HospitalInspections.org

# NJ00170380

Based on medical record review, staff interviews, and review of facility documents, it was determined the facility failed to ensure a non-verbal developmentally disabled patient's caregiver was provided with discharge instructions, in one of one medical record reviewed (Patient (P) 2).

Findings include:

Facility Policy titled, "Discharge Planning" dated 8/13/21, stated, "...Procedure: ...Planning: ...Discharge planning occurs in consultation with the patient and their family caregivers, or representative. ...Implementation: ...A written discharge summary is completed by the licensed healthcare provider involved in the patient's care. Discharge instructions are completed by the nurse involved in the patient's care. A copy of the discharge instructions including a phone number of a contact person in case there are questions post discharge is provided."

On January 17 and 18, 2024, P2's medical record was reviewed and revealed the following:

P2 was admitted to the facility on 12/17/23 at 9:04 AM with a diagnosis of pneumonia. The physician History and Physical (H&P) indicated the patient had a history of Reye's syndrome, cerebral palsy, seizures, scoliosis, and asthma, and was non-verbal at baseline.

On 12/18/23 at 8:00 PM, a Registered Nurse (RN) documented a skin assessment, which included a wound (blister) on the anterior, proximal right arm.

The Wound Care RN consult on 12/21/23 at 4:00 PM documented two additional wounds: a closed blister on the interior dorsal left foot and a blister on the posterior distal left leg. The Wound Care RN documented "multiple closed blisters with serous fluid inside on the left lower extremity and foot." The Wound Care RN recommended TruVue boots, low air loss (LAL) bed, and cover with foam every 72 hours.

P2 was discharged on 12/27/23 at 5:55 PM. Upon review of P2's discharge instructions, the section titled "Signatures," stated, "(Patient Name), on 12/27/23, received patient instructions and the after visit summary was reviewed with me. I have read or had the instructions reviewed with me and understand the instructions given to me by my caregivers." The "Patient/Caregiver:" signature section stated, "patient unable to sign."

On 1/18/24 at 12:38 PM, an interview was conducted with Staff (S) 34, a Registered Nurse (RN). S34 indicated that if a patient was unable to understand or sign the discharge instructions, the RN would reach out to the physician to let them know. The discharge instructions would then be given to the primary caregiver. S34 stated that a nursing note would then be written indicating the caregiver received discharge instructions.

The medical record lacked evidence that the discharge instructions were reviewed with P2's caregiver prior to discharge on 12/27/23, in accordance with facility policy. The After Visit Summary [discharge instructions] provided to the caregiver, lacked evidence of instructions for wound care post discharge.

P2 presented back to the Emergency Department (ED) on 12/27/23. On 12/27/23 at 7:37 PM the ED Provider Notes HPI (History of Present Illness) stated, "...The patient was admitted here for pneumonia and COVID, and was discharged earlier this morning. Mom states since being home, she noticed the left ankle wound, along with redness, blistering, and swelling to the area, with discoloration of the left 2nd toe. She states she is not sure of what caused his/her symptoms, and she was not told of any injuries while he/she was admitted." P2 was re-admitted on 12/28/23 at 3:50 PM for intravenous antibiotic therapy for cellulitis of the left foot, and was discharged on 1/13/24.

A review of the Verge complaint and grievance, entry date 12/29/23, stated, "...Responder Comments: 1/14/24 2:24 PM. Patient had blister on right arm documented on 12/18. On the 21st patient had multiple closed blister [sic] on the left LE [lower extremity] and foot discoloration of toe. Wound care consult was ordered and provider was notified. It does not appear that there was communication to the family about the new wounds prior to the patient being discharged on the 27th ..."

# NJ00169942

Based on medical record review, video surveillance observation, facility documents and staff interviews, it was determined the facility failed to ensure 1) patients are free from excessive use of force and abuse; 2) One-to-One observation monitoring is documented in Emergency Department in accordance with the facility policy and procedure.

Findings include:

1) Reference: Facility policy titled, "Use of Force," states, "Policy: Use of force should only be used when all other alternatives have been exhausted. ... Guidelines for the Use Of Force ...Use of physical force shall only be employed as a last resort after all other methods have been exhausted."

On 1/17/24 at 11:20 AM, medical record review of Patient (P)1 was conducted. P1 arrived at the Emergency Department (ED) VIA EMS (Emergency Medical Services) on 12/26/23 at 1:29 AM, with a chief complaint of Alcohol Intoxication. The ED Nursing Note on 12/26/23 at 1:29 AM stated, "Pt bib [brought in by] BLS [medical transportation] and JCPD [Jersey City Police Department]. As per ems, pt [patient] is drunk and was chasing a woman in the streets and punching cars. Pt is screaming during triage and not providing any useful information for triage. ... ." On 12/26/23 at 1:29 AM the ED Physician Note stated, " ...The patient was initially cooperative on arrival, however the patient got out of his stretcher and began urinating on the floor in the ED hallway and became aggressive. The patient presents a threat to the safety of staff and patients, was unable to be verbally de-escalated, prompting restraints/sedation. ...Non-physical interventions were attempted. Due to the imminent risk of the individual physically harming themselves or others, the patient was restrained. ... ." On 12/26/23 at 3:08 AM orders were placed for "CT [Computed Tomography Scan] Facial Bones Without IV [intravenous] Contrast. On 12/26/23 at 7:14 AM the Final Results for the "CT Facial Bones Without IV Contrast" were "1. Acute bilateral nasal bone fractures with fracture line extending through the midline nasal bone. ..." An Oral and Maxillofacial Surgery Consult from 12/26/23 at 12:17 PM stated; " ...Reason for Consult: facial trauma with facial fractures ...Physical Exam: ...Head: mild facial swelling overlying nose, consistent with the injury. ... Nose: Minimal dorsum deviation. No septal hematoma. ...Assessment/Plan: 21 y.o. [male/female] presents to ED with CT confirmed nasal bone fx [fracture] ... ."

On 1/17/24 at 2:36 PM, a review of the video surveillance was conducted in the presence of S1 (Vice President of Safety and Regulatory), S21 (Security Director) and S22 (Security Manager). The video surveillance reviewed did not have any audio recording. Review of the video surveillance dated 12/26/23 revealed the following:

First Camera View - "Rear Hallway Pod D" in the ED

1:30 AM - P1 was observed being transported on a stretcher in the ED hallway in the supine position while handcuffed to the stretcher. P1 appeared to be calm. S21 confirmed the video surveillance location was the "Rear Hallway" and identified the individuals in the camera surveillance as members of the local police department, EMS members, 2 (two) facility security officers - S19 and S40, and S17 (RN). S21 also confirmed that P1 was handcuffed to the stretcher by the local police department.

1:32 AM - P1 was observed to be transported to a room by EMS members and facility staff. P1 appeared calm and remained handcuffed to the stretcher.

1:34 AM - Police removed P1 from the handcuffs and exited the room. P1 appeared to be calm. S15 (Patient Care Technician [PCT]) and S17 were observed in the room. Security staff were observed standing outside P1's room.

1:36 PM - S17 exited the room and turned off the lights. P1 appeared calm.

1:37 PM - An EMS member walked into the room and P1 sat up and appeared to communicate in an aggressive manner. The EMS member exited the room.

1:39 PM - S15 and S17 were observed in the room. P1 appeared agitated and was observed to stand up and removed his/her pants and walked out of the room into the ED hallway.

Second Camera View - "ED-Stairwell Exit/Pod D"

1:39 AM - P1 was observed walking in the ED hallway and pushed a recliner chair into the hallway. S15 and S17 were observed walking behind P1.

1:40 AM - P1 was observed to walk out of view of the camera surveillance. S21 indicated that P1 began to urinate on medical equipment and a panic alarm was activated at this time. S15 and S17 were observed talking to P1. S15 walked into another room and returned with absorbent pads. S21 indicated the absorbent pads were to clean up the urine from P1. Four (4) Security Officers - S19, S20, S40 and S41, were observed standing in the hallway.

1:41 AM - P1 appeared agitated and verbally communicated in what appeared to be an aggressive manner. A stretcher was brought into the hallway. Security officers and S15 were observed to physically restrain P1 onto the stretcher in the supine position. S17 and the ED Provider were observed standing in the hallway communicating with each other.

1:42 AM- P1 appeared to lift his/her head and spit towards S20. S19 was observed to put his/her open hand on P1's throat and forcefully push P1 back down on the stretcher. S15, S19, S20, S40, S41 and S42 were observed to apply 4-point restraints to P1's wrists and ankles. S21 confirmed these observations and indicated that staff is not trained to put hands on a patient's neck through the facility Handle with Care Training. S21 indicated this was considered excessive use of force and the only time staff can use excessive force is when they are in immediate danger and need to defend themselves. S21 confirmed that S19 was not in immediate danger during this event.

Camera View - "Rear Hallway Pod D" in the ED

1:43 AM - P1 was transported back to the room. S19 appeared to hold the bed sheet up near P1's face during transportation in the hallway due to a limited view from video surveillance. P1's face was unable to be seen. S15, S19 and S42 were observed in the room standing around P1's stretcher. S19 appeared to strike P1's face with a closed fist. S21 confirmed these observations. S21 indicated he/she believes the bed sheet was held near P1's face to prevent P1 from spitting on staff and did not believe it was covering P1's face. S21 indicated S19 was immediately suspended pending an investigation which led to his/her termination.

1:44 AM - S19 and S42 exited the room. S15 was observed to stay in the room standing next to the stretcher. S1 confirmed S15 was the staff member responsible for the 1:1 observation of P1. The video surveillance concluded at this time.

On 1/17/24 at 2:45 PM, an interview was conducted with S21 and S22. Both S21 and S22 confirmed they were alerted that S19 and S20 were accused of hitting P1 on 12/26/23. S21 confirmed both S19 and S20 were both immediately suspended pending an investigation. S21 confirmed that S19 was terminated and S20 had resigned. S21 indicated through video surveillance review that S19 was identified as hitting P1 with a closed fist. S21 indicated that S20 was not identified during video surveillance to use excessive force.

The video surveillance review revealed that S19 used excessive force on P1 twice. There were multiple staff members present when S19 was observed to put his/her open hand on P1's throat and forcefully push P1 back down on the stretcher. No intervention was done at this time to remove S19 from P1's care and therefore S19 was able to use excessive force for a second time when he/she hit P1 with a closed fist leading to P1 having a nasal fracture.

2) Reference: Facility policy titled, "Patient Safety Watch for Non-Behavioral Locations" (effective 6/4/22), states, " ...One-to-One Observation: For patients exhibiting behaviors that present a danger to self or others as evidenced by ....uncontrollable, agitated, and/or threatening behavior, is actively violent and/or destructive ...RN or designated Staff Member- The Patient Watch Observation Form will be completed noting the behavior of the patient, by the designated staff member every 15/30 minutes as per order and report any changes in patient status or behavior to the RN immediately. Patient Watch Observation forms are a permanent part of the patient's medical record. ..."

Facility policy titled, "Restraints-Violent and Non-Violent Non Self Destructive" (effective 5/2022), states, "Definitions: Restraint: Any manual method or physical/mechanical device, material or equipment that immobilizes or reduces the ability of a patient to freely move his/her arms/legs/body or head ...Restraint types include those for Violent Self Destructive behaviors ...Violent Self Destructive- VSD (i.e Behavioral) Restraint: Used to protect the individual against the immediate risk of harm to self or others due to violent or self-destructive behavior. Restraints in this category may include locked restraints or 4 point restraints. ... Monitoring ...For Violent Self Destructive restraints: ...1:1 staff observation is required for all patients in VSD. ..."

On 1/17/24, a review of P1's medical record revealed, that on 12/26/23 at 1:45 AM, physician's orders were placed for "Restraints violent or self-destructive adult (age 18 and older)" and "1:1 patient" observation. On 1/17/24 at 12:17 PM, the 1:1 Patient Watch Observation Form for P1 was requested and could not be located. The medical record lacked evidence that the 1:1 Patient Watch Observation Form was completed.

On 1/17/24, a review of medical record for P15 revealed that P15 had physician's orders for "Restraints violent or self-destructive adult (age 18 and older)" and "1:1 patient" observation placed on 12/10/23 at 10:25 PM. On 1/17/24 at 1:06 PM, the 1:1 Patient Watch Observation Form for P15 was requested and could not be located. The medical record lacked evidence that the 1:1 Patient Watch Observation Form was completed.

On 1/18/24 at 1:36 PM, S1 (Vice President of Safety and Regulatory) confirmed the Patient Watch Observation forms were not scanned into P1 or P15's medical record. S1 indicated that the ED uses 1:1 Watch Observation forms, that are filled out on paper, and when the patient is discharged, the paper is supposed to be scanned into the electronic medical record.

# NJ00169942

Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure all restrained patients receive a face-to-face evaluation within one (1) hour after the application of restraints

Findings include:

Reference: Facility policy titled, "Restraints-Violent and Non-Violent Non Self Destructive" (effective 5/2022), states, "Definitions: Restraint: Any manual method or physical/mechanical device, material or equipment that immobilizes or reduces the ability of a patient to freely move his/her arms/legs/body or head ...Restraint types include those for Violent Self Destructive behaviors ...Violent Self Destructive- VSD (i.e Behavioral) Restraint: Used to protect the individual against the immediate risk of harm to self or others due to violent or self-destructive behavior. Restraints in this category may include locked restraints or 4 point restraints. ... Monitoring ...For Violent Self Destructive restraints: ...Face to Face: An LIP [Licensed Independent Practitioner] must see the patient in person within 1 hour after the initiation of the intervention (regardless of whether the intervention has already been discontinued). The evaluation includes: the patients immediate situation, the patients reaction to the situation, the patient's medical and behavioral condition and the need to continue or terminate the intervention. ..."

On 1/17/24, review of P5's medical record revealed P5 had a physician's order for "Restraints violent or self-destructive adult (age 18 and older)," placed on 12/20/23 at 6:08 PM. The medical record lacked documentation of a Face-to-Face evaluation from a LIP within one hour of the application of restraints on 12/20/23.

On 1/17/24, review of P7's medical record revealed P7 had a physician's order for "Restraints violent or self-destructive adult (age 18 and older)," placed on 12/23/23 at 9:47 AM. The medical record lacked documentation of a Face-to-Face evaluation from a LIP within one hour of the application of restraints on 12/23/23.

On 1/17/24 at 12:17 PM, during interview with S5 (AVP of Nursing), he/she confirmed the medical record for P5 and P7 lacked documentation of a Face-to-Face evaluation from a LIP within one hour of the application of restraints.

# NJ00170380

Based on medical record review, staff interviews, and review of facility documents, it was determined the facility failed to ensure an initial nursing skin assessment was completed for a patient presenting to the Emergency Department (ED), in one of three medical record reviewed (Patient (P) 2), in accordance with facility policy.

Findings include:

Facility policy titled, "Initial and Subsequent Nursing Assessments in Patient Care Settings" Effective date: 2/18/22, stated, "...1. Purpose Statement: ...Activities that comprise an assessment are determined by each discipline's scope of practice. (Refer to department specific Policies/Procedures or Bylaws). ...3. Procedure: Performed By (title/area): Nursing/Emergency Department...Required Action Steps: Initial Assessment... ."

On January 17 and 18, 2024, P2's medical record was reviewed and revealed the following:

P2 was admitted to the facility on 12/17/23 at 9:04 AM, with a diagnosis of pneumonia. On 12/18/23 at 8:00 PM, a Registered Nurse (RN) documented a skin assessment which included a wound (blister) on the anterior, proximal right arm. The Wound Care RN consult on 12/21/23 at 4:00 PM, documented two additional wounds: a closed blister on the interior dorsal left foot and a blister on the posterior distal left leg. The Wound Care RN documented "multiple closed blisters with serous fluid inside on the left lower extremity and foot."

P2 was discharged on 12/27/23 at 5:55 PM. P2 presented back to the Emergency Department (ED) on 12/27/23. On 12/27/23 at 7:37 PM, the ED Provider Notes HPI (History of Present Illness) stated, "...The patient was admitted here for pneumonia and COVID, and was discharged earlier this morning. Mom states since being home, she noticed the left ankle wound, along with redness, blistering, and swelling to the area, with discoloration of the left 2nd toe. She states she is not sure of what caused his/her symptoms, and she was not told of any injuries while he/she was admitted." P2 was re-admitted on 12/28/23 at 3:50 PM for intravenous antibiotic therapy for cellulitis of the left foot, and was discharged on 1/13/24.

P2's medical record lacked an ED nursing skin assessment. The first documented skin assessment was completed on admission to the Telemetry unit.

The following wounds were documented on the nursing flow sheet "Wound Assessment/Care" section:

12/28/23 at 4:21 PM - Foot Anterior; Left
12/28/23 at 4:22 PM - Foot Anterior; Left (2nd Toe)
12/28/23 at 4:23 PM - Distal Tibial; Left and Achilles; Left
12/28/23 at 4:24 PM - Foot Anterior; Right
12/28/23 at 4:26 PM - Dorsal Hand; Left and Dorsal Medial Hand; Left
12/28/23 at 4:32 PM - Pretibial Distal; Left

The wound care consult dated 12/29/23 indicated the following:

12/29/23 at 1:22 PM - Leg Left; Posterior; Lower - Partial Thickness
12/29/23 at 1:24 PM - Foot Anterior; Left - Full Thickness
12/29/23 at 1:32 PM - Dorsal Hand; Left and Dorsal Medial Hand; Left - Full Thickness
12/29/23 at 1:35 PM - Foot Anterior; Left (2nd Toe) - Full Thickness
12/29/23 at 2:00 PM - Foot Anterior; Right - Scabbed area
12/29/23 at 2:00 PM - Pretibial Distal; Left - Healed area

On 1/18/24 at 12:35 PM, a tour of the ED was conducted with S5 (Assistant Vice President of Nursing) and S39 (ED Director). At 12:36 PM, an interview was conducted with S37 (ED RN) who indicated that every patient that presents to the ED will have a skin assessment performed and would be documented in EPIC (electronic health record software) using the body avatar to document wounds. S37 indicated the priority is to stabilize the patient when they present to the ED, but every patient's skin is assessed. S37 indicated if a patient is going to be admitted, a skin assessment would "definitely" be done.

At 12:40 PM, an interview was conducted with S38 (ED RN) who indicated every patient's skin is assessed, even if the chief complaint is not skin related. S38 indicated each patient's skin assessment is documented in EPIC under the tab "wound assessment."


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