See Specific Tags:

A-144 Failure to provide care in a safe setting
A-171 Failure to renew behavioral/violent restraint orders every four hours

Based on interview and record review, the facility failed to provide care in a safe setting for 2 (1, 2) of 8 patients reviewed in the emergency department psychiatric setting resulting in the potential for less than optimal outcomes. Findings include:

On, 10/18/2022 at 1429, review of the medical record for patient #1 revealed she was a 19-year-old female who was admitted to the ED (Emergency Department) on 9/30/2022 at 2240 for suicidal ideation. Past medical history for patient #1 included autism spectrum disorder (a developmental disability caused by differences in the brain), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), post-traumatic stress disorder (PTSD), and developmental delay (developmental skills that are behind others compared at the same age). Patient #1 had a mental health petition (a request for a court-ordered involuntary hospitalization or treatment) and clinical certificate (a written conclusion or statement of a physician or licensed psychologist that an individual is a person requiring mental health treatment). A physician's order for a "constant observer for self-harm" was dated 9/30/2022 at 1604.

On 10/18/2022 at 1447, review of the medical record for Patient #2 revealed he was a 24-year-old male who was admitted to the ED on 9/30/2022 at 1520 for homicidal ideation, acute psychosis (indicated by rapid fluctuations in speech and behavior, the presence of visual hallucination, and the absence of mood delusions), and schizoaffective disorder (a mental health disorder including schizophrenia and mood disorder). A physician's order for a "constant observer for self-harm" was dated 9/30/2022 at 1529.

On 10/18/2022 at 1245, review of an incident report, dated 10/3/2022 at 0818, revealed an incident had occurred between 2100-2110 on 10/2/2022 and was reported to staff by Patient #1 at approximately 2200. After continued questioning, Patient #1 stated Patient #2 had "forced his way into the bathroom and immediately threatened (patient #1) stating (according to victim), 'If you tell anyone, I'll fuckin kill you" (patient #1) ... then states that her attacker pulled up her shirt and started kissing and sucking on her breast, kissing her on neck and kissing her on the face while placing genitals near her vaginal region rubbing up against it. Patient states she was extremely afraid and just did what her attacker told her to do." The incident report further stated physicians, security, police, and SANE (sexual assault nurse examiner), and the charge nurse were all notified and that the two patients were immediately separated.

On 10/18/2022 at 1350, review of video documentation from 10/02/2022 of Pod A (the mental health area of the emergency department) hallway revealed the following:

21:01:04 Patient #2 was standing in doorway of Patient #1's room talking to her
21:01:06 Patient #2 walked away. Male nurse visualized in far corner of the nurse's
station in front of a computer. Female nurse in medication room.
21:01:44 Patient #2 was standing near nurse's station desk looking into Patient #1's
room and talking
21:01:57 Patient #1 left her room and walked to bathroom
21:02:01 Patient #1 in bathroom
21:02:06 Patient #2 walked toward bathroom and abruptly turned in the opposite
direction when the male nurse got up and started walking across nurse's
station toward him
21:02:58 Patient #2 walked towards bathroom and knocked on the door
21:03:02 Patient #2 walked into bathroom with Patient #1 still in the bathroom.
While walking in, he placed his right hand on the door. Unable to tell
whether he was pushing the door or if Patient #1 is pulling it open for him;
however, the door swung open easily at a normal speed
21:03:08 Bathroom door closed easily with both patients inside
21:05:09 Bathroom door open and Patient #1 came out and walked at a normal pace
back toward her room. Affect appears normal.
21:05:14 Patient #1 stopped and got some hand sanitizer before entering her room.
Patient #2 visualized peeking out the bathroom door.
21:05:45 Patient #2 exited bathroom and walks past Patient #1's room.

On 10/18/2022 at 1450 further document review revealed neither patient had a "constant observer for self-harm" present at the time of the above incident.

RN (registered nurse) Staff M was queried on 10/19/2022 at 0922 regarding physician orders for patients 1 and 2. Staff M acknowledged he was aware of the constant observer orders for both patients. He was then asked as to if there were any constant observers present to which he stated, "Pretty much everyone down there was constantly being watched by me and the other nurse. There were no sitters (constant observers) available. We tried to get one, but no one was available... I made the charge nurse aware..."

During an interview on 10/19/2022 at 1311, Director of Patient Care Services Staff K stated, "We know there is a shortage of sitters and have had 14 PCAs (patient care associates) positions approved last week plus 9 MHTs (mental health technicians)... We are definitely focusing on assuring we have increased sitters and techs in the ED to increase surveillance."

At the time of the investigation, the facility administrators were verbalizing changes they would like to make based off the preliminary results of their RCA. However, the facility had not implemented any systemic corrective action through policy changes, education, or filling all of the approved MHT (Mental Health Technician) and PCA (Patient Care Associate) positions.

Based on interview and record review, the facility failed to renew restraint orders every 4 hours for 1 (#2) of 2 patients reviewed for restraints resulting in the potential for loss of patient rights and poor patient outcomes. Findings include:

Review of Patient #2's medical record on 10/18/2022 at 1447 revealed the following physician orders for restraints (please note that asterisks indicate more time elapsed than permitted by facility policy):

9/30/2022 at 2200 initial
9/30/2022 at 2315 renewal
10/1/2022 at 0315 renewal
10/1/2022 at 0822 renewal*
10/1/2022 at 1847 renewal*
10/1/2022 at 2304 renewal*
10/2/2022 at 0303 renewal
10/2/2022 at 0703 renewal
10/2/2022 at 1128 renewal*
10/2/2022 at 2245 initial
10/3/2022 at 0245 renewal
10/3/2022 at 0645 renewal
10/3/2022 at 1045 initial
10/3/2022 at 1445 initial
10/3/2022 at 1845 renewal
10/3/2022 at 2258 renewal*
10/3/2022 at 2303 initial
10/4/2022 at 0300 renewal
10/4/2022 at 0700 renewal
10/4/2022 at 1100 renewal
10/4/2022 at 2200 initial
10/5/2022 at 0200 initial
10/5/2022 at 0502 renewal
10/5/2022 at 0502 initial
10/5/2022 at 0600 initial
10/5/2022 at 1000 initial

Further review of the medical record revealed "Adult Restraint Flow Record Behavioral Health Standard Non-Psychiatric Care Units" revealed Patient #2 was placed in restraints on 9/30/2022 at 2200 and remained in restraints until 10/2/2022 at 1130. Patient #2 was placed back into restraints on 10/2/2022 at 2245, it was unclear exactly how long he was in the restraints as documentation was lacking for 10/4/2022 until 2200. There was one flow sheet present that was undated; however, it does not cover the full time from 10/3/2022 at 1700-10/4/2022 at 2200. The next time the restraint flow sheets indicated removal of restraints was 10/5/2022 at 2145.

Clinical Informaticist Staff D, who was conducting chart reviews with the surveyor, was queried on 10/18/2022 at 1510 as to if Patient #2 was in restraint the whole time between 10/2/2022 at 2245-10/5/2022 at 2145 to which he stated, "It appears that way."

Review of facility policy #CLN - CO-4.004 (formerly 1 CLN 008) titled "Restraint in the Non-Psychiatric Healthcare Setting" approved 2/28/2020 states in a table in Appendix A for "Violent/Self Destructive Restraint", "Initial Order: Physician/APP (advanced practice provider) designee must be contacted prior to application or within 30 minutes of emergency application. If order or authorization not obtained within 30 minutes of application, the restraints must be removed... Each order is time limited determined by the patient's age. 4 hours - age 18 and up... The RN (registered nurse) may report the results of most recent assessment and obtain a telephone orders (sic) for the continuation of restraints - order time limited as determined by the patient's age. Original order may be renewed within time limits for up to 24 hours. After 24 hours, before writing new order, a face-to-face re-evaluation by physician/APP is required. A new order is required when changing number or type of restraint (i.e., 4 to 2 limb restraints)."