HospitalInspections.org

Based on document review, observation, and interview, the facility failed to provide patient with protection from abuse for 1 of 1 patient observed in video footage review (P5).


Findings include:

1. Review of policy/procedure titled, "Psychiatric Patient Rights," PolicyNo.: RE 16, last revised 08/2018; indicated under: You have the right to: 6. Reasonable protection from physical or emotional abuse or harassment.

2. Review of policy/procedure titled, "Recognizing And Reporting Suspected Abuse/Neglect/Exploitation," PolicyNo.: CC.07, last revised 09/2024; indicated under Policy: Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and exploitation. Indicated under types of abuse: 2. Physical Abuse:
A willful infliction of injury by using physical force that may result in bodily injury, physical pain, or bodily function impairment. Examples of physical abuse include, but are not limited to, striking (with or without an object), kicking, hitting, pushing, shoving, shaking, beating, slapping, pinching, and rough handling.

3. Review of 01/09/25 comprehensive psychiatric evaluation at 1:05 p.m., P5 indicated another patient tried to attack them as they tried to go into their room and endorsed receiving a skin tear from the patient hitting their hand.

4. On 02/17/25 at approximately 11:55 a.m., this surveyor, accompanied by A1 (Quality Manager), viewed video footage of the incident on 01/08/25 involving P5 and P10. In the video, this surveyor observed P5 standing in the hall by the double doors, P10 was wandering around the unit headed towards the double doors. When P10 gets to P5 he/she reached out and grab P5's arm, it appeared as if he/she was smacking P5 and received a skin tear to their hand in the abuse. A8 (Certified Nurse Aide [CNA]) ran to separate both patients. P5 is seen shortly after sitting in the milieu, where A7 (Registered Nurse) takes photos and bandages P5's wound.

5. Interview with A1 on 02/17/25 at approximately 12:15 p.m., confirmed after reviewing video footage, on 01/08/25 there was an altercation between P5 and P10, and P5 sustained a skin tear from the incident.

Based on document review and interview, facility failed to ensure all hospital nursing personnel for whom a current license is required, had a valid and current license for 1 of 5 nursing personnel files reviewed. [A7 (Registered Nurse)]

Finding include:

1. Review of National Council State Boards of Nursing, Nurse Licensure Compact indicated under 1. Issued in your primary state of residence (PSOR). 4. When you change your PSOR (relocate) to another compact state, you need to apply for that state's nursing license within 60 days of relocating. You can only practice on your former multistate license until you are issued your new multistate license from your new PSOR. The former license then becomes invalid.

2. Review of A7 personnel file indicated a professional compact licensure issued from S1 (Another State). A7's date of hire with facility was 11/09/2022.

3. Review of A7's driver's license listed residence as S2 (Current State).

4. Interview with A2 (Chief Executive Officer [CEO]), on 02/17/25 at approximately 1:50 p.m., confirmed A7 is working on a compact license from S1 and has been employed at facility since 2022. A2 confirmed A7 needed an S2 nursing license and did not have one in personnel file.

Based on document review and interview, facility failed to ensure immediate completion of an incident report when a patient-to-patient incident occurred for 1 of 10 patient medical records reviewed (P5).

Findings include:

1. Review of policy/procedure titled, "Reportable Incidents," PolicyNo.: NR.36, last revised 03/2024; indicated under policy: reportable incidents are to be completed on state appropriate form and submitted to the applicable state department. Indicated under procedure: reportable incident notification must be completed within 24 hours of the date of discovery when incident occurs. Indicated under reportable incidents: assault by non-staff with injury: physical, involving a patient.

2. Review of policy/procedure titled, "Incident Reports," PolicyNo.: NR.11, last revised 03/2024; indicated under procedure: an incident report should be completed immediately when an incident occurs. Indicated under what should be reported: assault - patient on patient. Indicated under when should the incident report be completed: all incident reports must be completed and given to charge nurse or Director of Nursing (DON) for review prior to the end of the scheduled shift.

3. Review of 01/09/25 comprehensive psychiatric evaluation at 1:05 p.m., P5 indicated another patient tried to attack them as they tried to go into their room and endorsed receiving a skin tear from the patient hitting their hand.

4. On 02/17/25 at approximately 11:55 a.m., this surveyor, accompanied by A1 (Quality Manager), viewed video footage of the incident on 01/08/25 involving P5 and P10. In the video, this surveyor observed P5 standing in the hall by the double doors, P10 was wandering around the unit headed towards the double doors. When P10 gets to P5 he/she reached out and grab P5's arm, it appeared as if he/she was smacking P5 and received a skin tear to their hand in the abuse. A8 (Certified Nurse Aide [CNA]) ran to separate both patients. P5 is seen shortly after sitting in the milieu, where A7 (Registered Nurse) takes photos and bandages P5's wound.

5. Interview with A1 (Quality Manager) on 02/17/25 at approximately 12:35 p.m., confirmed there was not an incident report (IR) regarding the altercation on 01/08/25 between P5 and P10.

6. Interview with A2 (Chief Executive Officer [CEO]) on 02/17/25 at approximately 12:40 p.m., confirmed there was not an IR regarding the altercation on 01/08/25 between P5 and P10.