HospitalInspections.org

Based on observation, record review, and staff interview, the facility failed to ensure patients received care in a safe setting (A0144).

Based on observation, record review, and staff interview, the facility failed to ensure patients received care in a safe setting for six of ten patient records reviewed (Patients #1, #2, #4, #5, #6, #7). This could affect all patients receiving services in the facility. The facility census was 27.

Findings include:

The facility policy titled "Patient Rounding", issued on 1/2015, was reviewed on 07/11/19 at 2:00 PM. The policy stated that rounds are to be made on the unit on all patients by the assigned nursing staff at a minimum of every 15 minutes for each 24-hour period to check all aspects of security and safety while monitoring patient behavior and location. All patient accessible areas are checked to see that patients are safe, behavior is appropriate, and for contraband items or for damages. Contraband, damage, or unsafe conditions are corrected and reported to the nurse and designee immediately. Rounding includes ensuring that patients are not entering into rooms not assigned to them. Missing entries are to be reported to the DON. Nursing can initiate higher rounding precautions for safety of the patient and/or others and then notify the physician to review. Higher rounding precautions are listed as line of sight (LOS) and 1:1. With LOS the patient must always be in line of sight of staff members. With 1:1 line of observation, the patient will be assigned a staff member solely dedicated to the patient. The staff member will remain within 4 feet of the patient for safety.

The facility policy titled "Incident Reports", issued 5/2016, was reviewed on 07/11/19 at 4:30 PM. The policy instructs staff that an incident report should be completed immediately when an incident occurs. The policy further stated incident reports are completed following any situation where there has been harm or potential for harm to a patient, family member, visitor or employee.

1. Review of the medical record of Patient #4 revealed the patient was admitted on 06/27/19 with diagnoses including dementia with behavioral disturbance and a history of aggression. The medical record lacked documented evidence that on 06/29/19 the 15 minute checks were completed at 7:00 AM, 8:00 AM, 9:00 AM, 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM, 5:00 PM, and 6:00 PM.

Review of an email dated 07/01/19 from psychiatric management services sent to administrative staff at the hospital revealed an incident that happened with Patient #4 and Patient #1 on 06/30/19. Patient #1 started screaming and staff went to see what the issue was and found Patient #4 choking Patient #1 resulting in scratches on his/her neck and Patient #4 had bruises on his/her arms. The medical record lacked documentation staff increased the patient's level of observation to prevent the assault of other patients.

A note on the Patient Monitoring Record on 07/11/19 at 9:00 PM revealed Patient #4 was noted to be choking and punching another patient (#9). The medical record lacked documentation of notification of the incident.

Staff C was interviewed on 07/12/19 at 2:05 PM and was asked if anything could have been done to prevent the second assault by the same patient. Staff C stated Patient #4 could have been made a different level of care. Staff C was asked if he/she would have changed the level of observation if staff witnessed a patient assault another patient, visitor, or staff member. Staff C stated, "Absolutely, if it's reported to me." He/She explained that staff could initiate a higher level of observation and then get a physician order; however, in order to reduce the level of observation, an order must first be received. It was confirmed that the medical record lacked documentation staff increased the level of observation after Patient #4 assaulted the first patient.

Staff F was interviewed 07/11/19 and was asked to provide an incident report. Staff F stated he/she was unaware of the event so no incident report had been created. It was also noted the patient remained with the minimum level of observation of every 15 minutes. An investigation of the incident was not completed until 07/11/19 after a request was made to review the documentation for the investigation during the survey.

2. Review of the medical record for Patient #1 revealed the patient was admitted on 06/25/19 with diagnoses that included bipolar disorder secondary to schizophrenia, dementia with behavioral disturbance, and depression.

A nurse's daily assessment dated 06/29/19 at 12:00 PM documented the patient was agitated and yelling out. A progress note composed by a state tested nursing assistant (STNA) revealed Patient #1 was observed hitting another patient. The STNA documented there was no harm to the other patient. There was no documentation an incident report was completed after this event.

Staff A was interviewed on 7/11/19 at 4:40 PM. It was confirmed staff should have immediately created an incident report.

Review of a nursing daily assessment dated 06/30/19 at 9:00 AM documented Patient #1 was verbally hostile, pacing the unit, and intrusive and multiple verbal altercations with patients. Minimal effectiveness was achieved with verbal redirection. The medical record lacked documentation staff increased the patient's level of observation to prevent the assault of other patients.

3. Patient #2 was transferred to the facility on 06/13/19 at 9:18 PM from an extended care facility. The precipitating events on the Intake Assessment revealed staff from the extended care facility reported the patient had become increasingly anxious, volatile, and sexually inappropriate and attempts to re-direct, one to one (1:1) staffing, medication, and distraction were proven unsuccessful.

On admission, the patient was ordered to be monitored every 15 minutes. In the comment section of the Patient Monitoring form, at 2:15 AM on 06/14/19, the patient was attempting to suffocate another patient. The summary of event on the incident report noted the following: "Heard patient in Room #107 yelling. Upon checking saw Patient #2 in patient's room next to bed with the other patient's blankets around her neck and over her mouth, when told to stop, the patient immediately stopped what she was doing. When told, she had no recollection of the event." The victim of this witnessed assault was 94 years old. A nurse's note at 1:50 AM stated Patient #2 was assisted to ambulate on the milieu where safety was maintained. The medical record lacked documentation staff increased the patient's level of observation.

A nurse's note on 06/19/19 at 2:00 PM stated Patient #2 seemed "very occupied" with a male patient. Another note on 06/22/19 at 4:00 PM stated the patient and a male patient were observed "holding hands and nearly kissing each other." A nurse's note on 06/23/19 at 6:00 PM stated the patient was seen alone in his/her room with a male patient. It was further noted the patient became irritated when staff separated the patients. Staff noted in the comment section of the Patient Monitoring form at 9:15 PM on 06/24/19 that the patient became angry when staff prevented him/her from holding the hand of another patient. A nurse's note on 06/25/19 at 12:00 PM stated the patient was again seen alone in a room with a male patient. Patient #2 was noted to be wearing only a brief. The male patient was observed attempting to zip his pants. Neither patient was able to confirm or deny any inappropriate sexual behavior. And neither patient's level of observation was increased. After the alleged patient to patient sexual encounter, staff continued the minimal level of observation for both patients.

According to Staff A the decision was made to transfer Patient #2 to a hospital for an examination by a Sexual Assault Nurse Examiner (SANE). The exam report was requested, however, no report was provided at the time of exit. The patient was transferred to the facility location in Wilmington and never returned.

The facility policy titled Sexually Acting Out Precautions, issued 8/2018, was reviewed on 07/11/19 at 4:15 PM. According to the policy sexually inappropriate behavior includes suggestive comments, public masturbation, and unnecessary self-exposure or touching of staff members who provide close-up care, other staff members who are not rendering care, and/or other patients. Sexually acting out precautions will be ordered by the provider, but nursing staff may implement sexually acting out precautions if indicated by the history of the patient's behavior while awaiting the order. All patients placed on sexually acting out precautions will be assigned to an acuity level based on the severity of the behavior individuals being impacted or "targeted" by the patient's advances (if applicable), as well as the nature and history of the behavior. The levels included every 15 minute observation and line of sight observation. All patients are on an every 15 minute observation, at a minimum.

Staff A was interviewed on 07/12/19 at 9:05 AM. It was confirmed that the medical record lacked documentation the patient was placed on sexually acting out precautions due to the patient's reoccurring sexually inappropriate behavior.

4. Patient #7 was transferred to the facility from a hospital on 05/30/19 at 11:00 AM with a diagnosis of dementia with behavioral disturbance. The admission assessment stated the patient was transferred to the hospital after the patient attempted suicide by slitting his/her wrist with a razor blade. Staff at the extended care facility where the patient lived reported the patient became upset when he/she was told he/she was not allowed to smoke outside of designated smoke times. The patient went back to his/her room and slit his/her wrist.

The facility policy titled "Assessment for Suicidal Ideation", issued 5/2016, was reviewed on 07/11/19 at 4:00 PM. According to the policy, staff are instructed that every patient will be evaluated for suicidal ideation upon admission to the facility and at discharge. If the patient scores medium or high suicide risk, staff are instructed to notify the physician for orders. Orders for suicide precautions must be renewed every 24 hours and discontinued only by order of the physician. These facts were confirmed with Staff A on 07/11/19 at 4:10 PM.

According to the psychiatric physician's comprehensive evaluation, on admission, a staff nurse asked if the patient had thoughts of hurting him/herself or others, the patient stated, "I plan to use the sharpest thing I can find and cut myself up with it." The Columbia-Suicide Severity Rating Scale (C-SSRS) was completed by a staff nurse. Under suicide ideation, the suicide assessment tool directs staff to "ask questions that are bolded and underlined" and to utilize other prompts. Under question #1 titled "wish to be dead," the staff member checked "yes" to the question, "Have you wished you were dead or wished you could go to sleep and not wake up?" Under suicidal thoughts, question #2, the staff nurse checked the "no" box. The prompt question for suicidal thoughts read: "Have you actually had thoughts of killing yourself?" The suicidal thoughts section also included a prompt of, "general non-specific thoughts of wanting to end one's life." The "no" box was checked despite the report of the patient's plan to use the sharpest thing he/she could find to hurt him/herself. The C-SSRS tool directed staff to skip questions 3, 4, and 5 if no was answered to question #2 about suicidal thoughts. It was noted that skipping those questions made the patient a low risk for suicide.

Staff A was interviewed on 07/11/19 at 4:30 PM. It was confirmed the C-SSRS was incorrectly completed as question #2 should've been answered yes due to the patient's verbalized plan to hurt him/herself.

On 5/31/19, the day after the patient was admitted, a nurse's note between 6:00 PM and 7:00 PM stated the patient was noted to be pacing back and fourth in his/her room. The patient came out of the room with a pop can ripped apart stating, "I'm going to use this to harm myself." The can was grabbed by a staff member. The medical record lacked documentation of notification of the incident. Despite the discovery of contraband, staff continued with 15 minute checks, the minimal level of observation. It was further noted no incident report for this event was created.

An incident report dated 06/01/19 at 10:30 PM revealed Patient #7 was again discovered with a ripped pop can but now, he/she was cutting his/her wrist. The physician was notified and the patient was ordered to receive a 1:1 level of observation. The Patient Monitoring Record noted 1:1 observation was performed until 06/04/19 when line of sight observation was noted.

The Patient Monitoring Record revealed Patient #7 was monitored every 15 minutes, the facility's minimum level of observation. On 06/05/19 the record noted absent 15 minute checks at 7:00 AM, 8:00 AM, 2:00 PM, 3:00 PM, 4:00 PM, 5:00 PM, and 6:00 PM. Additionally, there was no physician's order to decrease this patient's level of observation.

Staff A was interviewed on 07/11/19 at 2:30 PM. It was confirmed the medical record lacked documentation the referenced 15 minute checks were performed as required by facility policy. Staff A also confirmed at 4:40 PM. in both instances, staff should've immediately created incident reports as required by facility policy.

5. Review of the intake assessment form dated 05/11/19 revealed Patient #6 was transferred from a hospital's emergency room (ER) due to a suicide attempt with a gun. The admitting diagnosis was major depressive disorder with psychotic features. The comprehensive psychiatric evaluation dated 05/12/19 revealed this was an involuntary admission and that the patient complained of being very depressed and had nothing to live for. It was also revealed the patient had a plan to electrocute him/herself.

Review of the Columbia-Suicide Severity Rating Scale (C-SSRS) for question #1 (wish to be dead) was marked as no and question #2 (suicidal thoughts) was also marked as no.

Interview with Staff A on 07/12/19 at 2:30 PM confirmed the C-SSRS was an inaccurate assessment as the patient had a history of an attempted suicide and verbalized a plan to electrocute him/herself.

6. On 7/10/19 at 3:00 PM observations were made for a total of 14 patient rooms with two hospital beds in each room for a total of 28 beds. The census at the time of the tour was 27. The beds were not bolted to the floor. Although the beds were in a locked position, they were movable. All patients observed during the tour were noted to be ambulating without any assistive devices. The discharge patient list was also reviewed. Two patients below the age of 65 were noted.

Staff A was interviewed during the tour. He/She reported the beds not being a risk for safety due to the facility only accepting geriatric patients over 65 years of age. It was confirmed with Staff A that moveable hospital beds put all of the patients at risk.

7. Review of the policy and procedure titled "Fall Prevention Protocol", issued 01/2015, revised 12/17, 04/18, revealed all patients admitted to the hospital will be place on a fall prevention protocol. A fall is an unplanned decent to the floor or extension of the floor with or without injury. The post fall investigation included that the Director of Nursing (DON), Assistant Director of Nursing (ADON) or delegated clinical manager will review the incident report and post fall documentation to ensure the patient care was appropriate.

Review of the medical record for Patient #5 revealed he/she was admitted to the hospital on 05/09/19. Diagnoses included unspecified dementia with behavioral disturbances. The medical record revealed Patient #5 had a witnessed fall on 05/11/19 at 8:13 PM. On 05/11/19 at 9:33 PM the patient had un unwitnessed fall and was found on the floor in the milieu. There was no investigation/assessment form for either one of these falls.

Interview with Staff A on 07/12/19 at 9:05 AM revealed each fall should have an investigation form and if there was not one with the packet it was not done.




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