HospitalInspections.org

Based on staff interviews, medical record review (#1), and review of facility policy and procedure, it was determined the facility failed to ensure Patient (P)1's plan of care was updated and new interventions were implemented after his/her involvement in physical altercations with peers and the Interdisciplinary Team (IDT) meetings with Patient #1 (P1) to discuss incidents which took place on 5/27/23, 8/19/23, and 8/30/23, are documented.

Findings include:

Reference: Facility policy titled "Person-Centered Care-Recovery Management Plan (RMP), 2023, states, " ... Exceptions to the regular treatment plan schedule, are a review of a patient's change in status, restraint review, placement on/off precautions, review of incidents, and level changes. In these instances, the Recovery Management Plan - interim update form ... is used. The interim update form indicates the reason for the interim review and records changes in the patient's treatment ... ."

Review of Medical Record 1 (MR1) on 11/22/23, revealed the following:

There was no evidence in the medical record P1 was placed on 1:1 (one-to-one) close observation for the month of May 2023. P1 was placed on 1:1 close observation in July, August, and October, 2023.

Documentation in the medical record revealed P1 was involved in incidents with other patients on 5/27/23, 7/25/23, 8/19/23, 8/30/23, and 10/22/23. P1 was the identified as the aggressor during the incident which took place on 8/19/23. After each incident, P1 was evaluated by a medical physician. P1 was sent to other units for a "sleepover" following the incidents occurring on the above mentioned dates. (A "sleepover" is a temporary transfer to another unit and not considered an official transfer to another unit). All incident reports contained documentation of the incident, witness statements, and all the necessary disciplines who were informed of the incidents. The 1:1 close observation sheets from 7/25/23, 8/19/23 and 8/30/23 were completed in entirety without missing spaces. Documentation in the medical record lacked evidence that the above mentioned incidents were discussed with P1 by the Interdisciplinary Team (IDT). During a facility tour on 11/22/23, the following staff members were interviewed and the following was revealed:

At 11:15 AM, Staff (S)6, Registered Nurse (RN), stated that an incident report is generated for incidents of self-injurious behavior (SIB), sexually inappropriate behavior, and physical/verbal assaults and threats. S6 stated that the Charge Nurse (CN) is responsible for completing all necessary sections of the incident report and also collecting witness statements to go with the incident report. S6 stated the interdisciplinary team (IDT) meets with the patient(s) involved in the incident to discuss what happened.

At 11:35 AM, S7, Licensed Practical Nurse (LPN), stated that the charge nurse is responsible for filling out most of the incident report. S7 stated that when a physical or verbal altercation occurs between patients, the patients are separated, all parties involved meet with the IDT, and then one of the patients is sent to another unit for a "sleepover." S7 stated that after the incident has been diffused the psychiatric physician and the medical physician will assess all parties involved in the incident.

On 11/22/23 at 11:45 AM, S1, Quality Assurance (QA) Coordinator, confirmed that MR1 did not contain documentation of the IDT meeting with P1 to discuss the incidents which took place on 8/19 and 8/30/23. On 11/22/23 at 1:31 PM, S2, the Chief Operating Officer (COO), also confirmed that MR1 did not contain documentation of the IDT meetings with P1 to discuss the incidents which took place on 5/27, 8/19, and 8/30/23.