HospitalInspections.org

Based on document review and interview, the facility failed to ensure a patient was free from abuse in one instance. (Patient # 6).

Findings include:

1. The hospital policy titled, Patient Rights and Responsibilities, PolicyStat ID 13517670, indicated on page 3, under PROCEDURE, have right to; 18. Receive care in a safe setting, free from verbal or physical abuse or harassment, Last revised 9/2021.

2. The hospital policy titled: Patient Observation, Policy Stat ID 12931622, indicated on page 1, under POLICY: patients will continue to be assessed and monitored during their treatment to ensure observation levels are appropriate, and under PROCEDURE: 2., observation levels can be increased or decreased by a provider's order. Last revised 10/2024.

3. Review of Patient # 6's MR (Medical Record) indicated the following:
(a). Patient # 6 admitted on 4/3/2025 on 100 unit; diagnosis of Alzheimers disease.
(b). Provider admission orders on 4/3/2025, included, but not limited to: Observation Level: Every 15 minutes.
(c). Nurse note on 4/4/2025 at 1:00 pm, reflected patient noted to pace and intrusive at times. Note at 11:00 pm, patient continues to wander into other patient rooms.
(d). Psychiatric progress note on 4/5/2025, by NP # 50 (Nurse Practitioner - Psychiatric) reflected patient is confused and requires redirection.
(e). Nurse note on 4/7/2025 at 10:10 pm, reflected patient was in milieu wandering around when shift started, patient is alert & oriented x 1 (person) and walks independently; he/she is intrusive and will occasionally wander into other patient rooms. At around 10:00 pm, patient was heard calling from another patient's room; upon inspection, patient was found beaten up on the face, with blood oozing by right ear and left eye; right eye was noted to be swollen.
(f). Psychiatric progress note on 4/8/2025, by NP # 50 reflected nursing reports patient was involved in a physical altercation with another patient last night. Patient is confused and intrusive.
(g). MR documentation lacked any increase by provider(s) for an appropriate patient's observation status to a Level II (every 5 minutes) or Level III (1:1 Observation); related to patient # 6's confusion, intrusiveness, wandering, and incident that occurred on 4/7/2025; that resulted in patient injury.

4. Review incident report dated 4/7/2025 at 10:15 pm indicated Patient # 6 send out to ER (Emergency Room) at AH # 60 (Acute Care Facility). Patient yelled from another patient's room; staff in to check; patient found on floor; blood by right ear & left eye, and swelling.

5. In interview on 4/23/2025 at approximately 3:04 pm, with N # 20 (Behavioral Health Associate - staff), confirmed the following:
a. Worked on 4/7/2025 & 4/8/2025, on 100 unit.
b. Patient # 6 was a wanderer, needed lots of redirection; tried to go into other patient's rooms, would have to redirect by staff.
c. Was helping another BHA with a patient in room 101, that was on 1:1. Did not see patient # 6 go into patient # 5's room right away. Heard noise; into room 107; found patient # 6 on floor near door. Patient had blood by nose and by right eye.

6. In interview on 4/23/2025 at approximately 3:30 pm (via telephone), with N # 21 (RN/Registered Nurse - staff), confirmed the following:
a. Recalled incident towards beginning of shift; was getting medications ready; heard yelling; ran back.
b. Found where yelling was coming from; found patient # 6 on floor by door of patient # 5's room. Patient # 6 had bleeding on face.
d. Patient # 6 was confused/wandering around.

Based on document review and interview, nursing services failed to obtain a provider order to increase observation level of a patient in one instance. (Patient # 6).

Findings include:

1. The hospital policy titled: Patient Observation, Policy Stat ID 12931622, indicated on page 1, under POLICY: patients will continue to be assessed and monitored during their treatment to ensure observation levels are appropriate, and under PROCEDURE: 2., observation levels can be increased or decreased by a provider's order. Last revised 10/2024.

2. Review of Patient # 6's MR (Medical Record) indicated the following:
(a). Patient # 6 admitted on 4/3/2025 on 100 unit; diagnosis of Alzheimers disease.
(b). Provider admission orders on 4/3/2025, included, but not limited to: Observation Level: Every 15 minutes.
(c). Nurse note on 4/4/2025 at 1:00 pm, reflected patient noted to pace and intrusive at times. Note at 11:00 pm, patient continues to wander into other patient rooms.
(d). Psychiatric progress note on 4/5/2025, by NP # 50 (Nurse Practitioner - Psychiatric) reflected patient is confused and requires redirection.
(e). Nurse note on 4/7/2025 at 10:10 pm, reflected patient was in milieu wandering around when shift started, patient is alert & oriented x 1 (person) and walks independently; he/she is intrusive and will occasionally wander into other patient rooms. At around 10:00 pm, patient was heard calling from another patient's room; upon inspection, patient was found beaten up on the face, with blood oozing by right ear and left eye; right eye was noted to be swollen.
(f). Psychiatric progress note on 4/8/2025, by NP # 50 reflected nursing reports patient was involved in a physical altercation with another patient last night. Patient is confused and intrusive.
(g). MR documentation lacked any increase by provider(s) for an appropriate patient's observation status to a Level II (every 5 minutes) or Level III (1:1 Observation); related to patient # 6's confusion, intrusiveness, wandering, and incident that occurred on 4/7/2025; that resulted in patient injury.

3. Review incident report dated 4/7/2025 at 10:15 pm indicated Patient # 6 send out to ER (Emergency Room) at AH # 60 (Acute Care Facility). Patient yelled from another patient's room; staff in to check; patient found on floor; blood by right ear & left eye, and swelling.

4. In interview on 4/23/2025 at approximately 3:04 pm, with N # 20 (Behavioral Health Associate - staff), confirmed the following:
a. Worked on 4/7/2025 & 4/8/2025, on 100 unit.
b. Patient # 6 was a wanderer, needed lots of redirection; tried to go into other patient's rooms, would have to redirect by staff.
c. Was helping another BHA with a patient in room 101, that was on 1:1. Did not see patient # 6 go into patient # 5's room right away. Heard noise; into room 107; found patient # 6 on floor near door. Patient had blood by nose and by right eye.

5. In interview on 4/23/2025 at approximately 3:30 pm (via telephone), with N # 21 (RN/Registered Nurse - staff), confirmed the following:
a. Recalled incident towards beginning of shift; was getting medications ready; heard yelling; ran back.
b. Found where yelling was coming from; found patient # 6 on floor by door of patient # 5's room. Patient # 6 had bleeding on face.
d. Patient # 6 was confused/wandering around.