HospitalInspections.org

Based on interview and document review, the facility failed to implement their policy/procedure that protected one patient (#1) from a peer (#4) that was identified and on precautions for sexual precautions, resulting in the potential for unsatisfactory outcomes for any of the 114 patients residing in the facility. Findings include:

See specific tag A-0144.
Failure to provide care in a safe setting for 1 patient (#1) of 5 patients reviewed for patient rights.

Based on interview and record review the facility failed to provide care in a safe setting for 1 patient (#1) of 5 patients reviewed for patient rights resulting in the potential for less than optimal outcomes for all 114 patients served by the facility.
Findings include:

Review of the medical record on 8/17/2021 at 1300 revealed the patient (#1) was a 16-year-old female who was admitted to the facility on 11/16/2020. The patient was discharged home to the care of her parents against medical advice (AMA) according to the provider's discharge summary dated 11/21/2020.

An interview was conducted with Staff K on 8/18/2021 at 1530. She explained that she was a lead preceptor and was on the unit on 11/21/2020. She said she was not assigned to the patient. Staff K said both patients (#1 and #4) were observed walking in the hallway. She said patient #4 was observed swinging his arms and accidently came into contact with the patient (#1's) lower back area. Staff K said the patient #1 started screaming, yelling and crying that "he (#4) molested her". Staff K said both patients were immediately separated. She said she attempted to console the patient (#1). Staff K said patient # 4 felt bad, embarrassed he said he did not know that he had touched her. Staff K said the patient #1 seemed to be okay after that.

Staff K said it was not until phone time (1730) that the patient called her parents and told them what happened. She said the patient was tearful again and after that her parents came and picked her up and took her home AMA.

A review of the medical record for patient #4 was conducted with the Director of Nursing (DON) on 8/18/2021 at 1045 and revealed the following:
The patient was 17-year-old male admitted to the facility on 11/17/2020. Admission orders included standard safety checks every 5 minutes for sexually acting out behaviors. Review of nursing notes dated 11/18/2020 through 11/23/2020 documented the following regarding patient #4:
On 11/18/2020 at 1600, often sexually inappropriate.
On 11/19/2020 at 1500, sexual precautions going in and out of groups.
On 11/20/2020 at 2213, other patients have complained that he is scaring them, redirected and maintained on precautions.
On 11/21/2020 at 1500, inappropriate touching.
On 11/23/2020 at 1120, intrusive to others continues to be on sexual behavior precautions.

Review of provider notes dated 11/19/2020 through 11/21/2020 revealed no mention of the patient's inappropriate sexual behavior. There was no evidence that nursing had informed the physician of the patient's inappropriate behavior.

The Director of Nursing (DON) was asked to explain why nursing had not documented the physician was notified that patient (#4) had continued to display inappropriate sexual behaviors towards his peers while on every 5-minute safety checks and she was asked to explain why the patient was not placed on 1:1 staff supervision to maintain a safe environment for all patients. At that time the DON explained nursing may have informed the physician verbally. However, there was no evidence that documented that was done.

Review of the facility's "Precautions" policy number 1975.00 revision date 8/2021, documented:
4. Following admission, if the patient demonstrates behavior that indicates a need for a precaution above Standard Safety Precautions, the treatment team will discuss the patient's behavior with the physician in the morning team conference and the physician will then order the most appropriate type and level of precaution.
a. Note: An RN (registered nurse) does not have to wait for the morning team conference to request a precaution order from a physician. The morning flash report will simply be a forum where patient precautions are discussed on a daily basis.
b. Prior to requesting the precaution, the RN will have already attempted less restrictive interventions
5. The RN will initiate the lowest level precaution that maintains the safety of the patients and staff to provide the least restrictive limitations.
6. If the precaution does not remedy the behavior, the RN will obtain an order from the attending physician or Medical Director for more intensive precautions. If the physician is not available, the RN may initiate the intervention and continue to pursue the physician's order.
7. The RN will be responsible for the deployment of the nursing staff to ensure the precaution level and intervention(s) are strategically maintained. The level of restrictions follows this order and are outlined in more detail in this policy section labeled "More Restrictive Interventions".
a. Close Observation - 15 Minute Checks
b. Close Observation - 5 Minute Checks
c. 1:1 Supervision
d. 1:1 Supervision WA (While Awake)
8. The RN will document all precautions beyond SSP in the patient's MTP. This will include any behavior plans for the patient and staff interventions to effectively maintain the precaution.
9. The RN will inform team members of the patient's precautions and interventions.
10. The RN will develop a plan for the unit staff to effectively maintain this level of precaution.
11. The RN/designated staff will record precautions on the patient information board and the Electronic Rounds.The physician's order, board and Electronic Rounds shall align.
12. The RN/designated staff will explain the precautions(s) to the patient and also describe the behavior(s) which will result in the termination of the precaution.
13. Any significant changes in patient's behavior will be thoroughly documented by the RN as these changes may result in a change in precaution level by the physician.
14. Specific Procedures for each Precaution include:
1. Inpatient unit observation for all patients - Unless a situation dictates more urgent use of staff, RNs will strategically position nursing staff to allow for total unit observation.
2. a. Standard Safety Precautions (SSP):
i. Patient location and behaviors to be entered on the electronic rounds.
ii. RNs will document at least once every twenty-four (24) hours on patient progress while on SSP.
b. Assault Precautions (AP):
i. Staff members will be on heightened alert for any assaultive behaviors such as threatening peers, posturing, or invading the space of other peers which may warrant the use of a higher observation level.
ii. RNs will document the patient's behavior every twelve (12) hours until the precaution is removed, and the patient is placed back on SSP.
c. Sexual Behavior Precautions (SBP):
i. Staff members will be on a heightened alert for any potential sexually aggressive behaviors such as exposing oneself, propositioning other patients and/or sitting too close to peers.
ii. Patients at risk for sexually acting out may require more restrictive interventions that may include, but are not limited to the following:
1. A staff member will be required to know the patient's whereabouts at all times and document, at minimum, every fifteen (15) minutes on the electronic rounds.
2. The patient's room may be changed to reduce close proximity within the unit to another peer that may be at risk. This may also include moving the patient closer to the Nursing Station.
iii. RNs will document the patient's behavior every twelve (12) hours until the precaution is removed, and the patient is placed back on SSP.
iv. Patient may be placed on a 1:1 if behavior warrants.
However, this was not done.

Based on record review and interview, the facility failed to ensure effective discharge planning and coordination of care for one (#3) of 3 patients reviewed for discharge planning, resulting in the potential for less than optimal outcomes for all patients (114) served by the facilty.
Findings include:

(See A-802) -The facility failed to follow their policy and procedure for changes to their discharge plan for a homeless single male patient (#3) who had a guardian.

Based on record review and interview the facility failed to follow policy/procedure for Discharge Planning for 1 (#3) of 5 patients reviewed for discharge planing resulting in the potential for unsatisfactory outcomes for all (114) patients served by the facility.
Findings include:

On 8/17/2021 at 1215 a review of the facility's complaints/grievance logs from the Office of Recipient Rights was conducted with the Director of Recipient Rights (Staff C). He explained he had received a voice mail message from the patient of concern (#3's) mother/guardian. He said he spoke with her on 8/9/2021 regarding the circumstances surrounding the patient's discharge on 8/6/2021. According to Staff C, the patient's mother said the patient was taken to a shelter that was located in the "worse part of a local inner city", hours before they opened.

Staff C explained the patient's mother said when she arrived to pick him (#3) up for discharge on 8/6/2021 she observed that staff had given him (#3) the discharge folder and she was upset because she had been assured that she would be given the discharge folder. Staff C explained that the patient's mother had expressed to staff prior to his discharge, that if the patient was given the folder it would make him upset because there would have been additional information noted on his discharge instructions for "other placement". Staff C said the complaint/grievance was still under investigation. Staff C explained there was an altercation on 8/6/2021 between the patient and his mother in the lobby and the mother refused to take him home. Staff C explained he was told by staff that a call was made to "Adult Protective Services" (APS) for direction and they (APS) responded; "do what you have to do." Staff C explained he had not reviewed the video surveillance yet. He explained that it was available for review.

Review of the medical record on 8/17/2021 at 1300 revealed the patient #3 was a 26- year-old male admitted to the facility on 7/16/2021. Review of the "Psychosocial Assessment" dated 7/19/2021 documented the following:
The patient was currently living with his mom/guardian. The patient did not desire to return to the same living environment and the patient could not return to the same living environment.

Further review of the psychosocial assessment documented the patient was admitted after assaulting his mom for being too loud on the phone in the morning. The patient was court ordered for treatment and his mom explained he could no longer live with her due to his violence towards her and that he would need group home placement.

Review of the patient's Discharge Plan and Home Medication form dated 8/6/2021 at 0905 documented:
Address: (patient's mother's address)
Primary phone: (patient's mother phone number)
Discharge Transportation: Family picking up
Schedule AfterCare appointments:
(name of Community Mental Health in the same city where the patient's mother resides)

An interview and record review was conducted with the Social Services (Staff G) on 8/17/2021 at 1500. At that time, when queried regarding the patient's discharge she explained that she was assigned on the date of the patient's discharge (8/9/2021). According to Staff G she was responsible for assessing the patient for his discharge readiness and for completing his "Crisis Safety Plan" on that day. She said she was covering for his regular Social Service Worker (Staff H). A review of an "untitled" note dated 8/17/2021 at 1114 per Staff G documented: "Late entry: On discharge date, (name of patient) was taken down to lobby by staff to his mother. As Social Worker (SW) and Utilization Review (UR) were walking out through the lobby, staff stopped SW and UR manager to inform them (name of patient) was discharged but his mother/guardian was unwilling to take him home and had left the hospital."

Staff G documented per a conversation with a "Behavioral Health Associate (BHA)" the patient had his discharge folder and placed it down to retrieve his things. The BHA picked up the folder and gave it to the patient's mother. The patient "bear hugged" his mother and put his arms around her to grab the folder, then pushed her away.

Staff G documented, the patient's mother/guardian later called the front desk and spoke with the UR manager who explained to her that she had agreed with the patient's original SW to bring him home after the process of finding housing through a local county had been started, so the process had stopped. The UR manager had stated that since she was the guardian, she was responsible in making sure he had appropriate housing since he was discharged...Social worker supervisor (Staff F) had suggested sending the patient to (name of a mental health urgent care) to be evaluated for 24 hours to determine if he needed to come back to this level of hospitalization or to receive services through (name of outpatient community mental health center). SW supervisor Staff F discussed the plan with the patient and he agreed...SW arranged transportation to (name of mental health urgent care)..."

An interview was conducted with the Clinical Manager of Social Services (Staff F) on 8/17/2021 at 1530 regarding the patient's discharge. At that time, Staff F said she and the UR Manager had discussed with the treatment team "what would have been an appropriate shelter for the patient to be discharged to on 8/6/2021." Staff F was asked if the attending psychiatrist was notified of the change in the patient's discharge plan from "home with mother/guardian to discharge to a mental health urgent care" and she replied the attending psychiatrist had not been informed. Staff F was asked if she or any facility staff had coordinated the patient's change in discharge plan with the "mental health urgent care" and/or with the patient's "community mental health case worker" and she replied she did not.

An interview was conducted with Staff I (transportation/driver) on 8/18/2021 at 1150. When queried at that time regarding the patient (#3) he said he did not recall the patient. He was observed as he reviewed his log for 8/6/2021. According to Staff I he picked the patient of concern up from the facility (a) on 8/6/2021 at 1520 and dropped the patient off at facility (b)1555 on 8/6/2021 via the transport van. Staff I said he worked by himself.
Staff I said he was familiar with the place that the patient was being dropped off at. Staff I said he was not required to escort the patient's in nor wait and see if they got in. He said typically there would be others (patients) in the van and he could not leave them alone. He said there were no greeters. He said (name of facility b) was one of two shelters/rehab that he would make frequent trips. Staff I said he recalled there were lots of cars and people standing outside, smoking and hanging out at the facility (b) when he dropped the patient off. Staff I said he did not know if the patient went into the faciity (b).

Review of the facility's "Discharge Planning" policy number 2.09.00 last revised on 8/2019 documented:
PROCEDURES:

Inpatient Discharge:
"...F) Intake:
1. Intake to enter into Meditech all required patient discharge information.

ALL STAFF: If at time of discharge the patient or significant other communicates to any staff member a change of status that would place the patient or others at risk of harm if discharged, they must communicate this information immediately to the charge nurse. The charge nurse must then speak with the patient and notify the attending psychiatrist before discharging the patient."
However, this was not done.