HospitalInspections.org

Based on document review and interview, the facility failed to ensure care in a safe setting related to Q15 minutes and/or 1:1 observations for 3 patients (P3, P5 and P6); failed to ensure freedom from verbal threats for 1 patient (P3); failed to ensure freedom from patient-to-patient sexual abuse for 2 patients (P5 and P6); failed to order and/or implement precautions related to assault, suicide, sexually acting out, seizure, self-harm and/or fall for 4 patients (P3, P5, P6 and P7).

Findings include:

1. The facility failed to follow policy titled, "Patient Rights and Responsibilities", PolicyStat ID 10359862, revised 9/2021, by not ensuring patients received care in a safe setting.

2. The facility failed to follow policy titled, "Patient Abuse and Neglect", PolicyStat ID 13034136, revised 1/2023, by not keeping patients free from verbal/sexual patient-to-patient abuse. This policy stated:
a. Abuse, verbal - The willful use of disparaging and derogatory terms to patients or their families regardless of their age, ability to comprehend or disability.
b. Abuse, sexual - A willful act which defies the sexual integrity of a patient through gestures, verbal and/or physical actions. Examples include, but are not limited to, verbal or physical sexual harassment such as inappropriate touching of private body parts, kissing, fondling, intercourse, or sexually offensive language, jokes and gestures, sexual coercion, or sexual assault.

3. The facility failed to follow policy titled, "Precautions", PolicyStat ID 12401049, revised 9/2022, by not ordering or implementing precautions for patients. Policy stated, precautions can be ordered by a provider or implemented as a nursing measure. Precautions and interventions can include (but are not limited to): Assault - high potential for aggressive behavior...Suicide, Sexually Acting Out, Seizure, Self-Harm and/or Fall.

4. Medical Record (MR) for P3 (same patient as P7; this was second visit), indicated:
a. Was admitted on 3/20/2023 at 1900 hours and lacked a Patient Observation Rounds form, therefore unable to determine if Q15 minutes observations were done for that date due to no form.
b. Daily Nursing Narrative on 3/21/2023 between 0700-1300 hours, indicated patient was transferred to Unit 100 per Physician Order due to verbal threats from another patient.
c. Daily Nursing Narrative on 3/22/2023 between 0700-1900 hours, indicated patient showed aggression toward another patient for cleaning the blackboard, threatened to fight him/her. Redirected to room. Precautions in place. Unable to determine type of precautions due to lack of documentation. At 0745 hours, transferred to Unit 300 and 1:1 observation initiated (start/stop times blank on Patient Observation Rounds form). Patient Observation Rounds forms were also blank for 1:1 observation start/stop times from 3/23/2023 to 3/27/2023. Physician Orders dated 3/28/2023 at 0900 hours, indicated to discontinue 1:1 observation.

5. MR for P5 indicated:
a. Was admitted on 2/4/2023 with a history of aggressive behaviors.
b. Daily Nursing Narrative on 3/3/2023, between 0700-1900 hours, indicated started showing interest in a patient, made inappropriate comments. Redirected. Between 1900-0700 hours, indicated has been displaying inappropriate sexual advances. Tries to get close enough to them to kiss them. Will pretend to be sleeping on the chair in the milieu and when he/she thinks staff is distracted, he/she will try to sneak into the [patient's] rooms. Around 2215 hours, [P6] ran out of his/her room crying and stated P5 came into his/her room and stuck his/her tongue into his/her mouth and woke him/her up.
c. Patient Observations Rounds form dated 3/3/2023, but crossed out and replaced with 3/2/2023 (dates at bottom of form were 3/3/2023 for Registered Nurse [RN]signatures), was blank for Q15 minutes observations and lacked assault and/or sexual acting out precautions.
d. Lacked Physician Order or nursing implementation of assault and/or sexual acting out precautions.

6. MR for P6 indicated:
a. Was admitted on 2/26/2023 and Admission Orders, indicated seizure and fall precautions and Q15 minutes observations.
b. Psychiatric Evaluation dated 2/27/2023, stated patient was verbally aggressive.
c. Patient Observation Rounds form dated 3/3/2023, but crossed out and replaced with 3/2/2023 (dates at bottom of form were 3/3/2023 for RN signatures), was blank for Q15 minutes observations and lacked assault, fall and/or seizure precautions. MR lacked Physician Order or nursing implementation of assault, fall and/or seizure precautions.

7. MR for P7 (same patient as P3; this was first visit) indicated, was admitted on 3/6/2023 for suicidal ideation and depression. Psychiatric Evaluation on same date indicated suicide attempt approximately one month ago. Admission Orders dated 3/6/2023, indicated suicide and self-harm precautions. Patient Observation Rounds forms dated 3/6/2023-3/8/2023 lacked suicide and self-harm precautions.

8. Staff S11 (Registered Nurse) was interviewed on 3/28/2023 at approximately 1105 hours, and confirmed Patient Observation Rounds forms are to be completed on all patients each day to include Q15 minutes observations and were lacking for P3, P5 and P6.

9. Staff S4 (Education) was interviewed on 3/28/2023 at approximately 1145 hours, and confirmed 1:1 start/stop times should be documented on Patient Observation Rounds form and was lacking for P3. Precautions may be ordered by a Provider or implemented by nursing, and the type of precaution should be documented regardless of how it's ordered or implemented; and was lacking for P3, P5, P6 and P7. Possibly assault precautions, which include aggression should have been in place for P3, but we don't know because the type of precaution in place wasn't documented; Assault and/or sexual acting out precautions should have been in place for P5; Assault, fall and/or seizure precautions for P6; and suicide and self-harm precautions for P7.