HospitalInspections.org

The Condition of Participation for Patient Rights has not been met.

Based on medical record reviews, review of hospital policies and interviews for two of ten patients reviewed for patient rights (Patients #8 and #9) the hospital failed to ensure that the patients were informed of their patient rights.

Refer to A117

Based on medical record reviews, review of hospital policies and interviews for one of ten patients reviewed for patient rights (Patient #12) the hospital failed to communicate the results of a patient grievance.

Refer to A123

Based on medical record reviews, review of hospital policies, observation of video monitoring and interviews for one of three patients reviewed for safety (Patient #1) the hospital failed to ensure that safety checks were conducted, failed to identify that a lapse in safety checks had occurred, failed to ensure that the integrity of utensils was checked following utensil return, failed to document MD notification, and failed to review and/or revise the plan of care when a change in condition was identified.

Refer to A144

Based on medical record reviews, review of hospital policies and interviews for two of ten patients reviewed for patient rights (Patients #8 and #9) the hospital failed to ensure that the patients were informed of their patient rights. The finding includes:

a. Patient #8 was admitted to the critical care unit on 1/25/22 with altered mental status and hypoxia and then transferred to the oncology unit. The nursing admission documentation for the receipt of the Bill of Rights was left unchecked by the admitting nurse. Observation of Patient #8 on 2/2/22 at 1:11 PM and per interview with nursing staff, Patient #8 was alert and oriented. Interview with Patient #8 on 2/2/22 at 1:11 PM noted that he/she did not recall receiving the Bill of Rights information. Patient #8 consented to allow the Wound Nurse to look for the patient informational folder which would have included the patient rights information. Observation and interview with the wound nurse at that time identified that the Bill of Rights information could not be located.

b. Patient #9 was admitted to the Oncology unit on 1/28/22 with generalized weakness and decreased urinary output. The nursing admission documentation for receipt of Bill of Rights was left unchecked by the admitting nurse. Observation of Patient #9 on 2/2/22 at 1:18 PM and per interview with nursing staff, Patient #9 was alert and oriented. Interview with Patient #9 on 2/2/22 at 1:18 PM noted that he/she did not recall receiving the Bill of Rights information. Patient #9 consented to allow his/her nurse to look for the patient informational folder which would have included the patient rights information. Observation and interview with the nurse at that time identified that the Bill of Rights information could not be located.

The Hospital policy entitled Patient Rights and Responsibilities identified, in part, the Patient Bill of Rights and Responsibilities is located in all patient handbooks, provided to all patients, and available through the Patient Relations Department.

Based on medical record reviews, review of hospital policies and interviews for one of ten patients reviewed for patient rights (Patient #12) the hospital failed to communicate the results of a patient grievance. The finding includes:

a. Patient #12 was admitted to the hospital from 12/1/21 to 12/2/21. The emailed grievance from Patient #12 dated 12/7/21 identified issues to include overnight noise, a medication usually taken in the evening (PM) was offered by the nurse in the morning (AM) and a morning antidepressant medication was not administered until 1:00 PM. The grievance further indicated that the night RN would not let him/her take the medications brought in from home, a lack of communication regarding the ordering of meals, and a delay in testing.

The Hospital response letter to Patient #12 dated 12/8/21 acknowledged Patient #12's emailed grievance, identified the matter would be looked into and Patient #12 would be made aware of the findings within 30 days.

Review of the Hospital investigation documentation identified that Patient #12's complaints were investigated by the Unit Manager and a physician reviewed care that was provided and found that the care met expected standards. The response letter to Patient #12 dated 12/20/21 noted Patient #12's concerns were shared with the Nurse Manager and the Director of Operations of the unit for their review and feedback along with opportunities were brought to the attention of staff involved in Patient #12's care. The letter to Patient #12 did not include the results of the Nurse Manager investigation or the opportunities that were identified.

The Hospital policy entitled Patient Complaints and Grievances identified grievance investigations must be responded to in writing within 30 calendar days from the date the Hospital initially receives the grievance and included in this response will be, in part, the results of the grievance process.

Based on medical record reviews, review of hospital policies, observation of video monitoring and interviews for one of three patients reviewed for safety (Patient #1) the hospital failed to ensure that safety checks were conducted, failed to identify that a lapse in safety checks had occurred, failed to ensure that the integrity of utensils was checked following utensil return, failed to document MD notification, and failed to review and/or revise the plan of care when a change in condition was identified. The findings included:


a. Patient #1's history included dry eye, major depression, anxiety and two prior suicide attempts. Patient #1 was admitted to the Behavioral Health Unit (BHU) from the medical unit on 1/7/22 following medical clearance and treatment (1/3/22 to 1/7/22) for intentional suicide overdose with rubbing alcohol and medications.

The initial treatment plan dated 1/7/22 identified safety issues due to suicidal thoughts/behaviors with interventions that included to monitor mood and behavior, assess for safety and maintain safe environment.

Physician admission orders dated 1/7/22 did not direct increased observational status.
The BHU protocol identified every 15-minute safety checks for all patients on the BHU.

The patient observation sheet dated 1/13/22 identified Psychiatric Technician (Psych Tech) #3 performed a 15-minute check on Patient #1 at 12:15 AM, 12:30 AM and 12:45 AM and Patient #1 was up and in his/her room.

Nursing narratives dated 1/13/22 by RN #1 indicated that around 12:40 AM Patient #1 went to the nursing station, complained of a headache, was unable to see from the right eye, was actively bleeding from both eyes and reported continuously scratching both eyes. The note further identified a sharp piece of a plastic fork was found in the patient's bathroom following a room search. The nursing narrative dated 1/13/22 at 1:12 PM noted Patient #1 stated he/she saved the prong of a fork and punctured his/her eyes because he/she wanted to be blind.

Diagnostic testing dated 1/13/22 and 1/14/22 noted Patient #1 sustained a fracture of the left eye lamina papyracea.

The video recording of the BHU dated 1/13/22 was reviewed with the Directors of Security and Regulatory Affairs on 1/24/22 at 10:04 AM. The recording from 12:15 AM to 12:47 AM identified that a safety check, beginning at 12:18 AM, was performed for all patients on the BHU by Psych Tech #3 and the last patient, Patient #1, was checked at 12:19 AM. Between 12:19 AM and 12:45 AM, Psych Tech #3 sat in a hall chair and neither he nor any other staff member performed patient safety checks in that time frame. At 12:44:53 Patient #1 exited his/her room, walked to the nursing station and appeared to speak with RN #1 at 12:45 AM. Patient #1 was escorted back to his/her bedroom by RN #1 and Psych Tech #3 at 12:47 AM.

Review of the video and interview with the Director of Regulatory Affairs on 1/24/22 at 10:15 AM to 10:26 AM noted that Patient #1 was not checked for safety at 12:30 AM as documented. In addition, the Director identified that the video had not been reviewed by hospital staff prior to the surveyors visit on 1/24/22.

Interview with Manager #1 on 1/24/22 at 10:59 AM identified that every patient is to be checked for safety every 15 minutes per unit baseline.

Interview with Psych Tech #3 on 1/26/22 at 7:33 AM indicated that every 15-minute checks are a guideline, and that he was sorry that he missed the check (s) following the 12:19 AM check on 1/13/22.

The hospital failed to ensure that safety checks were performed per unit protocol during the timeframe that Patient #1 exhibited self- injurious behavior, and that the documentation on Patient #1's safety check sheet was inaccurate. In addition, the hospital failed to conduct a thorough investigation to include viewing video evidence of the timeframe of the incident on the BHU.

The hospital's immediate action plan dated 1/20/22 did not identify the lapse in the BHU protocol for every 15- minute checks and subsequent measures to address the lapse were not in place as of 1/24/22.

The Hospital policy entitled Patient Rights and Responsibilities identified patients are entitled to care in a safe and supportive environment. The Hospital job description entitled Psychiatric Technician identified a major responsibility to demonstrate the ability to perform patient and environmental rounds while reporting clinical and customer service- related issues or questions to the supervising staff in a timely fashion. The Hospital policy entitled Patient Head Count identified patients are seen and checked every 15- minutes.


b. Patient #1's initial treatment plan dated 1/7/22 identified safety issues due to suicidal thought/behaviors and interventions included monitor mood and behavior, assess for safety and maintain safe environment.

Nursing narratives dated 1/13/22 by RN #1 indicated around 12:40 AM Patient #1 went to the nursing station, complained of a headache, was unable to see from the right eye, was actively bleeding from both eyes and reported continuously scratching both eyes. The note further identified a sharp piece of a plastic fork was found in the bathroom following a room search. The nursing narrative dated 1/13/22 at 1:12 PM noted Patient #1 stated he/she saved the prong of a fork and punctured his/her eyes because he/she wanted to be blind.

The Environmental Safety Check sheets dated 1/12/22 for the day and evening shifts lacked documentation for the performance of breakfast, lunch and dinner utensil "overview"/checks (utensil integrity check).

Observation of the noon meal on the BHU on 1/24/22 at 11:54 AM noted one Psych Tech handing out trays in the lounge and Psych Tech #1 filling out a paper counting and documenting the number of utensils as the utensils were distributed and returned. The documentation and verbalization by Psych Tech #1 did not reflect that the utensils were inspected for integrity on return.

Interview with the Regulatory Director on 1/25/22 at 10:15 AM indicated staff documented on the wrong environmental safety check sheet on 1/12/22 but, was confident that the check was performed.

Interview with Psych Tech #2 (worked 7:00 AM to 7:00 PM on 1/12/22) on 1/25/22 at 10:57 AM identified, prior to 1/13/22, each patient got a fork and spoon and the goal was to return these after the meal. When asked if she inspected the utensils, she stated she would "do a general overview".

Interview with Psych Tech #4 (worked 7:00 AM to 7:00 PM on 1/12/22) on 1/27/22 at 7:37 AM indicated prior to 1/13/22, utensils were monitored, collected and signed off on the safety check sheet and did not know how Patient #1 was able to break off a piece of the plastic fork without staff knowledge.

Hospital staff failed to inspect the integrity of Patient #1's plastic utensils when utensils were returned and Patient #1 left the dining room with a prong of plastic fork which was used to cause self-harm.

The Hospital policy last revised on 4/2018 entitled Environmental Safety Checks identified the Behavioral Health Tech will be assigned to perform a thorough environmental safety check of all Patient Common areas every shift (3 times a day) for the required elements listed on the form. The policy did not direct staff regarding utensils.

The Hospital submitted an immediate action plan dated 1/20/22. The plan included the revision of the Environmental Safety Check policy and directed a meal- time procedure. The mealtime procedure identified, in part, that all patients must hand in their utensils at the end of the meal and utensils are to be accounted for on the utensil count sheet. The revised policy directed staff to inspect utensils for integrity to address the initial deficient utensil check that enabled Patient #1 to obtain the prong of a fork without staff knowledge.

Subsequent to surveyor inquiry, the Hospital further revised the Environmental Safety Check policy dated 1/27/22 to include staff visualization of the integrity of utensils upon return followed by staff policy education.


c. Patient #1's initial treatment plan dated 1/7/22 identified safety issues due to suicidal thought/behaviors and interventions included monitor mood and behavior, assess for safety and maintain safe environment.

Nursing narratives dated 1/10/22 through 1/12/22 at 1:00 PM identified Patient #1 was intrusive and attention seeking at times.

Nursing narratives dated 1/12/22 at 8:33 PM by RN #2 identified, in part, that Psych Tech (#4) reported that Patient #1 was noted to spend extended periods of time in the bathroom (BR) and when the BR door was opened, Patient #1 had blood around the nose and mouth. RN #2's notes further identified that Patient #1 reported the blood was from an eyebrow scab, yet the scab was intact and open areas were not noted.

The nursing narratives did not identify that the on-call physician was informed of the change in behavior and that blood was observed around Patient #1's nose and mouth. In addition, assessments for suicidality, safety and/or change in the plan of care were not documented.

Nursing narratives by RN #1 dated 1/12/22 at 11:11 PM identified that Patient #1 endorsed frustrations and heightened anxiety, was unable to use coping skills, bilateral eyes were slightly swollen and blood shot, medications were administered, Patient #1 denied suicidal ideation and MD #2 was notified. Documentation that MD #2 had been notified of the blood previously observed on Patient #1's face was not documented.

Nursing narratives dated 1/13/22 by RN #1 indicated around 12:40 AM, Patient #1 went to the nursing station, complained of a headache, was unable to see from the right eye, was actively bleeding from both eyes and reported continuously scratching both eyes. The note further identified a sharp piece of a plastic fork was found in the bathroom following a room search. The nursing narrative dated 1/13/22 at 1:12 PM noted Patient #1 stated he/she saved the prong of a fork and punctured his/her eyes because he/she wanted to be blind.

Interview with RN #1 on 1/25/22 at 9:04 AM identified she informed MD #2 of Patient #1's increased anxiety, red eyes and MD #2 indicated he would initiate an EENT (eyes, ears, nose and throat) consult in the morning.

Interview with Psych Tech #4 on 1/27/22 at 7:37 AM noted that she saw dried blood on Patient #1 on 1/12/22, the patient acted very suspicious in the bathroom, the RN was informed and that Patient #1 "denied everything."

Interview with RN #2 on 2/4/22 at 8:04 AM (requested on 1/25/22) noted Patient #1's nurse went home sick on 1/12/22 and she and RN #5 took over the RN's assignment. RN #2 further identified although Patient #1's eyebrow scab was intact, Patient #1 insisted the blood observed by Psych Tech #4 was from that area and an assessment of Patient #1's face did not identify the origin of the blood. RN #2 stated this occurred at the change of shift (7:00 PM) and RN #5 called to notify the MD.

Interview with RN #5 on 2/4/22 at 11:06 AM indicated she informed MD #2 that Patient #1 had blood observed on his/her face by Psych Tech #4, further bleeding was not observed, and that Patient #1 spent increased time in the bathroom. RN #5 further noted Patient #1 had never spent excessive time in the bathroom prior to 1/12/22, Patient #1 was not observed bleeding prior to 1/12/22 and MD #1 instructed her to "keep an eye on Patient #1".

Patient #1 exhibited self- injurious behaviors on 1/12/22 from 7:00 PM to 11:00 PM, was first observed with blood on the face and, later, swollen blood- shot eyes and although MD #2 directed to keep an eye on Patient #1, the patient's treatment plan was not revised and increased monitoring of Patient #1 was not performed. Patient #1 was later found bleeding from both eyes and sustained a fracture of the left eye lamina papyracea.

Interview with MD #1 on 1/25/22 at 2:35 PM identified that blood noted on a patient's face was a significant change and would expect to be informed.

MD #2 was not available for interview at the time of the investigation.

The Hospital policy entitled Nursing Assessment/Safety Rounding/Care Planning and Patient Education Documentation identified patient reassessment occurs every twelve ours as a minimum and occurs to respond to a significant change. The policy further identified the plan of care is revised to meet patient needs based on changes in patient condition.