HospitalInspections.org

Based on observation, interview, record review and video review, the facility failed to:
- Create a therapeutic environment to prevent the escalation (increase in intensity) of one discharged patient (#30), of one discharge patient reviewed who had become agitated.
- Protect the dignity of one discharged patient (#30) of one discharged patient reviewed for dignity.
- Ensure ongoing nursing assessment, interventions, and oversight to meet the patient's care/services and/or prevention of complications for seven fall risk patients (#20, #23, #27, #22, #47, #48 and #49) of nine fall risk patients reviewed.
The failure to provide a therapeutic environment, and the lack of adequate evaluation and supervision of patient safety needs, had the potential to affect all patients at the facility. The facility census was 875. The Psychiatric Center Census was 33.

Findings Included:

1. Review of the facility's policy titled, "Restraints: Management of Violent and Self-Destructive Behaviors," dated 09/2017, showed that:
- Patients have the right to considerate, respectful, understandable and effective care with competent encounters with staff, recognizing their need for personal dignity.
- Behaviors that precipitate the decision to restrain should trigger further investigation aimed at understanding and eliminating the causes of the behaviors.
- Restraints should be used only after collaborative decision-making among physicians, nurses and other team members.

Review of Patient #30's medical record showed that:
- The patient was a 31-year-old voluntary (agreed to admission without a court order) male, admitted to the Psychiatric Center on 02/04/18, for depression.
- The patient's history included several psychiatric diagnoses.
- He was placed on 1:1 observation (one staff, also known as a "sitter", observes one patient at all times) because he attempted to hang himself while in the hospital.

Observation on 03/20/18 at 8:50 AM, of recorded video surveillance on 02/06/18 showed the following in the Psychiatric Center:
- Between 3:20 PM and 3:35 PM, several staff, which included Staff PPP, Sitter/Registered Nurse (RN); Staff VVV, Mental Health Technician (MHT); Staff YYY, Public Safety Officer (PSO); Staff UUU, PSO; Staff TTT, PSO; Staff MMM, Assistant Nurse Manager; Staff SSS, PSO; Staff OOO, Psychiatric Center Manager and Staff RRR, Assistant Psychiatric Center Manager responded in and around Patient #30's room (room confirmed by facility staff).
- At 3:28 PM, the four PSOs (Staff SSS, TTT, UUU and YYY) pulled the patient from his room into the hall.
- At 3:35 PM, staff lifted the patient up, transferred the patient through the hall to the seclusion room (a form of restraint, where patients are forced to stay in a room without other patients), with the patient's lower half of his body uncovered and genitals exposed.
- Eight staff, which included PSOs, RNs, one MHT and one leader, assisted or walked alongside the patient during the patient transfer, but failed to cover the patient's genitals.

During an interview on 03/20/18 at 1:44 PM, Staff PPP, Sitter/RN, stated that:
- On 02/06/18, the patient had been masturbating (form of self, sexual stimulation) under the covers.
- She approached the patient, asked him to stop masturbating and informed him that it was inappropriate.
- The patient pulled his scrub pants down and exposed his penis.
- When Staff VVV, MHT, came to take over her sitter responsibilities, Staff PPP went down the hall and told Staff YYY, PSO, about the patient masturbating in front of the nurses.
- Staff PPP and Staff YYY returned to the patient's room and told the patient to quit masturbating in front of the nurses.
- The patient became angry and stated, "The next bitch that lies about me, I'm gonna pop in the jaw."
- Staff YYY attempted to calm the patient and when the patient pushed Staff YYY and made him lose balance, Staff PPP yelled for help.
- During the take down (to gain control of) and transfer of the patient to the seclusion room, Staff PPP, directed other patients and visitors from the dining room into the television room. (In transferring the patient to the seclusion room, the path takes them through the dining room).
- The television room had a view of the dining room with large picture windows. (The patients, staff and visitors were able to see Patient #30 transferred).
- Patient #30 had no pants on during the transfer.

During a telephone interview on 03/20/18 at 3:45 PM, Staff VVV, MHT, stated that when Staff YYY went into the patient's room to speak with him, the patient became upset, stood up and punched the wall, so she went to get help.

During an interview on 03/21/18 at 2:00 PM, Staff YYY, PSO, stated that:
- Staff PPP, Sitter/RN, asked him to speak with Patient #30 about masturbating in front of the nurses.
- He entered the room and spoke calmly to the patient.
- The patient became angry and stated, "Those bitches were lyin."
- The patient stood up and punched the wall.
- Staff YYY radioed for assistance.
- The patient charged at him.
- The patient continued to fight him and the other PSOs that came into the patient's room.
- Both he and Staff SSS, PSO, attempted to walk the patient to the seclusion room.
- The patient resisted and the four PSOs wrestled the patient onto the bed.
- When they attempted to transfer the patient, the patient fought them, and they had to lower him to the ground.

2. During an interview on 03/20/18 at 2:52 PM, Staff UUU, PSO, stated that he and Staff TTT, PSO, attempted to gain control of Patient #30, which was when the patient's pants were ripped.

During an interview on 03/20/18 at 2:32 PM, Staff TTT, PSO, verified that Patient #30's genitals were exposed.

During an interview on 03/20/18 at 3:30 PM, Staff RRR, Assistant Psychiatric Manager, stated Staff YYY, PSO addressed Patient #30 about his masturbation, because they had no male (patient care) staff available to address it.

During an interview on 03/21/18 at 10:28 AM, Staff MMM, Assistant Psychiatric Manager (1 of 2), stated that Staff PPP, Sitter/RN, should have notified her (about the patient masturbating) instead of security. Staff MMM added that although the patient's dignity was compromised, she felt that safety was before dignity.

During an interview on 03/21/18 at 10:17 AM, Staff LLL, RN, stated that she would not have alerted security unless Patient #30 masturbated outside of his room, and confirmed that no staff attempted to cover the patient's genitals during the transfer.

During an interview on 03/21/18 at 10:00 AM, Staff KKK, RN, stated that the path from Patient #30's room to the seclusion room, went past the large wall of windows in the television room (the location of the other patients, visitors and staff).

During an interview on 03/21/18 at 10:47 AM, Staff OOO, Manager of the Psychiatric Center, stated that:
- Since the transfer of ownership of the Psychiatric Center, there was confusion for staff of the role of security.
- The situation was out of control and it was hard to think about dignity.
- Staff PPP, Sitter/RN, should have notified the nurse first, and then communicated with the physician.

During an interview on 03/21/18 at 11:07 AM, Staff NNN, Psychiatric Center Administrative Director, stated that the sitter should have brought this issue (masturbation) to the treatment team instead of security, and when she made it a security issue, it was their mistake.

During an interview on 03/22/18 on 9:35 AM, Staff BBBB, Chief Nursing Officer (CNO), stated that:
- The sitter practiced under the authority of the patient's RN and should have reported it to her (patient's RN) first.
- This was not their finest moment, but was a teaching moment.
- Her expectation was for the staff to follow their behavior management policy.

3. Review of the facility's policy titled, "Fall Prevention-Inpatient," revised 08/2017, showed the directives for RN's to document fall prevention interventions at admission, at least daily, on transfer to another unit, when the patient's condition changes and/or following a patient's fall. Assessment and interventions included:
- Complete the Fall Risk Assessment Tool utilizing patient assessment and observation, patient/family interview, past medical history and clinical judgement;
- Low fall risk requires low interventions;
- Moderate fall risk requires low and moderate interventions, including a yellow arm band;
- High fall risk requires low, moderate, and high interventions, including a yellow arm band; and
- Document on the Assessment flowsheet under the fall risk parameters, risk assessment/reassessment findings, and the risk level interventions implemented.

Review of the facility's policy titled, "Assessment/Reassessment of Patients," revised 09/2017, showed the directives that all patients receiving care are assessed by qualified individuals to determine the patient's initial needs, changing needs, and the effectiveness of care interventions:
- Assessment data from all disciplines are utilized to determine and prioritize the care needs of the patient.
- Reassessment across disciplines is ongoing and occurs at designated intervals during the course of the patient's treatment to determine the response to and effectiveness of the care and interventions.
- Elements of the assessment are defined by the components of the nursing flow sheet and the patient profile, which includes if the patient is identified to be at risk for fall, patient education and interventions will be implemented accordingly.
- The assigned RN is responsible for the patient care assessment.

Observation on 03/20/18 at 3:40 PM in the Surgical Intensive Care Unit (SICU), showed Patient #20 without a yellow arm band.

Review of Patient #20's fall risk assessment dated 03/19/18 through 03/21/18, showed that the patient was a high fall risk and that the patient had a yellow arm band.

During an interview on 03/20/18 at 3:45 PM, Staff AA, RN, stated that:
- Patient #20 did not have a yellow arm band on to indicate she was a fall risk;
- She had documented on 03/20/18 at 7:00 AM, that the patient was a high risk for falls, and had a yellow arm band;
- The documentation in the medical record should have been an accurate account of the interventions performed on the patient; and
- Her documentation was not accurate because the patient was not wearing a yellow arm band.

During an interview on 03/20/18 at 3:50 PM, Staff OO, Clinical Nurse Manger, SICU, stated that it was her expectation that the documentation in the medical record reflected true and accurate information of the interventions performed on the patients.

Observation on 03/20/18 at 2:05 PM, in the 7400 Orthopedic Unit, showed Patient #23 without a yellow arm band.

Review of Patient #23's fall risk assessment dated 03/20/18 at 12:15 PM, showed that the patient was a moderate fall risk and that the patient had a yellow arm band.

During an interview on 03/20/18 at 2:15 PM, Staff T, RN, stated that patient #23 should have had a yellow arm band. The fall assessment that she had documented in the medical record showed that the patient had a yellow arm band.

Observation on 03/20/18 at 2:20 PM, in the 7300 Orthopedic Unit, showed Patient #27 without a yellow arm band.

Review of Patient #27's fall risk assessment dated 03/20/18 at 12:30 PM, showed that the patient was a moderate fall risk and that the patient had a yellow arm band.

During an interview on 03/20/18 at 2:30 PM, Staff KK, RN, stated that Patient #27 should have had a yellow arm band on. The fall assessment that she had documented in the medical record showed that the patient had a yellow arm band.

Observation on 03/20/18 at 2:35 PM, in the 7300 Orthopedic Unit, showed Patient #22 without a yellow arm band.

During an interview on 03/20/18 at 2:38 PM, Patient #22 stated that she had been in the facility for two days and never had a yellow arm band.

Review of Patient #22's fall risk assessment dated 03/20/18 at 7:20 AM, showed that the patient was a moderate fall risk and that the patient had a yellow arm band.

During an interview on 03/20/18 at 2:40 PM, Staff TT, RN, stated that Patient #22 should have had a yellow arm band on. The fall assessment documented in the medical record showed that the patient had a yellow arm band.

During an interview on 03/20/18 at 2:45 PM, Staff CC, Clinical Nurse Manger, 7300 and 7400 Orthopedic Units, stated that if the nurses had documented interventions in the medical record, the interventions should have been performed on the patient. If the patients were moderate to high risk for falls, the patients should have worn a yellow arm band.

Observation on 03/21/18 at 10:45 AM, in the Hematology/Oncology Unit, showed Patient #47 without a yellow arm band.

Review of Patient #47's fall risk assessment dated 03/21/18 at 8:25 AM, showed that the patient was a moderate fall risk and that the patient had a yellow arm band.

During an interview on 03/21/18 at 10:55 AM, Staff FFF, RN, stated that patient #47 should have had a yellow arm band on. The fall assessment that she had documented in the medical record showed that the patient had a yellow arm band.

Observation on 03/21/18 at 10:45 AM, in the 7800 Intensive Care Unit (ICU), showed Patient #48 without a yellow arm band.

Review of Patient #48's fall risk assessment dated from 03/19/18 through 03/21/18, showed that the patient was a high fall risk and that the patient had a yellow arm band.

During an interview on 03/21/18 at 11:28 AM, Staff GGG, RN, stated that Patient #48 should have had a yellow arm band on. The interventions performed on the patient should have been the same as what was documented in the medical record.

During an interview on 03/21/18 at 11:30 AM, Staff HHH, Assistant Clinical Nurse Manager, 7800 ICU, stated that the interventions documented in the medical record should be the same interventions performed on the patient.

Observation on 03/21/18 at 10:45 AM, in the 7800 ICU, showed Patient #49 without a yellow arm band.

Review of Patient #49's fall risk assessment dated from 03/19/18 through 03/21/18, showed that the patient was a high fall risk and that the patient had a yellow arm band.

During an interview on 03/21/18 at 11:05 AM, Staff III, RN, stated that patient #49 should have had a yellow arm band. Every nurse that documented that the patient was high risk for falls from 03/19/18 through 03/21/18, failed to implement the yellow arm band.

During an interview on 03/21/18 at 11:10 AM, Staff JJJ, Assistant Clinical Nurse Manager, 7800 ICU, stated that the nurses' interventions for the patient should match the nurses documentation in the medical record.

Review of the facility's fall events per day, for 02/2018, showed that the facility had an average of 4.6 falls per day, with an average of one fall per day that resulted in harm.

During an interview on 03/22/18 at 10:05 AM, Staff DDD, Emergency Department RN, stated that when a patient was a fall risk, the staff should place a yellow arm band on the patient, which indicated to the multidisciplinary team that the patient was a fall risk.

During an interview on 03/22/18 at 9:00 AM, Staff AAA, Rehabilitation Manger, stated that her occupational, physical and speech staff (multidisciplinary) looked for patients' yellow arm bands as an indicator of fall risk when they provided therapy to patients.

During an interview on 03/22/18 on 9:35 AM, Staff BBBB, CNO, stated that her expectation was for the staff to follow their fall risk policy.









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