HospitalInspections.org

Based on record review and interview, the psychiatric hospital failed to ensure care in a safe setting. The deficient practice is evidenced by failure of nursing staff to monitor for signs of withdrawal as ordered for 1 (#1) of 1 reviewed patient records with orders for withdrawal assessments.
Findings:

Review of the medical record for Patient #1 revealed the patient was voluntarily admitted on 04/01/2024 with a diagnosis of bipolar disorder, suicidal ideations, and alcohol abuse.

Review of the orders for Patient #1 revealed an order initiated on 04/02/2024 at 10:42 a.m. for "Complete CIWA (Clinical Institute Withdrawal Assessment). Every six hours. Request Type: Now. Comments: Give PRN Ativan CIWA. >8." Further review of the order revealed the order duration was for 3 days starting on 04/20/2024 at 10:42 a.m. and ending on 04/05/2024 at 6:00 a.m.

Review of the medical record revealed the assessment was completed as listed below:
04/03/2024 at 9:30 a.m. and at 3:30 p.m.
04/04/2024 at 12:01 a.m., 6:12 a.m., 3:12 p.m., and 5:08 p.m.
04/05/2024 at 12:00 a.m. and 5:54 a.m.

In interview on 05/13/2024 at 12:03 p.m., S2DON verified the assessments were not performed every 6 hours as ordered.

Based on record review and interview, the facility failed to ensure all patients were protected and free from abuse. The deficient practice is evidenced by failure of the facility to restrict the access of 1 (#3) of 1 reviewed patient on Aggression/Violence Precautions after demonstrating violent tendencies towards another patient.
Findings:

Review of the policy titled "Nursing Service: Precautions," revised 03/21/2018, revealed in part, "PRECAUTIONS: . . . A registered nurse may place a patient on Precautions, without a prior order from a licensed practitioner, to ensure the safety and security of the patient. If the registered nurse places a patient on Precautions, that nurse is required to contact the authorized licensed prescriber on duty to obtain a corresponding order as soon as possible. . . . Aggression/Violent Behavior Precautions are ordered when a patient, by behavior, verbalization, history, or by report presents a risk of violence towards other, regardless of the specific type of risk (i.e. fighting, homicide, sexual assault). The determination for ordering these Precautions may be made based on verbal threats, threatening behavior, reports, or history. The following are components of Aggression/Violent Behavior Precautions: . . . 10-foot Parameter- The patient is required to remain a minimum of 10 feet away from individuals that are identified as potential victims up to and including all peers. Orders indicate whether the 10-foot parameter will be observed during group therapy sessions."

Review of the medical record for patient #3 revealed admission on 04/21/2024 after the patient's father requested an order of protective custody. Review of the Physician's Emergency Certificate revealed in part, "OPC by father. Patient is not taking meds, acting bizarrely, wandering in other people's yards, recently punched a stranger at a store."

Review of the self-reported incidents to the licensing authority in revealed two incidents between Patient #3 and Patient #R1. The first incident occurred on 04/30/2024 and the second incident occurred on 05/05/2024.

Review of the incident from 04/30/2024 revealed at 9:30 p.m. both patients were on the patio when Patient #3, who was on aggression precautions, hit Patient #R1 with a closed fist. Both patients were on 15 minute observation at the time and it was reported there had been no previous altercations or aggression between the patients. Further review revealed after the event, Patient #3 was placed on line of sight observation and Aggression/ Violent Behavior Precautions were continued. The report documented Unit Restriction, Sharps Restriction, 10-foot Parameter, and No Roommate as components of the Aggression/Violent Behavior Precautions.

Review of the incident from 05/05/2024 revealed both patients were on 15 minute observations. At 9:25 p.m. Patient #3, who was still on Aggression/ Violent Behavior Precautions, walked up to Patient #R1 in the dayroom and began hitting him in the face. Patient #R1 sustained a lactation above his right eyebrow and a black eye. Immediately after the incident Patient #R1 received neurological assessments every 2 hours.

In interview on 05/13/2024 at 12:30 p.m., S2DON verified Patient #3 was not placed on distance precautions from Patient #R1 after the first incident even though it was listed in the report to the licensing authority. S2DON verified that the components listed in the report and in the hospital policy, including the 10-foot restrictions, required additional orders and were not automatically a part of the Aggression/ Violent Behavior Precautions. Patient #3 was placed on line of sight observation on the day of the incident and later on 1 to 1 observation which was discontinued the morning of 05/05/2024. S2DON verified the order for distance precautions was not requested because they did not feel Patient #R1 was a potential victim after the first unprovoked attack.