HospitalInspections.org

Based on interview and record review, it was determined the hospital failed to protect and promote each patient's rights.

Findings include:

1. The hospital failed to ensure patients' received care in a safe setting. (Refer to tag A-144)

2. The hospital failed to ensure each patient was free from all forms of abuse or harassment. (Refer to tag A-145)

Based on interview and record review, it was determined the hospital did not ensure patients received care in a safe setting for 3 of 12 sample patients. Specifically, there were patient care and treatment concerns, which did not lend to a therapeutic and safe environment. (Patient identifiers: 3, 8, 11 and supplmental patient 12).

Findings include:

1. Patient 3's medical record review was completed on 8/25/2021.

Patient 3 was admitted on 7/27/2021, with diagnoses of major depressive disorder, suicidal ideation, and bipolar disorder. Patient 3 was discharged on 8/24/2021.

A review of the facility's incident log was completed on 8/25/2021 and revealed patient 3 had 4 incidents of aggression towards patients 8, 11 and 12.

2. Patient 8's medical record review was completed on 8/25/2021 and revealed the following:

Patient 8 was admitted on 8/11/2021, with diagnoses of major depressive disorder, disruptive mood dysregulation disorder, and suicidal ideation.

On 8/18/2021 at 8:23 PM, patient 8 was punched by patient 3.

On 8/19/2021 at 3:00 PM, it was documented on a nursing progress note that patient 8 had an increase in anxiety and felt scared of the peer (patient 3) that assaulted her. It was documented patient 8 was staying close to staff.

On 8/19/2021 at 8:15 PM, patient 8 was punched for the second time by patient 3.

On 8/20/2021 at 3:00 PM, it was documented on a nursing progress note that patient 3 "feels scared and unsafe." Patient 3 requested to spend time in her room due to increased anxiety from being attacked twice.

Patient 8 was discharged on 8/21/2021.


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3. Patient 11's medical record review was completed on 8/25/2021.

Patient 11 was admitted to the hospital on 8/18/2021 with a diagnosis of major depressive disorder (MDD) with suicide attempt. Patient 11 was discharged on 8/23/2021.

Patient 11 was admitted to the hospital for MDD recurrent with a suicide attempt (intentionally overdosed on 15 Trazodone). There were also reports of her trying to stab herself with a kitchen knife.

It was documented in a nursing progress narrative note dated 8/23/2021, at approximately 11:08 AM patient 11 was sitting in the day room on her tablet when patient 3 approached her and hit her on the right side of her face above her ear. It was documented that after the incident patient 11 was tearful and confused by the incident, and staff had assured her that she had not provoked patient 3.

It was documented in a medical progress note dated 8/23/2021, patient 11 had right temple pain after she was hit by another patient (patient 3) on the right side of "face/head."

It was documented in an acute psychiatric progress note dated 8/23/2021, patient 11 "was very scared and anxious during interview after getting hit in the head by another pt. (patient)." It also documented, that prior to the incident patient 11 was improving with her anxiety and depression.

A case management note entry dated 8/23/2021 documented, patient 11's parents were informed of the incident and were contemplating pressing charges. It was also documented, the parents decided that due to the incident it would be best to discharge patient 11 and have her come back home.

Patient 11's individual treatment plan had several short-term goals dated 8/21/2021. The original target date for meeting the short-term goals were 8/31/2021; it was then crossed out and replaced with her unexpected discharge date on 8/23/2021.

Note: due to the incident patient 11's treatment was unexpectedly cut short.

4. Patient 12 was admitted to the hospital on 5/21/2021 with a diagnosis of bipolar disorder. Patient 12 was discharged on 8/13/2021.

It was documented on the incident log that patient 12 was involved in an altercation with patient 3 on 8/6/2021. On 8/26/2021, a focused review of patient 12's medical record was completed, specifically for the date of 8/6/2021.

It was documented on a nursing progress note dated 8/6/2021, patient 12 was in a fist fight after another patient (patient 3) punched her in the face. It also documented, patient 12 was talking in a loud voice and triggered patient 3; patient 12 responded by punching patient 3 back.

It was documented in an acute psychiatric progress note dated 8/9/2021, that a peer (patient 3) attacked patient 12 and she defended herself and then she was calm. It was also documented that patient 12 handled it well and kept her emotions under control.

It was documented on a social services individual and family progress note dated 8/10/2021, that patient 12 had been involved in an altercation over the weekend, and "All reports indicate that pt (patient 12) was NOT the aggressor and only acted in self-defense and allowed staff to intervene and disengaged when they did."

5. On 8/25/2021 at 9:52 AM an interview was conducted with the hospital's chief nursing officer (CNO) and risk manager. They were both asked about the incidences involving patient 3. The CNO stated it was a challenge to try and keep patient 3 separate from the other patients. They had moved programs around to try and provide the least restrictive yet therapeutic environment to patient 3. Then out of the blue she would do something. The CNO stated isolation was unheard of and was not standard of practice, so they utilized one to one observation, and did not hesitate to do so when needed. The CNO further stated that after every incident, three he recalled, they responded accordingly the best they could.

Note: patient 3 was discharged on 8/24/2021, therefore there was no immediate threat to any other patients.

Based on interview and record review, it was determined the hospital did not ensure each patient was free from all forms of abuse for 4 of 12 sampled patients. Specifically, the hospital did not complete a thorough investigation into incidents of abuse, which led to more abuse. (Patient identifiers: 3, 8, 11 and suplemental patient 12).

Findings include:

1. Patient 3's medical record review was completed on 8/25/2021.

Patient 3 was admitted on 7/27/2021, with diagnoses of major depressive disorder, suicidal ideation, and bipolar disorder.

A review of the facility's incident log was completed on 8/25/2021 and revealed the following documentation:

There were 11 incidents of aggression documented involving patient 3.

The first incident was on 7/28/2021 at 6:41 PM, the day after she was admitted. Patient 3 wanted to "punch and assault another patient... after attempts to attack the other patient were thwarted, Pt (patient) began punching the walls."

On 7/29/2021 at 2:50 PM, patient 3 was restrained from trying to assault another peer.

On 7/30/2021 at 1:45 PM, patient 3 became agitated and started punching walls. At 9:00 PM the same day, patient 3 cut herself with a spork. She was transferred to a hospital for treatment of her injuries.

On 7/31/2021 at 12:35 PM, patient 3 started punching walls. She hurt her hand and required medical attention again.

On 8/3/2021 at 1:30 PM, patient 3 started punching walls, the floor and windows.

On 8/4/2021 at 8:30 PM, patient 3 used a spork she had been hiding to reopen the cut on her arm, after the cutting incident she began punching walls. Patient 3 was ordered to be on one to one supervision at this time.

On 8/6/2021 at 3:45 PM, patient 3 appeared agitated and anxious about another peer. Staff attempted to verbally deescalate and remove the patient from the situation when patient 3 suddenly ran to a peer (patient 12) and punched her. Patient 3 was ordered to be one to one supervision at the time.

On 8/11/2021 at 7:10 PM, patient 3 started punching walls.

On 8/18/2021 at 8:23 PM, patient 3 stated she was going to assault another patient. It was documented that before staff even had time to react patient 3 ran into the dayroom and started punching a peer (patient 8). Patient 3 was put into seclusion, and given an injection. After patient 3 calmed down she was sent to bed.

On 8/19/2021 at 8:15 PM, patient 3 approached a peer (patient 8) with the intent to apologize. Patient 8 did not want to have the conversation and backed away, which triggered patient 3 to punch patient 8 for the second time. Patient 3 was on one to one supervision at the time. Addtionally, it was documented in a nursing progress note dated 8/19/2021 at 11:00 PM, patient 3 asked her one to one staff member if she could go apologize to patient 8. Without requesting patient 8s permission, the staff member allowed patient 3 to approach patient 8. Patient 3 proceeded to punch patient 8 when she would not accept her apology.

On 8/23/2021, patient 3 was allowed to go into the dayroom to fill up her water bottle; patient 3 was with her one to one staff member. It was documented that without any warning patient 3 punched another peer (patient 11).

2. Patient 8's medical record review was completed on 8/25/2021 and revealed the following:

Patient 8 was admitted on 8/11/2021, with diagnoses of major depressive disorder, disruptive mood dysregulation disorder, and suicidal ideation.

On 8/18/2021 at 8:23 PM, patient 8 was punched by patient 3.

On 8/19/2021 at 8:15 PM, patient 8 was punched for the second time by patient 3.


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3. Patient 11's medical record review was completed on 8/25/2021.

Patient 11 was admitted to the hospital on 8/18/2021 with a diagnosis of major depressive disorder (MDD) with suicide attempt.

It was documented in a nursing progress narrative note dated 8/23/2021, at approximately 11:08 AM patient 11 was sitting in the day room on her tablet when patient 3 approached her and hit her on the right side of her face above her ear. It was documented that after the incident patient 11 was tearful and confused by the incident, and staff had assured her that she had not provoked patient 3.

4. Patient 12 was admitted to the hospital on 5/21/2021 with a diagnosis of bipolar disorder.

It was documented on the incident log that patient 12 was involved in an altercation with patient 3 on 8/6/2021. On 8/26/2021, a focused review of patient 12's medical record was completed, specifically for the date of 8/6/2021.

It was documented on a nursing progress note dated 8/6/2021, patient 12 was in a fist fight after another patient (patient 3) punched her in the face. It also documented, patient 12 was talking in a loud voice and triggered patient 3; patient 12 responded by punching patient 3 back.

It was documented on a social services individual and family progress note dated 8/10/2021, that patient 12 had been involved in an altercation over the weekend, and "All reports indicate that pt (patient 12) was NOT the aggressor and only acted in self-defense and allowed staff to intervene and disengaged when they did."

5. Additionally, on 8/25/2021, a review of the facility's policy titled "Reporting Patient Abuse and Neglect" was completed. The policy stated that all incidents of abuse should be documented on an occurrence form. The incident would then be investigated through an administrative review process with the "administrative review committee." The administrative review committee "shall make a written report to include recommendations."

An interview was conducted on 8/25/2021 at 9:55 AM, with the chief nursing officer (CNO) and the risk manager. They were asked about their policy titled "Reporting Patient Abuse and Neglect." They were unaware of an administrative review committee. They stated they had a patient safety committee every month. (Note: Their patient safety meeting minutes were reviewed on 8/25/2021 and revealed no specific patient information on incidents). The CNO and risk manager were asked if they had an occurrence form and the written recommendations for patient 3's incidents as per their policy. The risk manager stated they did not have any written documentation of the incidents besides what was in the patients chart. When asked to clarify that the hospital did not fill out a specific report on incidences, the CNO stated they do not create incident reports and that the incidences would be reflected in the medical record documentation, further stating, to create a report on every incident would be too time-consuming.

No documented evidence was provided of an "occurrence form" or any "written recommendations" of incidents as per policy. Additionally, no documented evidence of an incident report/investigation on the incidents was provided.

6. Note: Patent 3 was discharged on 8/24/2021; therefore there was no immediate threat to any other patients.