HospitalInspections.org

Based on medical record review, policy and document review, and staff interview, it was determined that the hospital failed to provide care in a safe setting for 9 of the 21 patient whose medical records were reviewed in the sample (Patient #'s 5, 6, 8, 10, 13, 15, 16, 18, and 21) by failing to follow patient observation and special precaution policies. Findings include:

The hospital policy titled "Special Precautions and Patient Level of Observation" states, "A Special Precaution is defined as an intensified level of staff awareness and attention to patient safety/security needs requiring the initiation of specific procedures and additional documentation...Continuous Observation on 1:1 Basis...Patient is in imminent danger of harm to self or others...A progress note entry by nursing staff should be documented in the medical record at least every hour, reflecting the patient's behavior, condition, mood and conversation...There must be a progress note entry by an RN every four (4) hours..."

The hospital policy titled "Patient Observation" policy states, "...Initiate patient observation form upon arrival to prevent self-harm, worsening of condition, and elopement, etc... RN/RS:...Review and update patient observation forms. Reflect changes in individual patient precautions levels...as they occur...Observe each patient, at a minimum of every 15 minutes and/or according to precaution level..."

Medical Record Documentation Requirements policy states, "Documentation of patient care must be performed to communicate the treatment provided and its results. This documentation is to be clear and concise, legible, timely, complete, and accurate."

The Registered Nurse job description states, "...Representative duties and responsibilities...Complies with Rockford Center patient care policies/procedures...Assists in the completion of patient rounds and monitoring patient safety ...."

The Charge Nurse Responsibilities policy states,"...The charge nurse shall ensure staff compliance with the patient observation process...."

Staff interview revealed:

In an interview with Employee #1, Chief Operating Officer (COO), at 9:02 am on 9/8/2022 he/she indicated that it is the expectation that all special precautions are noted on the Patient Observation Record. This is how unit staff are made aware of ordered patient precautions. These precautions are then discussed every day at treatment team meetings to determine if interventions need to be added for patient safety.

Medical record review revealed:

A. Patient #5
1. Admitted on 7/28/22 with diagnoses of major depressive disorder, recurrent, severe, and schizoaffective disorder, bipolar type. The patient was placed on 1:1 (one to one) precautions at time of intake.

2. Treatment plan progress notes revealed:
- 7/29/22 at 11:30 AM, "...Pt still attempting to obtain objects to cut self with ...comb which was removed immediately by 1:1 staff..."
- 8/2/22 at 1:00 PM, "...Pt with SI [suicidal ideation] thought and AV [auditory verbal hallucinations] telling her to hurt self. Pt with abrasive areas to left forearm sustain (sic) last night. Pt continues on 1:1 due to SI and SIB [self-injurious behavior]..."
- 8/5/22 at 4:30 PM, "...Pt took a piece of small metal and cut hand. NP [nurse practitioner] ordered to transfer pt to ER for further eval..."
- 8/16/22 untimed, "...Pt told another staff that she is going to hurt self at night..."

3. Review of Physician's Orders revealed:
- 8/12/22 at 12:00 PM - "Pt [Patient] needs to continue on 1:1 [one to one] level of observation ..."
- 8/18/22 at 2:35 PM - "...[Patient] to sleep in the glass day room. Pt [Patient] persistently states [he/she] will cut [himself/herself] very deep tonight..."
- 8/22/22 at 11:00 AM - "Continue on a 1:1 [one to one] level of observation day and night ...Surge (sic) patient twice a day for contraband..."

4. "Nursing Progress Notes" revealed:
- 8/7/22 at 1:40 PM, "Pt found a metal twist tie and tried to cut herself with it"
- 8/22/22 at 2:00 PM, "...Pt told staff she swallowed a piece of metal..."
- 8/22/22 at 6:00 PM, "...Pt also said she wants whatever she swallowed to cause internal bleeding..."

5. Review of "Patient Observation Records" revealed:
No evidence that observations were completed during the following time frames:
- 8/20/22 9:30 to 11:45 PM (10 observations not documented). Progress note from 8/21/22 suggested patient was in the ED, but no documentation of when patient left this facility on 8/20/22.
- 8/18/22 11:30 to 11:45 PM (2 observations not documented)

6. Review of nursing notes via "Daily Nurse Progress Note" and "Nursing Progress Notes" from 7/28/22 to 8/22/22 revealed:
- 107 missing RN (Registered Nurse) progress notes that were to occur every 4 hours.
- 9 missing RS (Recovery Specialist) notes that were to occur hourly.

7. Patient #5 was sent to the local emergency department and admitted to the hospital on 8/23/22 after an X-ray report from 8/22/22 at 9:36 PM demonstrated two small metallic wire-shaped radiodensities in the mid upper abdomen.

The findings that the nursing staff failed to document patient's behavior, condition, mood and conversation per facility policy while on 1:1 observation level, were confirmed on 9/9/22 between 12:47 to 12:48 PM by Employee #1 COO.

B. Patient #6
1. "Patient Observation Record" documents patient assigned observation level of Q (every) 15 (minutes).
a. No evidence that observations were completed during the following time frames:
- 8/20/22 6:00 to 6:15 PM (2 observations not documented)
- 8/20/22 6:45 to 7:45 PM (5 observations not documented)
- 8/20/22 8:30 to 9:30 PM (5 observations not documented)
- 8/22/22 2:45 to 3:00 PM (2 observation not documented)

These findings were confirmed with Employee #1 COO, on 9/9/22 between 1:00 to 1:27 PM.

C. Patient #8
1. "Patient Observation Record" documents patient assigned observation level of Q (every) 15 (minutes).
a. No evidence that observations were completed during the following time frames:
- 8/20/22 5:45 to 6:30 PM (4 observations not documented)
- 8/20/22 7:00 to 7:45 PM (4 observations not documented)
- 8/20/22 8:30 to 9:30 PM (5 observations not documented)
- 8/27/22 8:45 to 9:45 PM (5 observations not documented)

These findings were confirmed with Employee #1 COO, on 9/7/22 between 10:50 and 11:00 AM.

D. Patient #10
1. "Patient Observation Record" documents patient assigned observation level of Q (every) 15 (minutes).
a. No evidence that observations were completed during the following time frames:
- 7/22/22 5:30 to 6:15 PM (4 observations not documented)
- 8/20/22 6:00 to 6:15 PM (2 observations not documented)
- 8/20/22 6:45 to 7:75 PM (5 observations not documented)
- 8/20/22 8:30 to 8:45 PM (2 observations not documented)
- 8/22/22 2:45 to 3:00 PM (2 observations not documented)

These findings were confirmed with Employee #1 COO, on 9/9/22 between 1:00 to 1:27 PM.

E. Patient #13
1. "Patient Observation Record" documents patient assigned observation level of Q (every) 15 (minutes).
a. No evidence that observations were completed during the following time frames:
- 8/20/22 6:00 to 7:45 PM (8 observations not documented)
- 8/20/22 8:30 to 9:30 PM (5 observations not documented)

These findings were confirmed with Employee #1 COO, on 9/9/22 at 12:58 PM.

F. Patient #15
1. Admission orders dated 8/22/2022 included orders for the following precautions:
-Elopement risk
-Self Harm risk
-Sexual Victimization risk
-Suicidal precautions

2. "Patient Observation Record" shows that ordered precautions were not accurately indicated on the observation record as follows:
-8/27/22: missing Elopement, Sexual Victimization, and Self-injury precautions
-8/28/22: missing Sexual Victimization, and Self-injury precautions
-8/29/22: missing Sexual Victimization, and Self-injury precautions
-8/30/22: missing Sexual Victimization, and Self-injury precautions

3. "Daily Nurse Progress Note" on 8/28/22 states, "...Patient eloped the building..."

4. "Patient Observation Record" Nursing Progress Note from 8/28/2022 states, "Patient is extremely suicidal and eloped off the unit multiple times..."

These findings were confirmed with Employee #1 COO, on 9/8/22 between 2:54 pm and 3:17 PM.

G. Patient #16
1. "Patient Observation Record" documents patient assigned observation level of Q (every) 15 (minutes).
a. No evidence that observations were completed during the following time frames:
- 8/28/22 1:30 to 1:45 PM (2 observations not documented)

This finding was confirmed with Employee #1 COO, on 9/9/22 between 1:00 to 1:27 PM.

H. Patient #18
1. Admission orders dated 7/22/2022 included orders for the following precautions:
-Assault/Homicidal precautions
-Elopement risk
-Sexual Victimization risk
-Sexually Aggression risk
-Suicidal precautions

2. "Patient Observation Record" shows that ordered precautions were not accurately indicated on the observation record as follows:
-8/27/22: missing Suicidal and Assaultive precautions
-8/28/22: missing Suicidal and Assaultive precautions
-8/29/22: missing Suicidal and Assaultive precautions
-8/30/22: missing Suicidal and Assaultive precautions
-9/1/22: missing Suicidal and Assaultive precautions

These findings were confirmed with Employee #1 COO, on 9/8/22 between 8:56 am and 10:34 AM.

I. Patient #21
1. "Patient Observation Record" documents patient assigned observation level of Q (every) 15 (minutes).
a. No evidence that observations were completed during the following time frames:
- 8/20/22 6:00 PM to 7:45 PM (8 observations not documented)
- 8/20/22 8:30 PM to 9:30 PM (5 observations not documented)
- 8/27/22 8:45 PM to 9:45 PM (5 observations not documented)

These findings were confirmed with Employee #1 COO, on 9/7/22 between 11:00 and 11:05 AM.

Based on medical record review, policy review, and staff interview, it was determined that the hospital failed to keep 1 of 16 patients under the age of 18 (Patient #18) in the medical record review sample free from abuse. Findings include:

The hospital policy titled "Homicidal/Assault Behavior Patient Management Risk Reduction Guideline" outlines the following procedure in the event of patient on patient assault, "...Separate the patients involved. The nursing supervisor will notify the nurse manager during the day and/or the Administrator on call and the Risk Manager. The patient's physician or the physician on-call is notified. Patient(s) are assessed for injuries and treatment provided if needed...If the patients is a minor, the parents/guardians are notified of the incident...The involved patients should be debriefed if possible and willing and asked to provide their account of the incident...Leadership, RN and/or physician should determine if patient(s) need to change units or increase observation or precaution levels. Incident report will be completed prior to end of shift..."

The hospital job description titled "Recovery Specialist" states, "...Essential job duties:...Report all areas of concern regarding patient's mental or physical status to the Charge Nurse...Maintain patient, program, department and related documentation ensuring that forms are properly and promptly completed and routed..."

The hospital job description titled "Registered Nurse" states, "...Representative duties and responsibilities...Complies with Rockford Center patient care policies/procedures..."

The hospital policy titled "Charge Nurse Responsibilities" policy states, "...The charge nurse shall gather all clinical information from each member of the nursing staff throughout the shift...Charge Nurse shall ensure that all incident reports are reported to the house supervisor/manager, documented in the computer and that all required paper work is completed prior to the end of their shift."

Medical Record review revealed:

A. Patient #18 (admission 7/22/2022 to adolescent junior unit)
1. "Patient Self Inventory" dated 8/29/2022 has an attached letter written by the patient as part of a group therapy exercise that states "...we just ran for our life. I did it because I was...trigger by [peer] slapped me across the face. So that is why I ran...away..."

There is no evidence of facility response to the patient's allegation that he/she was hit by a peer.

In an interview at 11:41 AM on 9/8/2022 Employee #1, Chief Operating Officer (COO), confirmed the findings above as well as stating that the staff member conducting the group is expected to review any resulting documents (such as the Patient Self Inventory). The expectation would be that any abnormalities would be brought to the attention of the nurse to follow up on.

Based on medical record review, policy review and staff interview, it was determined that the registered nurse (RN) failed to supervise and evaluate the nursing care for 10 of 21 patient in the sample (Patient #'s 4, 6, 7, 8, 10, 12, 13, 15, 16, 21). Findings include:

I. The hospital policy titled "Patient Observation" states, "...Charge Nurse/Nursing Supervisor/Team Leader:...Ensures the Patient Observation Rounds are occurring as ordered, 24 hours per day, seven days a week with reviewing the rounding sheet every four hours and then sign, date, and time..."

The hospital policy titled "Medical Record Documentation Requirements" states, "Documentation of patient care must be performed to communicate the treatment provided and its results. This documentation is to be clear and concise, legible, timely, complete, and accurate...Entries shall be dated, timed, and signed..."

The hospital job description titled "Registered Nurse" states, "...Representative duties and responsibilities...Complies with Rockford Center patient care policies/procedures...Assists in the completion of patient rounds and monitoring patient safety..."

The hospital policy titled "Charge Nurse Responsibilities" states,"...The charge nurse shall ensure staff compliance with the patient observation process..."

Medical Record review revealed:

A. Patient #7
1. Patient Observation Record shows no record of nursing review every four hours for the following dates and times:
- 8/28/22 8:00 AM to 12:00 AM (16 hours)

These findings were confirmed with Employee #1 Chief Operating Officer (COO), on 9/9/22 at 1:00 PM.

B. Patient #6
1. "Patient Observation Record" shows no evidence of nursing review every four hours on the following dates and times:
- 8/4/22 8:00 AM to 4:00 PM (8 hours)
- 8/10/22 4:00 PM to 12:00 AM (8 hours)
- 8/14/22 8:00 AM to 12:00 AM 9 (16 hours)
- 8/19/22 4:00 PM to 12:00 AM (8 hours)
- 8/22/22 12:00 PM to 12:00 AM (12 hours)

These findings were confirmed with Employee #1 COO, on 9/9/22 between 1:00 to 1:27 PM.

C. Patient #8
1. "Patient Observation Record" shows no evidence of nursing review every four hours on the following dates and times:
- 8/20/22 8:00 AM to 12:00 AM (16 hours)
- 8/27/22 12:00 PM to 12:00 AM (12 hours)
- 8/28/22 12:00 PM to 12:00 AM (12 hours)
- 8/28/22 12:00 PM to 12:00 AM (12 hours)

These findings were confirmed with Employee #1 COO, on 9/9/22 between 1:00 to 1:27 PM.

D. Patient #10
1. "Patient Observation Record" shows no evidence of nursing review every four hours on the following dates and times:
- 7/19/22 8:00 AM to 12:00 AM (16 hours)
- 7/22/22 4:00 PM to 12:00 AM (8 hours)
- 7/23/22 12:00 PM to 12:00 AM (12 hours)
- 7/24/22 4:00 AM to 8:00 AM and 4:00 PM to 12:00 AM (12 hours)
- 7/25/22 12:00 AM to 12:00 AM (24 hours)
- 7/26/22 8:00 AM to 4:00 PM (8 hours) and 8:00 PM to 12:00 AM (4 hours)
- 7/27/22 8:00 AM to 4:00 PM (8 hours) and 8:00 PM to 12:00 AM (4 hours)
- 7/28/22 8:00 AM to 4:00 PM (8 hours)
- 7/31/22 4:00 AM to 8:00 AM (4 hours) and 4:00 PM to 12:00 AM (8 hours)
- 8/1/22 4:00 AM to 4:00 PM (12 hours)
- 8/4/22 12:00 PM to 4:00 PM (4 hours) and 8:00 PM to 12:00 AM (8 hours)
- 8/5/22 8:00 AM to 8:00 PM (12 hours)
- 8/14/22 8:00 AM to 12:00 AM (16 hours)
- 8/22/22 12:00 PM to 12:00 AM (12 hours)
- 8/24/22 12:00 PM to 12:00 AM (12 hours)

These findings were confirmed with Employee #1 COO, on 9/9/22 between 1:00 to 1:27 PM.

E. Patient #13
1. Patient Observation Record shows no record of nursing review every four hours for the following dates and times:
- 8/20/22 from 8:00 AM to 12:00 AM (16 hours).

These findings were confirmed with Employee #1 COO, on 9/9/22 at 12:58 PM.

F. Patient #15
1. Patient Observation Record shows no record of nursing review every four hours for the following dates and times:
-8/27/2022: 8:00 AM - 8:00 PM (12 hours)
-8/28/2022: 8:00 AM - 12:00 PM (16 hours)

These findings were confirmed with Employee #1 COO, between 3:05 pm and 3:08 pm on 9/8/22.

G. Patient #18
1. Patient Observation Record shows no record of nursing review every four hours for the following dates and times:
-8/27/2022: 8:00 AM - 12:00 AM (16 hours)
-8/29/2022: 4:00 PM - 12:00 AM (8 hours)
-9/1/2022: 8:00 AM - 4:00 PM (8 hours) and 8:00 PM - 12:00 AM (4 hours)

These findings were confirmed with Employee #1 COO, at 9:48 am on 9/8/22.


II. The hospital policy titled "Medical Record Documentation Requirements" states, "Documentation of patient care must be performed to communicate the treatment provided and its results. This documentation is to be clear and concise, legible, timely, complete, and accurate...Timeframe for Completion...Nursing Progress Notes...RN Daily each shift..."

The hospital job description titled "Registered Nurse" states, "...Representative duties and responsibilities...Conducts ongoing and individualized nursing care duties as assigned and as dictated by the patient's condition in accordance with physician orders and facility protocols...complete...Daily nursing assessments..."

The hospital policy titled "Charge Nurse Responsibilities" states, "...Charge nurse is responsible for daily documentation of progress notes..."

Medical Record review revealed:

A. Patient #4
1. "Daily Nurse Progress Note" shows no evidence of RN progress notes on the following dates and times:
- 8/28/22 day shift
- 8/28/22 evening shift
- 8/29/22 day shift
- 8/29/22 evening shift

These findings were confirmed with Employee #1 COO, on 9/9/22 between 1:00-1:27 PM.

B. Patient #6
1. "Daily Nurse Progress Note" shows no evidence of RN progress notes on the following dates and times:
- 8/4/22 day shift
- 8/10/22 day shift
- 8/20/22 evening shift

These findings were confirmed with Employee #1 COO, between 1:00-1:27 PM.

C. Patient #8
1. "Daily Nurse Progress Note" shows no evidence of RN progress notes on the following dates and times:
- 8/15/22 evening shift
- 8/20/22 evening shift
- 9/2/22 day shift

These findings were confirmed with Employee #1 COO, on 9/7/22 between 10:50-11:00 AM.

D. Patient #10
1. "Daily Nurse Progress Note" shows no evidence of RN progress notes on the following dates and times:
- 7/19/22 evening shift
- 7/21/22 day shift
- 7/25/22 day shift
- 7/27/22 day shift
- 8/20/22 evening shift
- 8/22/22 day shift

These findings were confirmed with Employee #1 COO, on 9/9/22 between 1:00 to 1:27 PM.

E. Patient #16
1."Daily Nursing Progress Note" shows no evidence of nursing review every four hours on the following dates and times:
- 9/1/22 evening shift
- 9/2/22 day shift

These findings were confirmed with Employee #1 COO, on 9/9/22 between 1:00-1:27 PM.

F. Patient #21
1. "Daily Nurse Progress Note" shows no evidence of RN progress notes on the following dates and times:
- 8/20/22 evening shift
- 8/22/22 day shift
- 8/29/22 evening shift
- 8/31/22 day shift

These findings were confirmed with Employee #1 COO, on 9/7/22 between 11:00-11:05 AM.

G. Patient #15
1. Admission orders dated 8/22/2022 included orders for the following precautions:
-Suicidal precautions

2. "Daily Nurse Progress Note" were incomplete for the following shifts:
-8/27/2022: Suicide risk assessment missing; day and evening shifts
-8/28/2022: Suicide risk assessment missing; day and evening shifts
-SI [suicidal ideation] was checked as being present for day and evening shifts

These findings were confirmed with Employee #1 COO, at 3:04 pm to 3:07 pm on 9/8/22.


III. "Diabetic Care" policy states, "...General nursing care of the diabetic patient...Blood glucose levels will be tested at the frequency ordered by the physician...The level will be recorded in the patient's medical record..."

Medical Record review revealed:

A. Patient #12
1. Practitioners Orders dated 8/7/22 included an order that the blood sugar level be obtained/documented before meals and at bedtime daily.
a. No evidence that the blood sugar level was obtained, or that the patient refused to have his/her blood sugar level checked on the following dates and times:
- 8/7/22 before dinner and at bedtime (2 missing)
- 8/8/22 before breakfast and lunch (2 missing)
- 8/9/22 before dinner and at bedtime (2 missing)
- 8/10/22 before lunch (1 missing)
- 8/11/22 before breakfast and lunch and at bedtime (3 missing)

These findings were confirmed with Employee #2, Chief Nursing Officer (CNO), during an interview on 9/9/22 between 1:34 to 1:36 PM.

Based on hospital document review, medical record review, employee record review, and staff interviews it was determined that the facility failed to ensure that all nurses providing services in the hospital adhered to the policies and procedures of the hospital for 2 of 16 patients under the age of 18 in the medical record review sample (Patients # 15 and 18). Findings include:

The hospital policy titled "Elopements: Prevention and Response Guidelines" states, "...If deemed appropriate and ordered by the physician, place the patient in hospital issued clothing..." (underline in original document)

The hospital job description titled "Registered Nurse" states, "...Representative duties and responsibilities...Complies with Rockford Center patient care policies/procedures..."

Medical Record review revealed:

A. Patient #15
1. "Interdisciplinary Master Treatment Plan"
- Elopement Risk added 8/29/2022. Specific interventions include "Patient #15 will wear hospital scrubs and slippers until such time as the treatment team assesses low risk for elopement".

2. "Patient Observation Record Nursing Note" on 8/30/2022 states, "Pt (patient) eloped off the unit with her peers because she was told she had to wear scrubs..."

No evidence of a physician order for the patient to wear hospital issued clothing.

Findings confirmed with Employee #1 COO, at 2:55 PM on 9/8/2022.

B. Patient #18
1. "Interdisciplinary Master Treatment Plan"
-Elopement Risk added 8/29/2022. Specific interventions include "Patient #18 will wear hospital scrubs and slippers until such time as the treatment team assesses low risk for elopement".

No evidence of a physician order for the patient to wear hospital issued clothing.

Findings confirmed with Employee #1 COO, at 9:44 AM on 9/8/2022.

Based on medical record review and policy and document review, it was determined that for 2 of 21 patients (Patient #'s 8 and 10) in the sample, nursing staff failed to administer medications in accordance with the practitioner orders and approved hospital policies. Findings include:

The hospital policy titled "Medication Administration for Nursing" states, "...Nurses are responsible for...administering their assigned patient's medications...the nurse must reference the MAR (medication administration record) when preparing and administering medications to compare the dosage ordered..."

The hospital job description titled "Registered Nurse" states, "...Administer patient medications as prescribed by physician..."

Medical Record review revealed the following:

A. Patient #8
1. 8/20/22 9:57 PM physician order for clorpromazine (Thorazine) tablet 25 mg (milligrams) oral now for agitation.
- no evidence in MAR that Thorazine 25 mg oral was administered on 8/20/22 as ordered or refused by patient
2. 8/28/22 2:16 PM physician order for diphenhydramine (Benadryl) capsule 50 mg oral STAT (immediately) for agitation.
- no evidence in MAR that Benadryl 50 mg oral was administered on 8/28/22 as ordered or refused by patient

These findings were confirmed with Employee #1, COO, on 9/7/22 between 10:50-11:00 AM.

B. Patient #10
1. 7/19/22 9:00 PM physician order for prazosin (Minipress) capsule 1 mg oral at bedtime for nightmares.
- no evidence in MAR that Minipress capsule 1 mg oral at bedtime was administered on 7/19/22 as ordered or refused by patient
2. 7/19/22 9:00 PM physician order for pimozide (Orap) tablet 1 mg oral at bedtime for tourettes (syndrome).
- no evidence in MAR that Orap tablet 1 mg oral at bedtime was administered on 7/23/22 as ordered or refused by patient
3. 7/27/22 12:43 PM physician order for loratadine (Claritin) tablet 10 mg oral now for allergies
- no evidence in MAR that Claritin tablet 10 mg oral was administered on 7/27/22 as ordered or refused by patient

These findings were confirmed with Employee #1, COO, on 9/9/22 between 1:00 to 1:27 PM.