HospitalInspections.org

Based on policy review, medical record review and interview, the hospital failed to protect and promote each patient's right to receive care in a safe setting and to be free from all forms of abuse/neglect when 1 of 3 (Patient #1) sampled patients received burns when left unattended in the shower.

The failure to promote and protect each patient's rights resulted in a SERIOUS AND IMMEDIATE THREAT to the health and safety of all patients in the hospital.

The findings included:

1. The hospital failed to provide care to all patients in a safe physical environment and failed to ensure all patients were protected from all forms of abuse. The hospital failed to protect Patient #1 from neglect, placing the patient in a SERIOUS AND IMMEDIATE THREAT for their health and safety.
Refer to A 145

Based on policy review, medical record review and interview, the hospital failed to ensure vulnerable patients were protected at all times, and ensure the patients' rights and well-being were preserved for 1 of 3 (Patient #1) sampled patients whose rights to be free from all forms of abuse/neglect was violated when the hospital failed to provide supervision for 32 minutes when Patient #1 was left alone in the shower and received burns to the arm and chest.

The hospital's failure to ensure Patient #1 received care and supervision in a safe environment and remained free from abuse/neglect resulted in an IMMEDIATE JEOPARDY for Patient #1 and placed all patients in a SERIOUS AND IMMEDIATE THREAT for their safety and well-being.

The findings included:

1. Review of the hospital's "PATIENT RIGHTS AND RESPONSIBILITIES" policy revealed, "To ensure all hospital staff and contract staff shall observe these patients' rights...All hospital staff, medical staff and contracted agency staff performing patient care activities shall observe these patient rights...Considerate, dignified and respectful care, provided in a safe environment, free from all forms of abuse, neglect, harassment and/or exploitation..."

2. Review of the hospital's "Patient's Rights & Responsibilities" acknowledgement form revealed, "...PRIVACY AND SAFETY...The patient has the right to receive care in a safe setting. The patient has the right to be free from all forms of abuse or harassment...".

3. Review of the hospital's "PERSONAL HYGIENE" policy revealed, "...All patients shall be encouraged or assisted in grooming daily or more often as needed...Shower or sponge bath to be provided with staff supervision and/or assistance".

4. Review of the hospital's "ROUNDS FOR PATIENT OBSERVATION" policy revealed, "...An accurate record of the whereabouts of all patients at [named facility] will be maintained during each shift...Every patient must be seen by a staff member every 15 minutes and checked off on the Rounds Sheet to include location, behavior, and staff initials for who conducted the round... Observe each patient a minimum of every 15 minutes and/or according to precaution level and document observation on the patient observation form... Visually observe patients when behind closed doors by: knocking on bedroom and bathroom doors...announce that they are stepping into the room for rounds...open the door and visually observe the safety of the patient...".

5. Medical record review for Patient (Pt) #1 revealed an admission date of 7/17/19 with diagnoses that included Schizophrenia and hallucinations. The patient resided in an Assisted Care Living Facility (ACLF #1) prior to admission.

Review of the Assessment and Referral Evaluation for Pt #1 performed on 7/17/19 revealed, "...Chief Complaint: Recent change in mental status with paranoia and delusions. Patient feels like something is crawling on her. Recent change in medication...".

Review of the Brief Evaluation Summary for Pt #1 performed on 7/17/19 revealed, "69 yo [year old] female presents with paranoia and delusions. Pt feels that bugs are crawling on her. During assessment she verbalizes that when she takes a bath the bugs float on the water".

Review of the Modified Morse Fall Scale for Pt #1 performed on 7/17/19 revealed, "...History of falling; immediate or within 3 months...yes...Ambulatory Aid...Crutches/cane/walker...Gait...Weak...". The score for high risk is 45 and up. Pt #1 scored a 50 on the fall scale.

Review of the Admission physician orders documented on 7/17/19 revealed, "...Safety Checks Q15 [every 15] and PRN [as needed]...".

Review of the Psychiatric Evaluation for Pt #1 performed on 7/18/19 revealed the pt was disabled, and listed hallucinations as one of the pt's liabilities due to poor judgement and insight.

Review of Shift Nursing Flowsheets revealed Pt #1 was documented as having poor judgment and poor insight on 7/17/19, 7/18/19, 7/19/19 and 7/20/19.

Review of the Patient Observation Form dated 7/20/19 for Pt #1 revealed the patient's observation level was to be documented every 15-Minute Checks.
Under the Special Precautions section of the form, "Fall" was documented.
Technician (Tech) #1 documented observations of Pt #1 as the patient being located in the dining room from 7:00 AM until 7:45 AM.
The Tech documented Patient #1's behavior from 7:00 AM until 7:45 AM as, "shower".
The Tech had documentated the observations and behavior for Pt #1 as different locations between 7:00 AM and 7:45 AM. The patient could not be in the dining room and the shower at the same time.

Review of Pt #1's Shift Nursing Flowsheet Note for 7/20/19 revealed Registered Nurse (RN) #2] was called to Patient #1's room by a Tech at 7:50 AM. The RN documented that upon arrival, she found Patient #1 unresponsive and sitting in the shower chair with the hot water running on her. The Tech stated she found Patient #1 found in that position with the hot water running in shower.

The RN documented Patient #1 was lowered to the shower room floor, and Patient #1 had, " Extrem [extreme] redness noted to patients abdominal area, down left side, skin to left arm approximately 75% [percent] to 90% not intact, redness to face & [and] neck area noted, room was extremly [extremely] hot from hot water running, floor [with] water in it. Patient able to open eyes and take deep breaths on command. Answered questions about all incorrectly"

The RN documented Patient #1's vital signs as:
Blood pressure (BP) was low at 95/45.
The patient's heart rate (HR) was 89.
The patient's respirations were 12.
The patient's temperature was elevated at 101.6 degrees axillary.
The RN documented Patient #1 was "alert and answering questions to best of ability"
Ground Emergency medical Services (EMS) was called.

Review of the Ground EMS assessment note on 7/20/19 beginning at 8:14 AM revealed, "...Upon arrival on scene, pt is found naked in her shower in the floor. Pt c/c [chief complaint] is partial thickness burns to the left arm and chest. Pt has global minor surface burns. Pt was in the shower unsupervised and has turned it to max heat and has burned herself...Pt is in increasing pain...Pt appears to have more developing burns as she is with EMS. Pt pain is increasing ...Pt's injuries warrant Burn Center transport via Aeromedical Evacuation...". Ground EMS documented the patient had 22.5 % of first degree burns on her body and 18% of second degree burns on her body for a total of 40.5% burns on her body.

Ground EMS left with Patient #1 en route to the Aeromedical/Flight EMS Evacuation heliport at 8:20 AM to be transported to a higher level of care Burn Center hospital. The patient was administered the pain medication Fentanyl times 2 doses for her severe pain while with Ground EMS.

Review of the Aeormedical/Flight EMS report revealed was Patient #1 picked up on 7/20/19 at 9:00 AM and was flown emergent to the Burn Center Hospital. Fight EMS documented en route, the patient was "tearful at this time and states she is 'scared'". Flight EMS documented the patient's temperature was 100 degrees axillary and Flight EMS provided cooling measures to decrease the patient's temperature. Flight EMS documented the patient arrived at the Burn Center hospital at 10:12 AM.

Review of medical record at the Burn Center hospital revealed Pt #1 arrived on 7/20/19 at 10:12 AM with superficial burns of multiple sites of the upper extremity, partial thickness burns of the abdomen, partial thickness burns of the left upper arm, partial thickness burns of the left lower extremity, acute kidney injury and pain. The physician documented the patient, "appears uncomfortable and in pain". The physician documented the patient had been left unattended in the shower and a nurse had checked on the patient an hour later and the patient was found to have diffuse superficial burns and partial thickness burns. The patient stated to the physician that she was unable to turn the water off due to weakness. The patient stated she currently was "feeling 'hurt' (referring to her pain) and also states 'my' nerves where [are] getting to me'. Reports feeling 'nerves' when describing anxiety".

The physician documented the patient required multiple doses of Fentanyl for pain, and documented the patient was admitted for treatment of the burns. The physician documented, "Patient's family does not want the patient to go back to the Geri-Psych facility [Hospital #1]. The physician documented upon discharge, Patient #1 would need to be admitted to a skilled nursing facility (SNF) for rehabilitation.

6. In an interview on 7/30/19 at 2:35 PM in the conference room, Licensed Practical Nurse (LPN) #1 was asked about the burn incident regarding Pt #1 on 7/20/19. LPN #1 stated, "...I was the medication nurse...I saw her [Pt #1] about 7:05 AM, she was fine and pleasant. After that I was doing my thing...hollered for me to help. Went to the bathroom and saw her [Pt #1] lying on the floor, wet, unclothed from the shower. [RN #2] and the tech [can't remember name] were with her. Told me possible seizure activity so I called the ambulance and her doctor...". LPN #1 stated she did not know how long Pt #1 had been in the shower unsupervised.

In an interview on 7/30/19 at 2:42 PM in the conference room, Tech #1 was asked about the burn incident regarding Pt #1 on 7/20/19 and Tech #1 stated, "That morning I was in the day room. I had the Q15s [Every 15 minute checks]. [Tech #3] was putting [Pt #1] in the shower. Later I was in the dining room and asked where's [Pt #1]. They said still in the shower and I marked her off. When breakfast was ready, [Tech #2] says someone's missing and that's when [Tech #3] said 'oh crap I forgot about [Pt #1]'. She [Tech #3] went in there to check on her. She hollered for help".
When asked to provide a description of Pt #1 and the bathroom, Tech #1 stated, "...the room was steamy. I said the water was too hot. [RN #2] came in. [Pt #1] was in the shower chair at the back of the shower. She was leaning up against the shower wall. Her body was red, shaking, and her false teeth were falling out".
When asked about Pt #1's ADL status, Tech #1 stated, "...very unsteady...I always stayed in there when I gave her a shower...".
Tech #1 failed to perform a visual observation of Patient #1 while assigned 15 minute checks.

In an interview on 7/30/19 at 2:50 PM in the conference room, Tech #2 was asked about the burn incident regarding Pt #1 on 7/20/19 and Tech #2 stated, "I was on 1 on 1 [observations] with another patient. We were doing breakfast and I said someone's missing. [Tech #3] said okay [Pt #1] in the shower and she would go check on her. Next I heard her [Tech #3] screaming for help. When I got in there [Tech #3] was on her [Pt #1] right side, holding her head up straight. We thought she was seizing. We lowered her to the ground and got her vitals. I tried to wake her up but she was unconscious. I think her temp [temperature] was 101 point something. She was shaking and unconscious is what made us think it was a seizure...".
When asked if she knew how long Pt #1 had been in the shower unsupervised, Tech #2 stated, "I have no idea". When asked to describe the bathroom of Pt #1, Tech #2 stated, "There was steam, it was very hot in there".

In an interview on 7/30/19 at 3:00 PM in the conference room, Registered Nurse (RN) #2 was asked about the burn incident regarding Pt #1 on 7/20/19 and RN #2 stated, "When I heard the tech holler for help, I went over and [Pt #1] was slouched in the chair, facing the curtain shower, head to her right. She was up against the wall, her left side. She [Patient #1] rolled her eyes when I touched her. It was hot in the bathroom. One of the techs lowered her to the floor. She was opening her eyes at that point. The other nurse called an ambulance. You could already see on her left arm, it was burned. She was pretty much red all over. It was hot in there. I don't mean to get no one in trouble, but I'm not lying to anyone...".
RN #2 stated she did not know how long Pt #1 had been in the shower without supervision.

In an interview on 7/30/19 at 3:40 PM in the conference room, the Risk Manager (RM) was asked to provide information regarding her investigation into the burn incident involving Pt #1 on 7/20/19. The RM stated, "I review all allegations...I was in the hospital that day and was able to look at the camera as soon as I was told about it.
At 7:02 [AM] you see the nurse enter the [patient's] room with tubes in her hand. I believe she had to draw blood that day.
At 7:12 you see [Tech #3] and [Tech #1] enter the [patient's] room.
At 7:16 both techs leave the [patient's] room.
At 7:21 you see [Tech #3] enter the [patient's] room and then leave again. No other staff enter the room again until 7:54 when [Tech #3] enters the room. Several seconds after this other techs and a nurse enter the room...".
The RM stated she made color photographs of Pt #1 before she left the hospital with EMS. The RM stated she could see burns at that point. The RM stated, "...she was alone in the [shower] room from 7:22 until 7:54. In my opinion, if they had layed eyes on her, this might not have happened".
The RM was asked if 15 minute checks are visual checks and the RM stated, "Yes. I do that part of the training and I emphasize laying eyes on the patient, all throughout training...she [Tech #1] just didn't do it that day, she took someone's word that the patient was in the shower...".

In an interview on 7/31/19 at 9:46 AM in the conference room, Tech #3 was asked to provide information regarding the burn incident with Pt #1 on 7/20/19 and Tech #3 stated, "I thought she was cognitive enough to take a shower, we obviously didn't know enough...that day I got her shower chair and all supplies set up, got the water ready, checked the temp and told her I'd be back to check on her and went to help with a two person transfer. Also set up two more showers and I got busy. I didn't have the 15 minute checks...went in to set up for breakfast, did head count and realized [Pt #1] was missing...found her sitting in the chair (shower), slumped and passed out...called for [RN #2]. We got her on the ground we thought she may be seizing...didn't notice burns till we got her on the stretcher (EMS). [RN #2] told me later that she had talked to the caregiver who told her [Pt #1] was known to turn the water as hot as it would go to get the bugs off of her...If I'd known that I would have never left her alone...[Pt #1] could stand up, dress herself...didn't need cueing on anything as far as I knew...I left her door open to the bathroom and the hallway ...when I found her it was steamy, water was still running...I was in panic mode so I don't remember what the temp (of water) was...she would have been able to turn the shower knobs...she could have gotten up...". Tech #3 verified that Patient #1 was left alone and unsupervised while taking a shower on 7/20/19.

In an interview on 7/31/19 at 10:26 AM in the conference room, RN #1 (the nurse who initially assessed Patient #1 on the date of admission on 7/17/19) was asked to provide information regarding Pt #1's ADL abilities and nursing assessment upon admission to the facility. RN #1 stated, "She was independent with ADLs. She was getting 15 minute checks, that's routine. She could bathe and reposition herself but had poor insight and poor judgment. The patient did not exhibit good decision making skills...she was anxious on my assessment, but could articulate her thoughts...very calm and cooperative. The only indication of anything psych [psychological] was the feeling of bugs crawling on her...she had had a fall in the last 3 months...she did shuffle a little when she walked...". RN #1 verified that she was not in the facility on 7/20/19, the day of the incident.

In an interview on 7/31/19 at 11:48 AM in the conference room, the hospital's Chief Executive Officer (CEO) was asked to provide information regarding the burn incident with Pt #1 on 7/20/19. The CEO stated, "I was the AOC [Administrator On Call] on 7/20/19. I got a call from [RN #2] and said first thought she [Pt #1] had a seizure. She called back and said it looked like burns and EMS was on the way. I came up here. EMS didn't take her to [Hospital #2]. With second degree burns they took her to [Hospital #1]...from watching the camera, looks about 32 minutes that she was in there...".
The CEO also verified 15 minute checks were not performed visually, as per facility policy.

6. On 8/1/19 at 10:00 AM the CEO and the RM were asked to provide this surveyor a copy of the video footage recording of the hallway outside of Patient #1's room for 7/20/19 the day the patient was left unattended in the shower. The CEO stated the video footage was unable to be retrieved for surveyor review. The RM and CEO stated they had both reviewed the video footage on 7/20/19 after the incident had occurred, and stated they noted from the video that Patient #1 had been left unattended in the shower for 32 minutes.

The facility failed to perform visual 15 minute observation checks and neglected to supervise ADL care on a high risk patient, resulting in burns to the upper extremities of Patient #1 on 7/20/19.