HospitalInspections.org

Based on facility policy review, medical record review, and interview, the facility failed to assist 1 patient (Patient #1) up from the floor after asking for staff assistance of 7 patients reviewed for neglect.

The findings include:

Review of the facility's policy titled "Patient Rights and Responsibilities" dated 12/9/2014, showed "...protect and respect the fundamental human and legal rights of all patients throughout the course of their hospitalization...Each employee shall uphold such basic human rights as will afford each patient the dignity, respect and consideration inalienable to the individual. Consideration shall also be given to the psychosocial, spiritual, and cultural variables that influence individual patients' perceptions of their illness(es) as well as their unique health care needs...right to humane care and treatment including recognition and protection of your personal dignity, receiving medical care and other professional services..."

Medical record review showed Patient #1 was admitted to the facility on 4/3/2021 with diagnoses including Bipolar Disorder, Alcohol Dependence, Pain, Dumping Syndrome (a condition where the stomach empties faster than normal) and Personal History of Pulmonary Embolism (blood clot).

Medical record review of a Nurse's Admission Assessment dated 4/3/2021 showed Patient #1 was independent with dressing, bathing, feeding, oral hygiene, and toileting and had no physical impairment. Patient #1's overall strengths include "...willing to participate in treatment...able to verbalize needs..." Further review showed Patient #1 was cooperative and showed no signs of aggressive behavior.

Medical record review of a Nurse's note dated 4/8/2021 at 1:45 AM showed "...[Patient #1] came out of her room at 11pm [11:00 PM], requested to go the bathroom. She was let in the bathroom, she walked in, and when she came out [of the bathroom] she stated she needed an ambulance. This is a continuation of her earlier behavior, c/o [complains of] various non-existent ailments and wanting an ambulance. She was cleared by [named the physician] at 7pm [7:00 PM]. When patient was advised she could not get an ambulance, she laid down in the floor and began screaming and kicking her legs. I verbally de-escalated her to get her to stop screaming. I explained that the Doctor had already looked at her and she was fine. She started telling me that something happened before I got here, and I told her I was here and had talked to the Doctor about her case then...She said 'well, get me a wheelchair then'...I told her no, she did not have a wheelchair ordered, nor did she need one, she was walking just fine. She then said 'Well you pick me up then'...I told her I was not going to do that either as she was able to get herself up, just as she had gotten herself down. Patient refused to get up. She was not endangering herself or anyone else, and it was felt she would get tired of lying on the floor and get up. Now at 130am [1:30 AM] she has voided on the floor, through her clothes. She continues to refuse to get up, even to dry herself. We have cleaned up the floor so there is no risk to staff or peers of falling. Patient continues to lie in the floor and refuses to get up or even help us to get herself up. She expects to be lifted manually. Will continue to monitor. Nurse supervisor aware of situation and monitoring. Patient asked another nurse for water to drink, when he gave it to her, she continued lying on her back to attempt to drink it; the other nurse took the water back, advising her she would aspirate attempting to drink it that way. I tried to talk to her at 2:05am [2:05 AM], she refuses to look at me or acknowledge me in any way. I have called for help and have arranged for a wheelchair, and we are going to try to lift her up. She is obese and does not appear to be apt to help..."

Medical record review of a Nurse's note dated 4/8/2021 at 2:33 AM showed multiple staff members from another unit came to Patient #1's room to assist in getting the patient up from the floor at 2:15 AM (approximately 3.5 hours after Patient #1 laid down on the floor).

During an interview on 9/9/2021 at 11:40 AM, the Assistant Superintendent for Quality Management Services stated "...all patients should receive the care you would expect your mother to receive..." Further interview confirmed Patient #1 did not receive the expected standard of care during the incident that occurred on 4/8/2021.

During an interview on 9/9/2021 at 1:01 PM, the Medical Director confirmed the nurse's actions did not follow the customary philosophy of the facility and allowing the patient to lay in the floor did not fit into the practice of the hospital.

During an interview on 9/9/2021 at 2:54 PM, the Utilization Manager confirmed the nurse's actions did not represent the facility's goal in providing patient care and the patient's rights had not been maintained in the treatment provided.