HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital failed to:
- Recognize and intervene when one patient (#58) of one patient reviewed suffered a stroke (a medical emergency that occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients).
- Protect one patient (#38) of one patient reviewed from abuse when she was restrained to prevent her from getting out of bed and falling.
- Ensure personal hygiene items, medical equipment, medical supplies and cleaning supplies were stored properly for 17 patients (#38, #39, #40, #48, #49, #51, #52, #53, #54, #55, #56, #57, #59, #61, #62, #63 and #64) of 20 patients reviewed with suicide precaution (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) orders.
- Ensure safety rounds (visualization and documentation of the safety of each patient) were completed for two patients (#60 and #69) of two patients reviewed.

The failures resulted in a systematic failure and noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights. The hospital census was 1,045.

As of 12/21/23, the hospital had provided an immediate action plan sufficient to remove the Immediate Jeopardy (IJ) when the hospital implemented corrective actions that included all current and oncoming staff were educated on ensuring a safe patient care environment for all patient with SP orders. All remaining staff were educated prior to the start of their next shift.

Based on observation, interview, record review and policy review, the hospital failed to:
- Recognize and intervene when one patient (#58) of one patient reviewed suffered a stroke (a medical emergency that occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients);
- Protect one patient (#38) of one patient reviewed from abuse when she was restrained (any manual method, physical or mechanical device that limits the ability of free movement of arms, legs, body, or head) to prevent her from getting out of bed and falling;
- Ensure personal hygiene items, medical equipment, medical supplies and cleaning supplies were stored properly for 17 patients (#38, #39, #40, #48, #49, #51, #52, #53, #54, #55, #56, #57, #59, #61, #62, #63 and #64) of 20 patients reviewed with suicide precaution (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) orders and
- Ensure safety rounds (visualization and documentation of the safety of each patient) were completed for two patients (#60 and #69) of two patients reviewed.

Findings included:

1. Review of the hospital's policy titled, "Admission and Discharge Guidelines to the Post Anesthesia (a state of controlled, temporary loss of sensation or awareness that is induced for medical purposes) Care Unit (PACU, a critical care unit where the patient's vital signs are closely observed following surgery)," dated 09/2021, showed:
- Discharge elements include level of consciousness (the state of being fully alert, aware, oriented and responsive to the environment) and sedation (when drugs are given for a calming or sleep-inducing effect).
- Clinical judgement must always super cede guidelines if the patient's condition is not satisfactory in a given area.
- Whenever doubt exists about diagnosis or patient safety, discharge should be delayed and the patient's condition re-assessed.

Review of the hospital's policy titled, "Acute Ischemic Stroke In-Patient Protocol," dated 05/2023 showed time urgency is paramount. Eligibility for Tissue Plasminogen Activator (tPA, medication that quickly dissolves the clots that cause many strokes) is when the stroke onset is well established to be less than 4.5 hours before treatment could begin.

Review of the hospital's undated document, "Barnes-Jewish Hospital (BJH) Badge Reminder Card," showed staff were directed to call a Code Stroke (priority assessment and care of a patient with signs and symptoms of stroke) if a patient could not move, smile, say hello or see.

Review of Patient #58's medical record showed:
- On 07/13/23 at 5:30 PM, she was extubated (removal of breathing tube) after surgery.
- At 5:30 PM and 6:00 PM, she was unable to move her extremities voluntarily or on command.
- At 6:30 PM and 7:00 PM, she was able to move two extremities on command. Her right-hand grip was moderate, her left-hand grip and lower extremities were not assessed.
- At 7:30 PM, 8:00 PM and 8:10 PM, she was able to move two extremities on command. Her right-hand grip was moderate. Her left-hand grip was absent. Her right dorsiflexion (the motion of the hand or foot up and towards the body) was weak, her left dorsiflexion was absent. Her right plantar flexion (the extension of the ankle so that the foot points down and away from the leg) was weak, her left plantar flexion was absent.
- At 8:06 PM, Staff UUU, Registered Nurse (RN) notified Staff KKKK, Physician, of Patient #58's left sided weakness. Staff KKKK came to assess the patient and performed a neurological (neuro, relating to or affecting the nervous system) assessment, no new orders were received.
- At 9:34 PM, Staff KKKK documented that the patient remained very somnolent (sleepy, drowsy) and uncooperative with the exam. Two plus reflexes (an involuntary action that your body does in response to something), and a down going Babinski (reflex that occurs after the sole of the foot has been firmly stroked) on both lower extremities. Slightly moved right, but not left extremities to command. Interphalangeal reflex (an involuntary action of your fingers or toes that your body does in response to a stimulus) present on both sides with strength to pain.
- On 07/14/23 at 2:56 AM, Staff KKKK documented that the patient remained somnolent but woke to sternal rub (painful pressure applied with the knuckles to the center of the chest of a patient who was not alert enough to elicit a response). She was able to state her name, that she was in the hospital, the year, and that she had back surgery. She continued to not move her left side voluntarily.
- At 7:42 AM, a Code Stroke was called for Patient #58 when her neurological assessment included left facial drooping (when facial muscles were not working properly) and severe slurred speech.
- At 7:45 AM, a head and neck computed tomography (CT, a combination of x-rays and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray) was ordered.
- At 8:02 AM, the head and neck CT were completed. Findings were consistent with a right posterior cerebral artery (PCA, artery in the mid-brain) infarct (tissue death due to inadequate blood supply to the affected area). The infarct was suspectedly due to stenosis (an abnormal narrowing of a bodily canal or passage) in the region with hypotension (low blood pressure) during the procedure or a cardioembolic (a blood clot or debris that is pumped from the heart and blocks the blood vessels in the brain) event. It was noted that Patient #58 had episodes of Atrial Fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow) during the procedure.
- At 8:08 AM, an electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) was completed and showed A-fib.
- At 9:41 AM, the Hyperacute Stroke Treatment Team (HASTE) documented that the Code Stroke was called in response to facial palsy (weakness or problems with using the muscles), left upper and lower extremity weakness, uncoordinated movement and a decreased level of consciousness. Patient #58 had a National Institutes of Health Stroke Scale (NIHSS, a systematic, quantitative assessment tool to measure stroke-related neurological deficit) score of ten, indicating the patient had suffered a moderate stroke.
- At 1:47 PM, the HASTE team note was signed and stated that the patient was a "no go" on tPA.

During an interview on 12/27/23 at 2:00 PM, Staff KKKK, Physician, stated that when she performed her initial post-operative assessment of Patient #58, the patient was too sleepy to assess. The patient would only arouse to a strong sternal rub. She returned later after the nurse notified her of the patient's left sided weakness. She stated that the patient answered simple yes/no questions with slurred speech. She did not have spontaneous movement but moved with strength when agitated. She moved her right side more than her left. She thought the examination was "suspicious," so she requested that a senior resident (doctor in training) assess the patient as well. The senior resident thought the exam was "strange" due to the extreme sleepiness of the patient. She and the senior resident called the Spinal Fellow (a board-certified physician who has finished residency training and was pursuing more), and they walked through the neurological exam. The Spinal Fellow felt that in spite of the lack of Patient #58's spontaneous movement, the positive interphalangeal reflexes eliminated a concern for a stroke. The Spinal Fellow did not come to the patient's bedside. One sided paralysis would make her think that the patient may have suffered a stroke. She referred to the senior physicians because she was unfamiliar with what was normal after spinal surgery. She denied that the patient had any obvious facial drooping but had wondered if the patient had any "past cosmetic surgery." The patient's face was "still" when she was aroused. She did not know the patient's functional status before the surgery. The patient did not have any change in her assessment overtime. She "knew that something was different from normal, that was why she ran it up the chain. It was something that was missed related to the complicated spinal surgery."

During an interview on 12/20/23 at 2:45 PM, Staff TTT, Nurse Practitioner (NP), stated that he met Patient #58 on the day the Code Stroke was called. He stated that it would have been appropriate to perform an NIHSS assessment when she displayed stroke-like symptoms in the PACU. He would have expected some form of management for a patient with facial drooping and upper extremity weakness in the PACU such as initiation of a stroke scale score. It may have been appropriate to address the patient's symptoms before the morning of the Code Stroke.

During an interview on 12/26/23 at 12:30 PM, Staff UUU, RN, stated that Patient #58 had left sided weakness during her time in the PACU. There was no movement from Patient #58's left upper or lower extremities. Her assessment consisted of hand grasps and feet pushing and pulling efforts. Patient #58's right side exam was normal. The patient was overall sleepy and weak from anesthesia. She notified the provider, and the provider assessed the patient and performed a neurological exam. No orders were received. She was under the impression that the provider was going to speak with one of her peers about Patient #58, but the provider did not return with any additional orders. The role of the nurse was to escalate her observations. When asked if she thought any further intervention was warranted, Staff UUU, RN, stated that "it was not her role to judge the physician's assessment." The patient was only able to answer simple yes or no questions. It was hard to say what a normal neurological assessment would have been in relation to the patient being sedated from anesthesia. She would not have expected unilateral (pertaining to one side) changes in response to this patient's surgical procedure.

During an interview on 12/27/23 at 2:30 PM, Staff HHHH, RN, stated that throughout the night of 07/14/23 the patient had right upper extremity weakness. Her left upper extremity had strength when gravity was removed. Her left lower extremity would only withdraw from pain. He stated that it was unusual for Patient #58 to have upper extremity weakness after lumbar surgery.

During an interview on 12/28/23 at 7:30 AM, Staff IIII, Physician, stated that he did not see the patient after surgery in the PACU or on the hospital floor. He was notified of the patient's left sided weakness on the morning of 07/14/23 while boarding a plane. He requested that a CT scan was ordered at that time. He stated that prior to surgery, Patient #58 had weakness in both lower extremities. She was only able to walk short distances due to pain. She had full function of her upper extremities.

During an interview on 12/21/23 at 1:10 PM, Staff OOO, Chief Nursing Officer (CNO), stated that there could have been a delay in activating the additional care needed for Patient #58. She expected staff to call a Code Stroke if they realized a patient displayed stroke-like symptoms. If the nurse was unsure if the displayed symptoms were stroke-like, the nurse should have called the provider team, a rapid response (a changing situation that requires more staff to address the current needs of the patient) or escalated the concern to the charge nurse. She then expected a Code Stroke to have been called and neurology consult requested. If facial drooping was unexpected, she expected a Code Stroke was called. The nurse was the primary advocate for the patient.

During an interview on 12/20/23 at 2:35 PM, Staff RRR, NP, Supervisor Neurosurgery (surgery performed on the nervous system, especially the brain and spinal cord), stated that lethargy and lower extremity weakness was expected with this surgery. Upper extremity weakness could have been related to how the patient was positioned in surgery. Facial drooping would not have been expected. She would have expected some form of management related to the upper extremity weakness. She expected an NIHSS assessment with symptoms of a stroke regardless of other potential causes for the symptoms.

During an interview on 12/21/23 at 10:45 AM, Staff BBBBB, Surgical Services Director, stated that if a patient displayed any symptoms of a stroke, a Code Stroke should have been called. The Stroke team then would have performed a neurological examination including the NIHSS.

2. Review of the hospital's undated document titled "Abuse/Neglect (Child/Disabled/Domestic/Elder/Patient Abuse)," showed all patients in BJH will be protected from abuse by anyone including but not limited to staff, other patients, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends or any other individual. Physical abuse is non-accidental use of physical force that results in bodily injury, pain, or impairment (slapped, bruised, cut, burned, physically restrained improperly).

Review of the hospital's undated document titled "Restraints: Management of Non-Violent and Non-Self-Destructive Behaviors," showed:
- Restraint application should only occur after restraint alternatives have been considered and/or attempted, deemed unsuccessful and if needed to ensure the immediate safety of the patient and/or others.
- Behaviors that precipitate the decision to restrain should trigger further investigation aimed at understanding and eliminating the cause of the behavior.
- Restraints were not to be used as a means of coercion, discipline, convenience, or staff retaliation.
- Non-violent restraints may be considered if a patient's behavior is disruptive in a way that interferes with medical treatments.
- The use of restraints or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member or others and must be discontinued at the earliest possible time.

Review of Patient #38's medical record dated 12/13/23 through 12/20/23 showed:
- She was a 61-year-old female.
- Diagnoses included mania (a period of time when a person cannot sleep for days, feels elevated, and is easily distracted), delirium (an abrupt change in the brain that causes confusion) and history of stroke with weakness on both sides.
- On 12/14/23 she was admitted to the Behavioral Health Unit (BHU).
- On 12/16/23 at 2:47 AM, the restraint order showed a left wrist restraint was ordered for the patient's attempts to get out of bed.
- On 12/16/23 at 3:27 AM, nursing documentation showed a soft wrist restraint was ordered for the patient to prevent falls.
- On 12/16/23 at 2:39 PM, the restraint order showed a left wrist restraint and a right ankle restraint were ordered for the patient attempts to get out of bed.
- On 12/17/23 at 11:15 PM, the restraint order showed a left wrist restraint and a right ankle restraint were ordered for the patient's attempts to get out of bed.
- On 12/17/23 at 11:23 PM, the restraint order showed hand mitten restraints on both sides, a left wrist restraint and a right ankle restraint were ordered for the patient's attempts to get out of bed.

During an interview on 12/19/23 at 4:10 PM, Staff MMM, RN, stated that soft restraints were applied to patients who were aggressive, hit staff, attempted to remove intravenous (IV, in the vein) catheters, etc. The soft restraints were usually just placed on the patients' wrists.

During an interview on 12/19/23 at 4:18 PM, Staff VV, Nurse Manger, stated that soft restraints were used if a patient attempted to hit staff or pulled IV catheters out.

During an interview on 12/20/23 at 2:10 PM, Staff SSS, Interim Psychiatric (relating to mental illness) Medical Director, stated that he expected restraints to be used as a last resort. Restraints were used to keep the patient, other patients and staff safe. Restraints were not used to keep the patient in the bed.

During an interview on 12/21/23 at 11:05 AM, Staff OOOO, Physician, stated that she remembered she ordered restraints for Patient #38. There were factors considered other than falls and attempting to get out of bed for the patient, but that information did not make it into the patient's medical record and the documentation that was in the chart should have been more detailed. He stated he documented it wrong.

During an interview on 12/22/23 at 10:00 AM, Staff RRRR, RN, stated that Patient #38 was restrained to keep her from falling. It was documented "attempted to get out of bed" because that was the only option available to choose in the electronic medical record (EMR) system.

During an interview on 12/20/23 at 9:15 AM, Staff OOO, CNO, stated that it would be considered abuse if the only reason a patient was restrained was to prevent them from getting out of bed.

During an interview on 12/20/23 at 10:50 AM, Staff PPP, Interim Psychiatric Services Director, stated that fall risk was not an indication for restraints. She expected proper psychiatric safe fall precautions with a one-to-one (1:1, continuous visual contact with close physical proximity) sitter. Staff should know why a patient was restrained and it should be documented.

During an interview on 12/27/23 at 2:35 PM, Staff SSSS, RN, stated that attempting to get out of bed was not an appropriate reason to restrain a patient.

3. Review of the hospital's undated document titled "Psychiatry Services Policies/Procedures," showed:
- The psychiatric patient care unit will be assessed daily and when necessary to assure that all safety guidelines were being followed.
- The patient rooms will be assessed twice daily during room searches and as necessary to assure that all safety guidelines were being followed.
- The use of medical equipment that may pose a risk to safety will be reviewed and evaluated on a case-to-case basis by clinical staff and psychiatry leadership.
- Patients who require medical equipment will be assessed for self-injurious behavior risk, suicide (to cause one's own death) risk, assault risk and fall risk, and subsequently placed on appropriate precautions.
- All medical equipment that was not in use will be stored in appropriate locations that are out of the reach for patients.

Observations on 12/19/23 at 4:25 PM, on the 15300 Psychiatric Unit, showed:
- Patient #53's room had a wall-mounted door stop that was pushed into the wall with drywall edges exposed.
- Patient #54's and Patient #64's shared room had a medical face mask and a plastic fork.
- Patient #55's room had a shower chair in the shower. The shower was not in use.
- Patient #56's room had a shower chair, multiple bottles of shampoo and lotion and two packages of personal care wipes. The shower was not in use. Patient #56 was seated on the bed and had a walker in front of her.
- Patient #62's room had a pink plastic tub with multiple bottles of hygiene supplies.

Observations on 12/19/23 at 12:38 PM, on the 15400 Acute Psychiatric Unit, showed:
- Patient #38's room, had a container of cleaning wipes and two boxes of rubber gloves on the nightstand.
- Patient #39 and #40's room had two unlocked metal boxes mounted on the wall above the patient beds. Exposed were the oxygen hook up, the vacuum hook up, two crosshead screws and two metal bars. Staff VV, Nurse Manager, attempted to lock the box multiple times with different keys. The correct key was secured in the medication dispensing machine.
- Patient #48's room, had one box of plastic colostomy (a piece of the colon is passed through a surgically-created opening in the abdominal wall so as to bypass a damaged part of the colon) bags, three hot pack bags, six packages of personal cleaning wipes, one roll of paper tape, one bottle of roll on deodorant, one tube of moisturizing cream, one bottle of powder, two tubes of stoma (an opening in the abdomen connected to either the digestive or urinary system to allow urine or feces to be diverted out of your body) adhesive and three bars of soap.

Observation on 12/19/23 at 4:05 PM, on the 15500 Acute Psychiatric Unit, showed:
- Patient #49's room contained multiple bottles of shampoo and lotion.
- Patient #51's room contained multiple bottles of shampoo and lotion.
- Patient #52's room had a door stop that was bolted to the floor with crosshead screws.
- Patient #57's room contained multiple bottles of shampoo, lotion, a toothbrush and a comb.
- Patient #59's room contained multiple bottles of shampoo, lotion and a toothbrush.
- Patient #61's room contained multiple bottles of shampoo, lotion and a toothbrush.
- Patient #63's room had four crosshead screws which secured the door locking mechanism to the bathroom door.

During an interview on 12/19/23 at 12:34 PM, Staff VV, Nurse Manager, stated that cleaning supplies such as cleansing wipes and patient care supplies such as gloves should be removed from patient rooms when not in use and should not be left unattended. The wall-mounted boxes should be kept locked unless in use. She had looked for the key to lock the metal boxes and could not find it. Patients in need of oxygen would have 1:1 observation.

During an interview on 12/19/23 at 4:10 PM, Staff MMM, RN, stated that all patients on the 15400 Psychiatric Unit were placed on SP regardless of risk.

During an interview on 12/19/23 at 4:05 PM, Staff AAA, Charge RN, stated that all the patients on the 15500 Psychiatric Unit had SP.

During an interview on 12/19/23 at 4:18 PM, Staff VV, Nurse Manager, stated that all patients on the psychiatric units were on SP. She had no idea how long the metal boxes on the walls in the patients' rooms had been unlocked.

During an interview on 12/19/23 at 5:00 PM, Staff GGG, RN, stated that Patient #56's medical record showed no order for her walker. Patients needed a physician order to have a walker while on the psychiatric unit "because it could be used as a weapon."

During an interview on 12/20/23 at 2:10 PM, Staff SSS, Interim Psychiatric Medical Director, stated that cleansing wipes and gloves should not be left in patient rooms. The metal boxes on the patient room walls should have been locked unless they were in use. Colostomy care supplies should have been stored somewhere other than the patient's room.

During an interview on 12/22/23 at 10:00 AM, Staff RRRR, RN, stated that personal hygiene items were limited to one each in a patient's room. Personal hygiene items were given to the patients to use and when the patients were finished, they returned them to the nurse's station. Room checks for excessive personal hygiene items should have been completed each shift. Medical supplies, such as colostomy supplies and medical equipment, should not have been left in the patient rooms.

During an interview on 12/27/23 at 2:21 PM, Staff OOOO, Physician, stated that he did not know how many personal items each patient was allowed to have. If medical supplies and equipment were left in a patient room, it should be on a case-to-case basis.

During an interview on 12/20/23 at 9:15 AM, Staff OOO, CNO, stated that when a patient was on SP, all precautions should be used and she expected those orders to be followed. All rooms were expected to be ligature-reduced. Clothing, blankets, shampoo, cleansing wipes, gloves and non-psychiatric safe screws should not be in the psychiatric rooms. Cabinets should be closed and locked. Shower chairs should be locked in the bathroom when not in use.

During an interview on 12/20/23 at 10:50 AM, Staff PPP, Interim Psychiatric Services Director, stated that all patients on the psychiatric units had SP orders. Supplies should have been limited in the rooms. There should not have been cleansing wipes, gloves, shampoo, colostomy supplies etc. in the rooms. Shower chairs should have been in a locked room when not in use. She expected all rooms to be psychiatric safe.

During an interview on 12/27/23 at 2:35 PM, Staff SSSS, RN, stated that, there was no guidance on how many personal hygiene items each patient was allowed to have in their room. Medical supplies were to be taken into the room, used and then removed. She had not realized a shower chair could be dangerous if left in a room until recently.

4.Review of the hospital's policy titled "Suicide Precautions - In-Patient Psychiatry Services," dated 07/2022, showed that all patients admitted to the inpatient psychiatry units will be observed at a frequency of four times an hour not to exceed 20 minutes apart.

Review of Patient #60's medical record dated 12/19/23 through 12/21/23 showed he was a 58-year-old male who was admitted to the BJH-Delmar Psychiatric Support Center (PSC) with diagnoses that included bipolar (a mental disorder that causes unusual shifts in mood by alternating periods of emotional highs and lows) and suicidal ideations (SI, thoughts of causing one's own death).

Review of Patient #60's documentation showed observations were completed:
- On 12/19/23 at 2:24 PM and 3:08 PM, 44 minutes later.
- At 3:08 PM and 3:30 PM, 22 minutes later.
- At 5:27 PM and 5:48 PM, 21 minutes later.

Review of Patient #69's documentation showed observations were completed:
- On 12/17/23 at 5:49 PM and 6:10 PM, 21 minutes later.
- On 12/18/23 at 1:37 AM and 2:00 AM, 23 minutes later.
- At 2:24 AM and 2:47 PM, 23 minutes later.
- At 4:04 PM and 4:30 PM, 26 minutes later.
- On 12/19/23 at 8:09 AM and 9:02 AM, 53 minutes later.

During an interview on 12/20/23 at 10:50 AM, Staff PPP, Interim Psychiatric Services Director, stated that all psychiatric patients were rounded on every 15 minutes.

During an interview on 12/20/23 at 9:30 AM, Staff CCC, RN, stated that patients in the Delmar PSC were rounded on every 10-15 minutes by the behavioral health technicians and every hour by the RNs.




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