HospitalInspections.org

Based on record review and interview, the hospital failed to:

1) maintain patent rights to dignity and comfort during admission;

2) follow their General Grievance and Patient Advocacy policy for one (Patient #1) of 24 patients reviewed. This failed practice had the potential to leave emotionally fragile patients at risk for feelings of hopelessness in an environment where they came to resolve/control mental health issues. (Refer to Tag A0118)

Based on record review, interview and observation, the hospital failed to:

1) Ensure one patiet (Pt #11) received care in a setting free from unwanted sexual advances after sexual misconduct/familiarity by another patient (Pt #20);

2) Ensure the safety of all patients on the unit from potential sexual misconduct by Pt #20 and 21 by not removing the alleged perpetrator or initiating one on one during an investigation of sexual familiarity;

3) Ensure a safe environment was maintained for Pts #18 and 22 by failing to detect and remove contraband during admission;

4) Ensure a safe environment was maintained for Pt #24 by failing to prevent access and storage of plastic cutlery;

5) Follow their "Levels of Observation and Precautions Policy" and "Patient Abuse, Neglect and Exploitation Policy."

These failed practices posed an Immediate Jeopardy to patient health and mental well being, and had the potential to result in a repeated offence on all patients on the Meadows Unit with whom the offenders had unrestricted access and posed an Immediate Jeopardy to patients residing at the facility after:

a) acts of sexual familiarity against peers and staff perpetrated by Pt #20, 21;

b) a threat of self harm by way of plastic cutlery found under the mattress of Pt #24;

c) potential access to alcohol hidden in a common area bathroom by Pt #18 and all patients who had access to the common area bathroom before the alcohol was found/removed and un-prescribed medications not identified or removed from the pockets of Pt #22.


On 09/25/18, at 2:20 pm, the CEO, QA Director, and members of the hospital leadership team were notified of the immediate jeopardy conditions identified in the Meadows and Cedars units. The facility provided an acceptable Plan of Removal prior to exit effective 09/26/18 at 4:00 pm consisting of:

* Updated Policies on "Sexual Acting Out and Sexual Victimization) to be distributed, read and initialed by all staff to verify it was viewed.

*Distribution to all nursing/PCA staff with a signature sheet showing they read the new policies to include staff response for questions regarding new policies.

*Completion of sign in sheets to show current and oncoming staff would complete the new polices review with the House Supervisors at the beginning of their shifts.

*A mandatory meeting for all staff for details on implementation of new policies and procedures to ensure client and staff safety.

*A dated signature page to verify new policies and procedure on Sexual acting Out and Sexual Victimization policy and a Response and Notification Checklist for Alleged/Actual Patient Sexual Incident.


On 09/27/18, at 3:50 pm, the surveyors verified the hospital's plan of removal of the immediacy by interview with staff members who stated they had completed a review of the updated policy and checklist and could give details on policy and procedure changes for patient and staff safety.

Based on record review and interview, the hospital failed to:

1) maintain patent rights to dignity and comfort during admission;

2) follow their General Grievance and Patient Advocacy policy for one (Patient #1) of 24 patients reviewed. This failed practice had the potential to leave emotionally fragile patients at risk for feelings of hopelessness in an environment where they came to resolve/control mental health issues.

Findings:

A hospital policy titled, "General Grievances and Patient Advocacy" documented requirements for the hospital to handle all patient complaints submitted in writing as a grievance to be investigated with attempts to resolve the issue within 48 hours and then written notification to the patient or patient's representative no longer than 20 business days from when the complaint was received.

A patient advocate request form dated 04/30/18 showed Pt #1 complained about being strip searched upon admission and not told why.

A patient advocate letter dated 05/11/18 documented the patient's account of being strip searched without being told why. Neither administrative and complaint records nor clinical records showed an investigation into this allegation. Documentation showed no resolution to the allegation.

On 09/21/18 at 2:13 pm, the Patient Advocate stated the allegation was not investigated, would normally be investigated and should have been investigated.

Based on record review, interview, and observation, the hospital failed to:

1) Ensure one patient (Pt #11) received care in a setting free from unwanted sexual advances after sexual misconduct/familiarity by another patient (Pt #20);

2) Ensure the safety of all patients on the unit from potential sexual misconduct by Pt #20 and #21 by not removing the alleged perpetrator or initiating one on one during an investigation of sexual familiarity;

3) Ensure a safe environment was maintained for Pts #18 and #22 by failing to detect and remove contraband during admission;

4) Ensure a safe environment was maintained for Pt #24 by failing to prevent access and storage of plastic cutlery;

5) Follow their "Levels of Observation and Precautions Policy" and "Patient Abuse, Neglect and Exploitation Policy."

These failed practices posed an Immediate Jeopardy to patient health and mental well being and had the potential to result in a repeated offence on all patients on the Meadows Unit with whom the offenders had unrestricted access and posed an Immediate Jeopardy to patients residing at the facility after:

a) acts of sexual familiarity against peers and staff perpetrated by Pt #20 and #21;

b) a threat of self harm by way of plastic cutlery found under the mattress of Pt #24;

c) potential access to alcohol hidden in a common area bathroom by Pt #18 and all patients who had access to the common area bathroom before the alcohol was found/removed and un-prescribed medications not identified or removed from the pockets of Pt #22.


Findings:

A hospital policy titled, "Levels of Observation and Precautions" documented, one-to-one observation was the most restrictive level of observation for the patient and staff must be within an arm's reach of the patient at all times.

A review of a hospital document titled "Patient Abuse, Neglect and Exploitation" showed, patients had the right to be free from mental, physical, sexual and verbal abuse, neglect, exploitation, retaliation, and humiliation, and it was the facility's policy to protect patients from real or perceived abuse from anyone.

A hospital policy titled, "Patient Belongings, Valuables, Contraband and Restricted Articles" documented: glass/metal containers were restricted items to be locked and access to item was not allowed; medications were to be locked in the med room and admitting staff would secure items at admission.


Sexual Misconduct/Sexual Familiarity

Pts #11
A review of clinical records and risk management reports dated 08/17/18 documented sexual familiarity perpetrated against Pt #11 at 5:30 am on 08/17/18 by Pt #20.


Pt #20
A review of risk management reports showed Pt #20 was redirected several times and then restrained after committing the sexual misconduct, and was secluded for an hour and then brought back to the same unit (Meadows). Documentation showed a bed block was instituted to prevent another patient from being admitted to the same room as Pt #20.
Documentation showed no additional initiation of protective measures to prevent Pt #20 from committing a second offense on the same patient or another patient on the Meadows unit (such as a one-to-one) from 6:40 am to 10:00 am after the sexual misconduct occurred.

Documentation showed no removal of Pt #20 from the patient population (or immediate one-to-one) to another unit (Cedars) until 5:00 pm on 08/18/18, the day after the offense.

On 09/25/18 at 12:00 pm, SA surveyor observation of video recording of the sexual familiarity (Pt #20 against Pt #11) showed the following:

08/17/18
5:31 am, Incident of sexual familiarity against Pt #11. Pt #20 touched the breast of Pt #11. Pt #20 verbally redirected and walked away.

5:32 - 5:33 am, Pt #20 slowly returned to the nursing station where Pt #11 was standing. Hospital staff was observed donning gloves. Pt #20 was observed inappropriately touching Pt #11. Hospital Staff immediately intervened verbally and then physically restrained Pt #20.

5:36 am, Pt #20 restrained (walked) to seclusion

5:53 am, Pt #20 received chemical restraint

6:39 am, Pt #20 was removed from seclusion and taken back to the same room on the Meadows unit

6:42 am, Nurse exited room of Pt #20

7:12 am, Pt #20 exited the room Pt #20 occupied (unattended)

7:14 am, Pt #20 re-entered own room (unattended)

7:18 am, Pt #20 exited room (unattended)

7:23 am, Pt #20 remained out of room and sitting at table in common area (unattended)

7:27 am, Pt #20 returned to room accompanied by PCA

7:28 am, PCA left the room of Pt #20

10:01 am, one-to-one initiated and PCA was within arms reach of Pt #20

10:45 am, on 08/17/18 am through 9:00 am, on 08/18/18 (when one-to-one was discontinued) showed one-to-one was not maintained and staff were not always within arms reach of patient. Observation showed periods of time when the nursing station was unattended and periods when the nursing station was occupied but staff members' backs were facing the patient's door. Note: observation (of video) was inconsistent with written documentation which documented staff initials every 15 minutes to verify one-to-one.


On 09/25/18, at 11:40 am, Staff A stated:

1) Patient was not initially a one-to-one because the patient was in the room asleep until one-to-one was initiated;

2) a one-to-one meant staff was never an arms length from patient, a staff member was with the patient at all times and patient was not a one-to-one until 10:00 am on 08/17/18;

3) The room for Pt #20 was directly across from the nursing station and the patient was continually observed by staff. Note: Neither documentation nor observation showed Pt #1 was in constant view of the staff.

4) Although the patient's room was located across from the nurses station, the patient could not be viewed from the nurses station;

5) There may be times when a nurse was not immediately at the nurses station but they were still in the vicinity;

6) When patient was a one-to-one, the facility required documentation in 15 minute intervals.

7) The video tape showed gaps in constant observation, no documentation completed every 15 minutes and staff was not always within "arms reach" of Pt #20 between the time one-to-one started and ended.

8) "Sexual familiarity" encompassed any allegations of a sexual nature to include inappropriate touching.


Pt# 21
A review of clinical records and risk management reports showed:

1) on 07/12/18, at 9:00 am, Pt #21 stood up in the dayroom, exposed his genitals to an unnamed female peer and was directed by staff to pull his gown down.

2) At 3:00 pm, Pt #21 grabbed a staff member in the crotch.

3) At 9:40 pm, Pt #21 approached an unnamed female peer and grabbed at peers genitals. Documentation showed no facility efforts to keep other patients safe from unwanted observations of male genitalia/sexual familiarity until 9:55 pm (12 hours after the initial behavior began) when patient was separated and moved to the other side of the Meadows unit after groping an employee's genitals twice, at which time patient was placed on one-to-one.


Clinical documentation showed on 07/14/18 at 8:00 pm (Pt #21 remained one-to-one), an unnamed female peer reported patient (#21) came up to her at noon and rubbed up and down her leg and showed her clay that he had molded into the shape of a penis. Documentation failed to show how patient was allowed in such close proximity to allow touching of another patient while on one-to-one.


On 10/01/18 at 1130 am, Staff A stated:

1) Pt #21 was not placed on one-to-one until 12 hours after the behaviors were observed and

2 Pt #21 should have been directed/redirected to ensure peers remained safe from unwanted sexual familiarity.


Contraband

Pt #18
A review of the clinical record showed patient admit to the facility on 08/03/18 with a history of Psychosis. Facility records showed a report of a bottle of wine found in a common area. Facility investigation showed the patient's husband helped sneak the bottle of wine during the initial assessment for Pt #18. Facility investigation stated education was to be provided to reception staff to ensure they were looking for contraband. Documentation showed no verification of training

On 09/26/18 at 3:00 pm, Staff A stated the bottle of wine had been found in a bathroom used by patients, it should have been found during admission, and competency and safety training had been scheduled for August but August training had been delayed until September and then delayed again until October 2018.


Pt #22
A review of the clinical record showed patient admit to the facility with a history of Schizoaffective Disorder. Facility records showed a report of Pt #22 was found with "two blue pills" (Xanax) in their pocket after being checked in at admission to the unit.

On 09/26/18, at 3:05 pm, Staff A stated the patient had free roam of the unit prior to the medications being found and the potential existed for taking the medication or sharing the medication (with other patients) before staff discovered the mediation.


Pt #24
A review of the clinical record showed Patient #24 admitted to the facility with psychosis. Facility risk management records showed a report of patient becoming upset and threatening she could kill herself while on one-to-one.

Documentation showed at 7:00 pm on 07/05/18, the room of Pt #24 was immediately searched and was found to have two plastic knives under the mattress. Documentation showed the immediate removal of the knives as well as any other item in which Pt #24 could cause self harm.

Documentation showed the agency rated the severity of the occurrence "inconsequential" (as opposed to minor, major or grave) and no other findings or staff training was pursued.


On 09/26/18 at 2:45 pm, Staff B stated:

1) the knives should not be in a patient's room or under their mattress and that a person could hurt themselves or others with a plastic knife.

2) they (facility staff) were uncertain how Pt #24 was able to get plastic knives out of the cafeteria or into the patient room.

On 09/26/18 at 2:49 pm, Staff C stated the facility no longer offered plastic knives to patients as a result of the incident.

On 09/26/18 at 3:00 pm, Staff A stated the facility was supposed to have training on maintaining safety in August 2018 but it had been delayed until September and delayed again until October 2018.

Based on record review and interview, the hospital failed to ensure ongoing problem-prone employee complaints regarding concerns for patient safety were identified in QAPI activities or performance improvement projects. This failed practice placed the hospital at risk of repeated complaints by all direct care staff and possible safety mishaps for all patients secondary to failure to address the complaints, identify the existence of a recurring problem areas and failure to implement measures for correction.

Findings:

A review of QAPI records showed ongoing monitoring of data pre-determined by the corporate office for their nationwide hospitals. Documentation showed no inclusion of problem areas specific and unique to the (local) hospital.

A review of employee complaints showed:

1) a steno page dated 08/23/18 with hand written bullet statements expressing PCA reports of inadequate staffing and concerns for patient safety. Documentation showed no investigation into the complaints of patient safety concerns or inadequate staffing concerns and an explanation that HR explained the grid to the staff member.

2) a typed memo dated 09/20/18 from a staff member to the DON showed concerns of inadequate staffing and concerns of patient safety directly related to a PCA shortage. Documentation showed no investigation into the complaints of patient safety or inadequate staffing, but instead, an investigation into the employee's Internet activities that night that would allow him time to compose a memo while at work and presumably understaffed.

3) no organized means for an employee to safely make a complaint.

4) no policies regarding the process for employees to make safety complaints without reprisal.

6) no identification and incorporation of repeated staff concerns into the hospital's QAPI program.

7) no QAPI interventions to address a growing number of complaints directly related to concerns of staffing shortages, patient safely and fear of poor outcomes related to staffing shortages.

8) no QAPI interventions to ensure the grid for staffing was adequate to meet an increased census, increased acuity, changes in patient dynamics and changes in the staff to patient ratio.


A review of complaint reports showed no employee based incidents/complaints/grievances. Staff interviews with direct care staff yielded the following complaints:

On 09/26/18, at 11:30 am, Staff J stated, the hospital was short staffed, they had concerns about keeping patients safe and they had made a complaint to the DON, CEO, and HR.

On 09/26/18, at 11:44 am, Staff K stated, there was no consistency in patient to staff ratio and administration kept changing the grid.

On 09/26/18, at 11:45 am, Staff L stated, the hospital was short staffed, they had concerns about keeping patients safe and they had made a complaint to the DON, CEO, and HR.

On 09/26/18, at 11:10 am, Staff M stated, the hospital was short staffed, they had concerns about keeping patients safe and they had made a complaint to the DON, CEO, HR, and QA.

On 09/26/18, at 12:00 pm, Staff N stated, the hospital was short staffed, they had concerns about keeping patients safe and they had made a complaint to the DON.

On 09/26/18, at 12:47 pm, Staff O stated, the hospital was short staffed, they had concerns about keeping patients safe and they had made a complaint to the DON, CEO, and HR.

On 09/26/18, at 1:44 pm, Staff P stated, the hospital was short staffed, they had concerns about keeping patients safe and they had made a complaint to the DON.

On 09/26/18, at 2:12 pm, Staff Q stated, the hospital was short staffed, they had concerns about keeping patients safe and they had made a complaint but was unwilling to say to whom the complaint was made.


Administration Interviews:
On 09/26/18, at 3:07 pm, Staff A, B, and C stated, the hospital had no employee complaints.

On 09/27/18, at 10:00 am, Staff B stated, he had "conversations" with employees based on the hospital's staffing but he considered them conversations, not complaints.

On 09/27/18, at 10:30 am, Staff B stated, an employee had left the unit to come tell Staff B their concerned about patient safety due to too few PCAs scheduled. Staff B stated, if the employee was so concerned, why would he leave them (the other PCS staff on the unit) even shorter staffed to go make a complaint. Complaint records showed no intake or documentation of the complaint.

On 09/27/18, at 10:37 am, Staff B stated, employee complaints had began five to six months ago but they were because employees didn't understand the staffing grid.

On 09/27/18, at 10:40 am, Staff F stated, one employee had made a complaint on patient safety and staffing issues on behalf of all the PCAs and it was considered one complaint. Staff F stated, a second employee made a complaint alleging inadequate staff to patient ratio but an investigation into that employee's activities that night showed he had been on the Internet all night so there was obviously no problem caring for the patients. Documentation showed no investigation into the allegations of patient safety concerns secondary to inadequate staffing.

On 09/27/18, at 2:00 pm, Staff A, B, and C stated, the hospital's census, patient acuity, patient population, and staff to patient ratio (grid) had changed a few months ago which had caused increased staff complaints about poor staffing because staff had become spoiled and accustomed to being overstaffed and caring for a cherry picked clientele and they now had to care for a broader variety of mental health patients.

On 10/01/18, at 1:25 pm, Staff B stated, their QAPI program was a corporate design and repeated employee complaints about patient safety secondary to inadequate staffing had not been included in their program at the local level. When asked why increased complaints involving direct patient care and quality of care wasn't included, no clear response was given.

Based on record review and interview, the hospital failed to:

1) Ensure medication was administered according to physician's orders for one (Pt #23) of 24.

2) Ensure medications were stored per facility policy and procedures. This failed practice caused an unnecessary exacerbation of hyponatremia and emergency room admission due to staff oversight of medications provided by patient/family at admission for Pt #23.

A policy titled, "Patient Belongings, Valuables, Contraband and Restricted Articles" documented all belongings would be logged and medications would be locked in the med room.


Findings:

A patient admission form showed an admission date of 08/18/18 with a diagnosis of hyponatremia (a condition in which the sodium in the blood is too low).

A treatment planning and co-morbid medical conditions document (undated) showed a medication ordered to treat the medical condition of hyponatremia. Documentation showed interventions to continue "Samsca" (medication used for the treatment of hyponatremia), orders for the medication, and orders for staff to administer the medication.

A signed medication order sheet, dated 08/18/18, at 8:14 am, showed an order for Samsca 15 mg tablet by mouth daily.

A form titled "Home Medication Belongings" dated 08/19/18 showed, the facility received 19 pills of Tolvaptan 15 mg (generic for Samsca).

A 7:00 am -7:00 pm shift, nursing assessment dated 08/20/18 showed, staff was still awaiting "Samsca."

A laboratory service report dated 08/22/18 showed, the patent had a low sodium blood level.

A physician's order dated 08/23/18, at 9:40 am, ordered the patient to be sent to the emergency department for hyponatremia.

A progress note dated 08/23/18, at 10:15 am, showed, the client was transferred to the hospital for hyponatremia.

A medical consult follow-up form dated 08/23/18 showed, the patient had been without their Samsca since admission.

A psychiatric inpatient progress note dated 09/24/18 showed, the patient had been sent to the hospital due to a low sodium blood level.


A risk management incident report dated 08/24/18 showed, the patient was sent to the hospital on 08/23/18 due to not having medication to regulate hyponatremia (patient had an exacerbation of hyponatremia) and the medication had been found on 08/24/18 in a bag under the patient's bed. The report showed the medication was brought in by the family on 08/19/18 and the medication was not marked by staff for continued use due to the staff only checking for medications they were responsible for administering (such as medication only administered on a certain shift or time of day).


On 09/27/18, at 2:17 pm, Staff A stated, Patient #23 family brought the Samsca to the hospital but it had been reported the Samsca had not been brought to the hospital. Staff A stated, upon discharge from the hospital, the Samsca was found under the patient's bed and the patient had not taken the medication from 08/18/18 to 08/23/18 (five days without the medication).