HospitalInspections.org

Based on medical record review, observation, and staff interview the hospital failed to ensure a safe setting for patients by failing to ensure the female bathroom was locked on a co-ed patient care unit for 1 of 3 co-ed units toured (U1/1-East).

The findings include:

Open medical record review of patient #29 revealed a 32 year-old female admitted 05/26/2010 with schizophrenia. Review of registered nurse's notes dated 07/11/2010 at 2050 revealed, "Pt (patient) became loud, yelling at about 6:45 pm. Pt upset because male peer in female bathroom. Staff requested pt to step in hallway so that the peer could be assisted from bathroom. Pt refused and was yelling at peer. Pt did step away from the bathroom stall. Staff verbally encouraged male peer to remove himself from bathroom. Pt continued to verbalize anger about male peer being in female bathroom. Male staff escorted male peer from area. Writer instructed to remain near female bathroom to lock door when pt stepped out of bathroom...."

Observation during tour of the U1/1-East patient care unit on 07/22/2010 at 1215 revealed 3 male patients and 1 female patient were sitting in the dayroom with 4 staff members. Observation revealed the bathroom was accessible from the dayroom. Observation revealed the female bathroom was unlocked. Interview with the charge nurse during the observation revealed, "The bathroom should be locked since we have a female (patient) on the unit."

Interview on 07/23/2010 at 1545 with administrative nursing staff revealed the hospital does not have a policy that states bathroom doors must be locked. Interview revealed, "We don't require bathroom doors to be locked."

Based on policy review, medical record review, incident report review, and staff interview the hospital's nursing staff failed to supervise and evaluate patient care by failing to implement constant observation precautions following incidents of aggressive behavior per policy for 4 of 16 sampled patients with incidents of aggressive behavior (#40, #35, #36, and #29).

The findings include:

Review of the "Rapid Response Behavioral Emergencies" policy effective 07/06/2009 revealed "Aggressive Behavior is defined in the following manner: Any physical act which causes intentional injury (such as but not limited to laceration, bruise, contusion, fracture, etc ...); or any intentional physical act with the potential for serious injury; or any intentional, willful, and forceful physical contact between two individuals intending to cause physical harm/injury .... Following any aggressive behavior, the aggressor is immediately placed on CO (continuous observation requiring a staff member to be within arms reach of the aggressor) precautions until he/she can be evaluated by the Clinical Director/designee or attending Psychiatrist/designee until an order indicating otherwise has been previously received or is obtained. Note: an order from a Psychiatrist is not necessary to place a patient on CO precautions following any aggressive behavior."

1. Open medical record review of patient #40 revealed a 52 year-old male admitted 07/02/2010 with bipolar disorder current manic. Review of registered nurse shift notes dated 07/16/2010 recorded the patient's behavior as "agitated/angry/hostile" and "verbally aggressive to others." Nursing notes for the 0700 to 1500 shift documented the "Patient is wandering the unit using profanity with staff and peers. Patient has been noted as being verbally aggressive with peers." Notes for the 1500 to 2300 shift documented "Patient is angry and grandiose, seeks attention from staff, is cursing and using foul language." Further review of nursing notes dated 07/16/2010 at 2145 recorded the patient "became involved in a fight in the unit... then (patient #40) grabbed (another patient) from behind in a choke hold. Staff separated them, then within 10 minutes (the victim patient) attacked patient #40 back, once again separated by staff." Review of the "Precaution Flowsheet" dated 07/16/2010 revealed no evidence the patient was placed on CO precautions after the aggressive behavior on 07/16/2010. Further record review revealed no evidence CO precautions were implemented according to the hospital policy.

Review of an incident report revealed on 07/16/2010 at 1935 two other patients were involved in a fight on the U2/3W unit (adult admissions unit) when another patient tried to jump in the fight. Review revealed patient #40 grabbed the patient from behind "in a choke hold." Review of the incident report revealed interventions included "talked to patient." Review of the interventions revealed CO precautions were not circled as done.

Review of an incident report dated 07/16/2010 at 1955 revealed patient #40 was chased by another patient who cornered him in a chair in the dayroom. Review revealed the patient "struck (patient #40) in the left eye." Review of the interventions revealed staff "talked to patient." Review revealed no evidence CO precautions were in place when the incident occurred or after the incident.

Interview on 07/23/2010 at 1500 with administrative nursing staff revealed CO precautions is a safety measure that is initiated by the nurse whenever there is physical contact due to aggressive behavior. The interview revealed a staff member is assigned by the nurse to remain within arms reach of the aggressive patient until the physician has evaluated the patient and /or written an order to discontinue the CO precautions. The staff member reviewed patient #40's record and stated the CO precautions should have been started on the patient after the aggressive incident on 07/16/2010 at 1935. Interview revealed there was no evidence the CO precautions were started or in place when the second incident occurred on 07/16/2010 at 1955. Interview confirmed nursing staff failed to follow hospital policy regarding safety precautions.



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2. Open medical record review of patient #35 revealed a 50 year old female admitted on 03/06/2010 with a diagnosis of paranoid schizophrenia. Record review revealed physician orders dated 17/15/2010 at 1600 "Cancel discharge order, Give Prolixin Decanoate (a medication used to treat chronic schizophrenia) 25 mg IM (intramuscular) today." Record review revealed nursing documentation dated 07/16/2010 at 0400 (shift note beginning 2300 on 07/15/2010 through 0700 on 07/16/2010), "Per shift report and orders from Dr. (name of physician), pt (patient) will NOT be discharged this am due to need for further stabilization after striking SW (social worker) without provocation or known reason..." Record review revealed the patient was not on any special precautions on 07/15/2010, before or after the patient's physical aggression toward the social worker. Record review revealed no documentation that the staff implemented CO precautions after the patient hit the social work (incident of aggression).

Review of Incident Report dated 07/15/2010 at 1545 revealed "She (patient #35) hit writer in chest. No injury." Review of report revealed "INTERVENTIONS" implemented "Talked to Patient." Review of report revealed intervention type "CO" was not implemented.

Interview with staff on 07/23/2010 at 1105, during unit tour and open medical record review, revealed the "Aggression Protocol" was not implemented on 07/15/2010. Interview confirmed there was no available documentation that the patient was placed on CO precautions after she hit the social worker on 07/15/2010.

Interview on 07/23/2010 at 1500 with administrative nursing staff revealed CO precautions is a safety measure that is initiated by the nurse whenever there is physical contact due to aggressive behavior. The interview revealed a staff member is assigned by the nurse to remain within arms reach of the aggressive patient until the physician has evaluated the patient and /or written an order to discontinue the CO precautions.

3. Open medical record review of patient #36 revealed a 57 year old female admitted on 06/07/2007 with a diagnosis of Schizoaffective Disorder. Record review revealed nursing documentation dated 07/13/2010 at 1235 (shift note beginning 0700 on 07/13/2010 through 1500 on 07/13/2010), "...sitting in day room, became angry at peers who were laughing and talking, felt that this was directed at her and picked up a chair and threw it , this did strike another pt (patient). pt. (patient #36) was calmed by talking with her..." Record review revealed the patient was not on special precautions before or after the act of physical aggression. Record review revealed no documentation that the staff implemented CO precautions after the patient hit another patient with a chair (incident of aggression).

Review of Incident Report dated 07/13/2010 at 1243 revealed "Pt (patient) thought peers were talking about her...became angry, picked up chair and threw it, hitting above pt. on the (right) hand." Review of report revealed "INJURY TO VICTIM: B. Minor." Review of report revealed "INTERVENTIONS" implemented "Talked to Patient." Review of report revealed intervention type "CO" was not implemented.

Interview with staff on 07/23/2010 at 1138, during unit tour and open medical record review, revealed "patient should have been place on Aggression Protocol (CO precautions)." Interview confirmed there was no available documentation that the patient was placed on CO precautions after she hit another patient with a chair on 017/13/2010.

Interview on 07/23/2010 at 1500 with administrative nursing staff revealed CO precautions is a safety measure that is initiated by the nurse whenever there is physical contact due to aggressive behavior. The interview revealed a staff member is assigned by the nurse to remain within arms reach of the aggressive patient until the physician has evaluated the patient and /or written an order to discontinue the CO precautions.





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4. Open medical record review of patient #29 revealed a 32 year-old female admitted 05/26/2010 with schizophrenia. Record review revealed on 07/11/2010 at 1845 the patient was not on special precautions. Review of registered nurse's notes dated 07/11/2010 at 2050 revealed, "Pt (patient) became loud, yelling at about 6:45 pm. Pt upset because male peer in female bathroom. Staff requested pt to step in hallway so that the peer could be assisted from bathroom. Pt refused and was yelling at peer. Pt did step away from the bathroom stall....Pt continued to verbalize anger about male peer being in female bathroom. Male staff escorted male peer from area. Writer instructed to remain near female bathroom to lock door when pt stepped out of bathroom. Pt struck writer in left cheek and continued to walk past writer....Pt...was focused on smoke break and missing 7 pm smoke break....Pt. told that she would not smoke until 9 pm, that she could not go to courtyard. Pt argumentative but no further aggression. On call psychiatrist on unit and reviewed chart." Record review revealed no documentation that the staff implemented CO precautions after the incident of aggression. Record review revealed the on-call psychiatrist evaluated the patient at 1950 (1 hour and 5 minutes after the incident of aggression).

Review of an incident report revealed on 07/11/2010 at 1845 revealed Patient #29 hit the nurse on the left cheek after exiting the bathroom. Review of the incident report revealed interventions included "talked to patient". Review of the incident report revealed no documentation that the staff implemented CO precautions after the incident of aggression.

Interview on 07/23/2010 at 1500 with administrative nursing staff revealed CO precautions is a safety measure that is initiated by the nurse whenever there is physical contact due to aggressive behavior. The interview revealed a staff member is assigned by the nurse to remain within arms reach of the aggressive patient until the physician has evaluated the patient and /or written an order to discontinue the CO precautions. The staff member reviewed patient #29's record and stated CO precautions should have been started on the patient after the aggressive incident on 07/11/2010 at 1845. Interview revealed there was no documented evidence that CO precautions were implemented after the incident of aggression on 07/11/2010 at 1845. Interview confirmed nursing staff failed to follow hospital policy regarding safety precautions.


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