HospitalInspections.org

Based on interview and record review the facility failed to ensure the patient's right to receive care in a safe setting for 1 out of 10 sampled patients (SP#6).

Finding Include:


The Risk Manager B on 6/20/17 at 2:08 pm confirmed that Sampled Patient (SP) #6 was choked by another patient on the unit. The event/incident happened on 1/27/17 at 9:30 am in the CAAP unit in the common area. The staff observed the event and the fight was broken up. SP#6 was sent to the Pediatric Emergency Department and the patient was cleared to come back to the Psychiatric unit. SP#6 came back to the CAAP unit at 12:40 pm.

The Discharge Documentation on 01/27/2017 showed the patient was grabbed by another patient on the unit after a verbal altercation occurred. The patient was sent to the ER (Emergency Room) for medical clearance prior to being discharged home.

The Director of Quality on 6/21/17 at 12:30 pm requested to provide the medical record for the adolescent that choked SP#6 on 1/27/17. She was unable to identify the patient, and did not provide records for the other patient involved in the incident with SP#6. The facility was unable to provide evidence of separation between SP#6 and the other adolescent who choked SP#6.

The facility's policy "Patient Rights and Responsibilities" (revised: 02/28/2017), states under the Patient's Bill of Rights and Responsibilities (on page 5 of 6) to receive care in a safe setting.

Based on record review, policy review and interview the facility failed to have adequate numbers of licensed registered nurses, to provide nursing care to all the patients as needed on the Child and Adolescent Crisis and Inpatient (CAAP) unit on the 7:00 PM to 7:00 AM shift on June 17, 2017.


The findings:


Review of the staffing for 06/17 /2017 showed that on 7pm-7am shift, Registered Nurses (RN) Staff O and Staff S were the staff assigned on the CAAP unit.

Review of the Child and Adolescent Crisis and Inpatient (CAAP) unit staffing with the Interim Chief Nursing Officer on 6/20/17 at 10:30 am revealed that on (Saturday) 06/17/2017 on the 7p-7a shift that there were 11 patients, with 2 nurses, and 2 Mental Health Specialist (MHS). Review of the staffing showed a note, "TO BT 4:30 a 3 Admit". Review of the census for the CAAP unit provided on 6/20/17 at 1:22 pm revealed that there were 11 patients.


Interview with Registered Nurse (Staff O) on 06/20/17 at 12:25 pm revealed that he works as an RN on the 7pm-7am shift on 06/17/2017, and on the CAAP unit the nurse to patient ratio is 1 (one) nurse to 9 patients. He further stated that on rare occasion, when another unit get slammed with admissions such as like last Saturday at 4:00 am to 5:00 am he was left as the only RN by himself on the CAAP unit, and the RN working with him was sent to another unit to help. He further stated that the Administrator in Charge (AIC) explained why, and that is to help admit patients. He stated that he took care of nine patients, and then admitted two patients. Eleven total patients he took care of by the end of the shift.

Interview with Registered Nurse (Staff S) on 6/20/17 at 2:45 pm revealed that on 6/17/17 she floated to another unit to help as requested by the AIC for admissions. She went to the BT unit around 4:00 am, admitted patients, and finished on the BT after 7:00 am. She further stated that she stayed on the BT unit. She stated that when she left the CAAP unit, there was one RN and 2 MHS, with 10 pts.

Review of the CAAP Scope Care showed Staffing Patterns: 7:00 pm-7:30 am patient ratio for RN to patient is nine patients to one RN, and two Mental Health Specialist. The facility failed to follow its own policy in providing appropriate staffing.

Based on record reviews and interviews, the facility failed to reassess the patient's discharge plan and provide an appropriate discharge for 1 out of 10 Sample Patients (SP) #1.

Findings include:


Record review of the Behavioral Health Progress Notes for sample patient (SP) #1, the Plan showed the patient continues to require 24-hour observation, nursing care, and inpatient treatment and cannot be treated in a less restrictive environment. This plan was documented consistently and repeatedly on February 25, 26, 27, 28 and March 1, 2017. This documentation was verified, and signed electronically by the Attending Psychiatrist.

Record review of the Behavioral Health Progress Notes for SP #1, the History of Present Illness showed I saw and evaluated today with Attending Psychiatrist and the treatment team, discussed in morning report. I also received face- to- face sign out from nursing staff. No behavioral problems, was not a management problem. Remains psychotic, disorganized behavior, paranoid upon approach, crying inappropriately and appears internally preoccupied. Patient has limited insight as to her illness and medications, posing a risk to self and/or others, as well as risk for self- neglect, necessitating management in restrictive environment. This was documented by (name of Resident) and co-signed by Attending Psychiatrist on 3/1/2017.


Record review of the Discharge Documentation for SP #1 dated 3/2/2017 revealed the Disposition was to Supportive Housing- (name and address of an Independent Living Facility (ILF).

Record review of Policy & Procedure Manual Section 100-200 Administration. Subject: "Discharge Planning" states that throughout the patients hospitalization the multidisciplinary team will monitor, coordinate and reassess the patient's progress towards treatment goals and review the discharge plan to determine if the plan is meeting the needs of the patient. The facility failed to follow this policy.