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1351 ONTARIO RD

GREEN BAY, WI 54311

QUALITY IMPROVEMENT ACTIVITIES

Tag No.: A0283

Based on record review and interview, facility staff failed to follow their policy to complete an incident report when a patient has an unusual event or incident in 1 of 10 records reviewed (Patient #1) in a total sample of 10.

Findings include:

The facility policy, titled "Completion of Incident Reports" last reviewed/revised 11/2019 revealed,..."POLICY: An incident is any unusual occurrence that is outside of the normal course of the patient's admission, care, and discharge...Examples include, but are not limited to...self-inflicted injuries. PROCEDURE:..Incident reports must be completed prior to the end of the shift on which they occur. Incident reports must be completed by the staff member who witnessed/had first-hand knowledge of the incident at the time of occurrence."

Record review of Patient #1's medical record revealed, the Psychiatric, nursing and therapist progress notes from 8/8/2021 - 8/29/2021 reveals a pattern of difficulty with impulsivity, reactivity, poor frustration tolerance, and conflict with peers on the unit which has led to several peer to peer altercations. Patient #1 is currently isolated on the unit and placed on a one to one observation. The patient continues to self-harm by scratching forearms and reported to staff twice (8/13/2021 and 8/20/2021) that s/he attempted to strangle him/herself with the T-shirt s/he was wearing. Neither incident was witnessed by staff. Patient #1's level of safety/observation has varied from every 15 minute checks (standard for all patients), Line of Sight (LOS) at all times, LOS while awake. 1:1 observation which has been in place since 8/26/2021 at 12:10 PM and still in place as of 8/30/2021 at 10:30 AM. On 8/21/2021 at 8:00 AM an order was placed for no roommate and still in place as of 8/30/2021 at 10:30 AM.

A review of facility incidents reported from 03/31/2021-08/26/2021 revealed, there was no incident report from 08/13/2021 at 5:56 PM regarding Patient #1 "attempt to strangle him/herself with the T-shirt s/he was wearing."

During an interview on 8/30/2021 at 1:15 PM with Director of Quality & Risk B when reviewing the incident log, asked if there was an incident report on 8/13/2021 for Patient #1, Director of Quality & Risk B stated "No".

CONTENT OF RECORD: ORDERS,NOTES,REPORTS

Tag No.: A0467

Based on record review and interview, facility staff failed to follow their policies to document patient events and nursing assessments in the medical record when a patient has an unusual event or incident in 1 of 10 records reviewed (Patient #1) in a total sample of 10.

Findings include:
The facility policy, titled "Clinical Services Documentation in Patient Record" last reviewed/revised on 12/2019 revealed, "Procedure: 2. The Registered Nurse (RN) will document in the medical record every shift and, more often as is indicated by a change in the patient's condition....4. The RN will make an additional entry, charting in the event (behavioral) have an unusual event or incident [sic] if it is not mentioned on the flow sheet. This note will include a description of the event, staff intervention (action), and patient (response) to the intervention."

The facility policy, titled "Assessment & Reassessment of the Patient" last reviewed/revised on 12/2019 revealed, "Policy: Patient will have reassessments that occur on a regular basis to ensure proper care and treatment planning during their stay. Reassessment of Patient: "3. The reassessment will be completed by the RN on the need or change of patient condition."

The facility policy, titled "Completion of Incident Reports" last reviewed/revised 11/2019 revealed,..."POLICY: An incident is any unusual occurrence that is outside of the normal course of the patient's admission, care, and discharge...Examples include, but are not limited to...self-inflicted injuries. PROCEDURE:..Incident reports must be completed prior to the end of the shift on which they occur. Incident reports must be completed by the staff member who witnessed/had first-hand knowledge of the incident at the time of occurrence."

Patient #1 was admitted to the facility on 8/7/2021, with primary diagnosis: Disruptive mood dysregulation disorder.

A review of Patient #1's medical record revealed, on 8/20/2021 at 4:02 PM an order was placed for level of observation-Line of sight (LOS) at all times, however, there was no corresponding nurse progress note addressing why the observation level was changed and no nursing assessment documented.

During an interview on 8/26/2021 at 3:20 PM, when asked about Patient #1's suicide attempts while inpatient, staff nurse D stated, S/he literally took the shirt off his/her back to strangle him/herself, this was reported by the patient, not witnessed by staff. On 8/20/2021 I put him/her on line of sight (LOS) at all times, the night shift nurse changed the order to line of sight while awake. I questioned them (management) why this got changed, I was given no explanation why. Note: This incident was self-reported by the patient to Therapist E. There was no documentation of this alleged suicide attempt in the medical record. There is no documentation that the supervision was increased from 15 minute checks to LOS at all times after this incident. There was no nursing assessment documented of the patient condition after the alleged suicide attempt.

During an interview on 8/30/2021 at 1:53 PM, when asked about Patient #1's level of observation order change on 8/20/2021 at 11:50 PM, Staff nurse I stated "I was helping out [name] nurse and called the provider earlier in the evening to clarify the level of observation order. Patient #1 had been on 15 minute checks and there was a new order for Line of sight (LOS) at all times. There was no progress note why s/he was placed on LOS at all times. The provider ordered LOS while awake at 11:50 PM."

During an interview on 8/30/3021 at 2:55 PM, DON C confirmed the absence of the progress note and stated "I would expect to see a nurse progress note as to why the order was placed or changed."