HospitalInspections.org

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Based on medical record review, document review, review of the facility's video surveillance, and interview, it was determined the facility failed to provide care for its patients in a safe setting. Specifically, the facility failed to maintain close monitoring of all patients on the Behavioral Health Unit (BHU). This finding was noted in 2 of 5 medical records reviewed. (Patients #2 and 6).

This failure may result in harm to patients.

Findings include:

Review of medical record for Patient #2 revealed a 26-year-old female who presented to the Emergency Department (ED) on 11/4/19 at 8:33 PM for a psychiatric evaluation. The ED physician noted that the patient was alert and oriented to herself, place, situation, and time. She was calm and cooperative, and she was placed on constant observation. The Behavioral Health Licensed Master Social Worker (LMSW) charted at 11:57 PM that the patient had a medical history of Bipolar and Post Traumatic Stress Disorder. A family member informed the LMSW that the patient was acting out at home, destroying possessions, and threatening a family member with a knife.

The psychiatrist evaluated the patient on 11/5/19 at 5:47 AM, and noted that the patient had an Acute Mania, Psychosis and medication non-compliance and she was admitted to the Behavioral Health Unit (BHU).

A BHU nurse noted on 11/9/19 at 12:15 AM that she heard a scream coming from Patient #2's room. The nurse reported that she found Patient #2 lying underneath the covers and a male patient (Patient #6) lying on top the patient's covers with his hand wrapped around Patient #2's neck.

Patient #6 was removed from Patient #2's room and was placed on close observation.

The BHU nurse noted that Patient #2 had redness around her neck. The physician charted that the patient sustained abrasions around her neck and ordered a Cat Scan of the neck.
The psychiatrist placed Patient #2 on a one to one observation for her safety. Patient #6 was placed on one to one observation.

During a tour of the BHU on 4/23/21 at 10:33 AM, it was noted that the unit has 26 beds with male and female patients. The unit had three (3) stations. The front of the unit had no camera, the middle station is the nursing station, and it has a video monitoring of all the hallways.
The rear station has a video monitor with a Mental Health Behavioral Counselor (MHBC) monitoring the hallways. It was noted that a MHBC made rounds on the unit every 15 minutes.

A review of the facility's video surveillance on 4/21/21 at 9:00 AM, revealed that Patient #6 entered Patient #2's room on 11/9/19 at 12:16 AM wearing a closed hospital gown. The BHU nurse was viewed running into Patient #2's room at 12:23 AM. The MHBC staff responded at 12:25 AM and Patient #6 was noted running out of the room with his gown opened.

There was no indication that patients in the hallway were monitored for safety; Patient #6 was not observed entering Patient #2's room.

During an interview with Staff I, RN on 4/23/21 at 2:24 PM, she stated that "if my colleague did not hear her (Patient #2) scream, I would not have known that he (Patient #6) was in the patient's room. It was very scary; he was on top of her choking her and she was trying to fight him off."

Patient #11 is a 26-year-old female who presented to the ED on 1/29/21 for a psychiatric evaluation for agitation and paranoid behavior. The psychiatrist evaluated the patient, noted that the patient had a history of Schizophrenia, Bipolar disorder with psychosis and admitted the patient to the BHU on 1/29/21.

Patient #12 is a 19-year-old male patient who was admitted to the BHU on 2/6/21 for disturbing thoughts and not thinking clearly. The psychiatrist noted that Patient #12's past psychiatric history was unclear.

The BHU nurse noted on 2/7/21 at 3:06 AM that during a 15-minutes round, Patient #12 was not in his room. The BHU nurse noted that Patient #12 was wearing a hospital gown lying in bed next to Patient #11 on top of the covers. The BHU nurse reported that Patient #11 was found asleep and unaware that Patient #12 had been lying on top of the covers beside her.

A review of the facility's incident investigation on 2/8/21 noted that Patient #11 was lying underneath the covers fully clothed. Patient #12 was found in his hospital gown lying on top of the covers and there was no physical contact.

A review of the facility's video surveillance on 4/21/21 at 9:00 AM, revealed that Patient #12 was wearing a closed hospital gown when he entered Patient #11's room on 2/7/21 at 2:58 AM.
At 3:06 AM, the BHU nurse entered Patient #12's room and ran out immediately looking for Patient #12. The BHU found Patient #12 at 3:06 AM in Patient #11's room. Patient #12 was viewed running out of Patient #11's room with his hospital gown opened.

There was no indication that patients in the hallway were monitored for safety; Patient #12 was not observed entering Patient #11's room.

During an interview with Staff D, Administrative Director-Director Behavioral Health and Recovery Center which was conducted on 4/23/21 at 10:33 AM, she confirmed that there was a staff shortage and there was no one monitoring the hallways those nights.
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Based on medical record reviews, document review and staff interview, it was determined the facility failed to (a) collect data for some indicators and (b) identify, analyze and implement corrective measures for problems identified in its Quality Assessment and Performance Improvement program in order to improve the quality of care provided to its patients.

These failures may place patients at risk for serious harm.

Findings include:

Review of the facility's "Scorecard" from 3/2020 to 3/2021, showed no evidence that the facility collected data on medication errors, mortalities, and adverse events.
See findings at A 0273.

The facility failed to use all data collected from the Incident/Occurrence Reports to analyze and identify problems to improve clinical performance.
See findings at A 0283.

The facility failed to ensure that interventions that were taken to address the high-pressure injury rates in its Quality Assurance and Performance Improvement (QAPI) project were used to effect positive changes hospital-wide in accordance with its Quality and Patient Safety Plan for 2020 and 2021.
See findings at A 0297.

The Governing Body failed to provide adequate oversight of the Performance Improvement Committee (PIC) and the QAPI program.
See findings at A 0309.
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Based on document review and interview, the facility failed to use the data collected in its Performance Improvement Program to address problem areas and take appropriate action to improve patient outcomes.

Findings include:

The Quality and Patient Safety Plan for 2020, states that the facility will facilitate a culture to prevent inadvertent harm through the reporting of an error or mistake to enact an incident investigation failure or root cause with action or improvement.

The Performance Improvement Committee (PIC) minutes for 9/9/2020 to 3/10/2021, showed no documented evidence that data collected was reviewed and analyzed and that plans were developed to improve outcomes.
The following are some of the indicators that was collected on the facility's "Scorecard" but was not addressed in the PIC minutes:
*Hospital acquired infections
*Fall incidents
*Restraints
*Resuscitation rates
*Infection prevention rates

In addition, the "scorecard" showed inconsistencies and outliers that were not explored or addressed.
Example:
-The "Resuscitation Scorecard" for "Survival to Discharge" documented:
In October 2020, the 5 patients that were resuscitated, had "0%" survival rate to discharge.
In November 2020, the 15 patients that were resuscitated had "0%" survival rate to discharge.
In January 2021, the 12 patients that were resuscitated had "0%" survival rate to discharge.
In February 2021, the 23 patients that were resuscitated had "0%" survival rate to discharge.

The PIC minutes showed no evidence that this information was discussed to provide clarification of the data and to determine the reasons for survival rate of "0". It did not include an analysis of the data to determine the morbidity of these patients and how long they survived post resuscitation.

-The scorecard showed that from September 2020 to March 2021, the facility had more than 120 incidents of hospital acquired Decubiti ulcers.
-The scorecard showed 141 instances of restraints for September 2020, 104 in October 2020 and 92 in December 2020.

The Performance Improvement Committee minutes showed no documented evidence that these data were reviewed, discussed, and analyzed. The facility did not indicate if the number of decubiti ulcers or patients placed in restraints were acceptable. The facility did not provide any benchmark for these indicators.

During interview on 4/27/2021 at 2:05PM Staff G, the Quality Management Coordinator was asked to provide clarification of the "Resuscitation scorecard". She confirmed that the 0% survival rate was correct and stated, "most patients survived the cardio-pulmonary arrests, but not to discharge," i.e. they died before they could be discharged from the hospital. She confirmed that this information was not documented or discussed in the PIC minutes.


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The facility failed to collect data which had potential to have adverse impact on patient care.

Review of the "Scorecard" from 3/2020 to 3/2021, showed no evidence that the facility collected data on medication errors, mortality, and adverse events.
Additionally, the Performance Improvements Committee minutes from 09/9/2020 to 3/10/2021, showed no documentation or discussion of these indicators.

During interview on 4/26/2021 at 10:05 AM, Staff B, Director of Risk Management, acknowledged the findings and stated that the pharmacy department is responsible for collecting information on medication errors.

Review of the pharmacy scorecard showed no documentation of any medication errors. In addition, the scorecard document did not have any designated section for the collection of this information.
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Based on document review, video surveillance and interview, the hospital failed to ensure that the Performance Improvement Committee (PIC) used all data collected from the Incident/Occurrence Reports to identify actual and potential problems concerning patient care and improve clinical performance.

Findings include:

The Quality and Patient Safety Plan for 2020 and 2021 states the "Quality improvement teams will be organized to collect and analyze the data and formalize action plans to effect positive changes and improve outcome."

The hospital Performance Improvement Minutes from 9/ 9/2020 to 2/10/2021 showed no evidence that all incidents/occurrences were reviewed, trended, or analyzed to identify problems and develop action plans to improve outcomes.

The hospital's occurrence and grievance reports for 10/2020 to 03/2021, showed documentation of incidents relating to ill treatment of patients by Security Officers, patient falls and (patient safety) patient to patient violent activity in the Behavioral Health Unit (BHU).

The following are examples of incidents that were not discussed or reviewed by the facility to prevent re-occurrence or prevent further harm:

A BHU nurse noted on 11/9/19 at 12:15 am that she heard a scream coming from a female patient's (Patient # 2) room. The nurse reported that she found Patient #2 lying underneath the covers and a male patient (Patient # 6) lying on top the patients covers with his hand wrapped around Patient #'s 2 neck.

The BHU nurse noted that Patient # 2 had redness around her neck. The physician charted that the patient sustained abrasions around her neck and ordered a Cat Scan of the neck.

Example #2:
The BHU nurse noted on 2/7/21 at 3:06 AM during a15 minutes round that Patient #12 was not in his room. The BHU nurse noted that Patient #12 was wearing a hospital gown lying in bed on top of the sheet next to Patient #11. The BHU nurse reported that Patient #11 was found asleep and unaware that Patient #12 had been lying on top of the covers beside her.

Patient #11 was lying underneath the covers fully clothed. Patient #12 was found in his hospital gown lying on top of the covers, there was no evidence of any physical contact.

The facility Policy and Procedure titled: "Safety and Event Reporting in the Converge Platform" states that the Risk Manager will trend all Occurrence Reports.

The hospital "Quality and Patient Safety Plan" for 2020 did not include Incident/Occurrence as an indicator to be monitored.

During an interview on 4/26/2021 at 2:50 PM with Staff B, Director of Risk Management acknowledged findings, and stated that these types of events are entered in Verge (internal reporting system), but was not trended, discussed or reviewed in the PIC meeting.
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Based on document reviews and interviews, it was determined the facility failed to ensure that interventions that were taken to address the high-pressure injury rates in its Quality Assurance and Performance Improvement (QAPI) project were used to effect positive changes.

Findings include:

The Quality and Patient Safety Plan for 2020 and 2021 states the "Quality improvement teams will be organized to collect and analyze the data and formalize action plans to effect positive changes and improve outcome."

The policy titled "Pressure Injury Prevention, Management, and the use of Specialty Mattresses" which was revised 11/20 states, the purpose of this policy is "to identify patients at risk for developing alteration in skin integrity; to prevent the development of new, or the progression of an existing pressure injury ..."

Review of facility's documents revealed there were 120 hospital acquired decubiti ulcers between 9/2020 and 3/2021.

Review of the facility's project for turning and positioning which was conducted from July 2020 to September 2020 in the Medical Intensive Care Unit (MICU) revealed that prior to the study, patients at high risk for the development of hospital acquired decubiti ulcers were repositioned every 2 hours at a rate of 16.67% on the night shift and 45.83 % on the day shift. July rate was 32.00% on the night shift and 22.73% on the day shift. At the end of the study in September 2020, the turning rate on the night shift was 33.33% and the day shift was 73.91%. During the study, a timer was used to remind the staff to turn the patients every two (2) hours, and there was improvement in the handover and implementation of a turn and position nurse assignment.

The QAPI project revealed performance improvement in the repositioning of patients at risk for developing pressure injuries in the MICU; however, these measures were not used hospital-wide to improve the quality of care of patients susceptible to pressure injuries.

These findings were confirmed with the Staff H, Wound Ostomy Continence Nurse during an interview conducted on 4/27/21 at 10:20 AM.
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Based on review of documents and interviews, it was determined that the hospital's Governing Body failed to provide proper oversight of the Performance Improvement Committee (PIC). Specifically, the Governing Body failed to ensure that the PIC Program adhered to their guidelines to assess performance and establish goals to improve the quality of patient care and safety at the facility.

Findings include:

Review of the Governing Body (Board of Trustee) minutes from August 2020 to February 2021 showed no documented evidence of any review or discussion on the Performance Improvement Program or any of the patient care data that was collected on the hospital's "scorecard".

According to the facility 2020-2021 Quality and Patient Safety Plan:
"The Board of Trustee has the ultimate authority for the implementation of the Quality and Patient Safety Plan. The Board assumes the responsibility to oversee the monitoring and evaluation of the provision of quality and safe care and delegates the planning and implementation to the Performance Improvement Committees."

During interview on 4/26/2021, Staff A, the Chief Nursing Officer acknowledged the findings, and stated that the information was discussed but was not documented in the Board meeting minutes. She was not able to produce any documentation to support this information.
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Based on medical record review, document review and interviews, in two (2) of 12 medical records reviewed, it was determined the nursing staff failed to implement policies and procedures to prevent and manage pressure injuries. (Patients #1 and 4).

These failures place patients at risk for developing pressure injuries and may contribute to delays in managing pressure injuries.

Findings include:

Patients who were identified upon admission as high risk for developing pressure injuries acquired multiple unstageable wounds and/or Stage III or IV deep tissue injuries (pressure/decubiti ulcers) during their hospitalization. See detailed findings at A 0395.
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Based on medical record review, document review and interviews, in two (2) of 12 medical records reviewed, it was determined the nursing staff failed to follow its policy for prevention and management of pressure injuries. (Patients #1 and 4).

These failures place patients at risk for developing pressure injuries.

Findings include:

The policy titled "Pressure Injury Prevention, Management, and the use of Specialty Mattresses" which was revised 11/20 states, the purpose of this policy is "to identify patients at risk for developing alteration in skin integrity; to prevent the development of new, or the progression of an existing pressure injury ..."

Review of medical record for Patient #1 revealed this was a 64-year-old patient who presented to the Emergency Department (ED) from a nursing home on 4/30/2020 because of altered mental status, decreased responsiveness, shortness of breath, and cough for one (1) week. Upon arrival to the ED, the patient was in acute respiratory distress which required intubation and placement on a ventilator. The patient had been admitted to this facility on 4/18/20 - 4/21/20 for Urinary Tract Infection and hypoxia (low oxygen level) and was COVID-19 negative upon arrival. Prior to the admission, the patient had lived in a group home and was "independent." The patient's previous medical history included Schizophrenia, Hypertension, Pneumonia, and hypoxia. The patient's skin was intact, warm, dry and it had a normal color. The Braden Score was 12/23 (high risk for pressure injury).

By 5/12/2020, the patient had (1) an open deep tissue injury on the right buttock which measured 9cm long (L) x 5cm wide (W) which the wound care nurse documented would likely progress to a Stage 3 or 4 pressure injury; (2) an open coccyx (tailbone) deep tissue injury measuring 2cm (L) x 3cm (W) which would likely develop to a Stage 3 or 4 pressure injury; (3) a left buttock open deep tissue injury which measured 3cm (L) x 5cm (W), (4) a left heel, serous (body fluid) filled blister, Stage 2 pressure injury which measured 2cm (L) x 3cm (W) and (5) a right heel serous filled blister which was a Stage 2 pressure injury that measured 2cm (L) x 3cm (W).

By 5/26/20, the right buttock wound had progressed to 11cm (L) x 6cm (W), it was an unstageable wound with 90% slough (dead cells in wound drainage). The wound care nurse documented that the coccyx wound may have integrated into the right buttock wound and the left heel had evolved to a 4cm (L) x 4cm (W) deep tissue injury. On 6/15/20, the right buttock had a deep wound which measured 10cm (L) x 5cm (W) and the left heel wound had eschar (a dry, dark scab).

There was no documented evidence that Patient #1 was consistently repositioned every two (2) hours according to the facility's policy.

Review of medical record for Patient #4 revealed this 55-year-old patient was admitted on 3/8/21 after he presented to the ED for lethargy. He was admitted for Acute Metabolic Encephalopathy (Chemical imbalance in the brain) secondary to Sepsis and Renal Failure. His Braden score was 11 on admission. Upon admission, the patient had perianal excoriation. By 3/21/21, the patient had a Stage III wound to the coccyx measuring 2cm (length) x 0.8cm (wide) x 0.3cm (deep) which had serosanguinous (wound discharge present in healthy wounds) drainage and on the left and right buttocks some dry deep purple changes to the skin with intact blisters present. The wound consult was called because the patient had a blackened area on the sacrum.

The policy titled "Pressure Injury Prevention, Management, and the use of Specialty Mattresses" which was revised 11/20 states, "For any patient determined to be at risk for alteration in skin integrity (Braden 18 or below) or have an existing pressure injury, also implement the following: manage moisture on the skin and minimize pressure to bony prominences by using pressure reducing devices to turn and reposition patients, optimize nutrition and hydration."

There was no documented evidence that Patient #4 was consistently repositioned every two (2) hours according to the facility's policy.

These findings were shared with Staff A, the Chief Nursing Officer on 4/27/2021 at 3:05 PM.
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Based on medical record review and interview, it was determined that the nutrition department failed to (1) assess and evaluate patient tolerance to therapeutic diet and (2) timely supervision of the nutritional aspects of patient care for patients with pressure injury. This was evident in three (3) of 6 medical records reviewed (MR #1, 4 and 5).

Findings include:

Patient #1
Patient is a non-ambulatory 67-year-old male who was admitted to the hospital on 4/30/20 due to altered mental status and acute respiratory failure requiring intubation. The skin assessment in the Emergency Room on 4/29/2020 and the initial nursing assessment on 4/30/20 found skin intact with no pressure injury

Nutrition Assessment on 4/30/20 identified the patient at high nutritional risk.
Patient was NPO (nothing by mouth) and was receiving intravenous fluid (D5NS) at 75 ml/hr which provided the patient with only 306 calories/day. The Dietitian calculated the patient's nutritional needs per day at: 1245-1660 calories and 99-166 grams (gm) of protein. The current diet order is Peptide 1.5ml at a goal rate of 45ml + 200ml free water every six hours. This diet would provide 1620 calories, 102 gm Protein and 832ml of water.

On 5/2/20, the patient was found to have "pressure injuries, Stage 2, and an opened, deep tissue injury on the right and left buttock, left and right heel and sacrum/coccyx".
On 5/26/20, both buttocks progressed to unstageable wounds, the left heel evolved to a deep tissue injury, the right heel to Stage 2, and the left ischium (base of pelvis) has deep tissue injury.
On 6/2/20, there were no changes in the status of the pressure injuries.

After the initial nutritional assessment on 4/30/20, there was no other nutrition reassessment documented for this patient.
A table titled Progress Notes on 5/6, 5/11, 5/18, 5/22, 5/28, 6/3, 6/10 and 6/16 documented patient's current diet order, lab values (data) with no evidence of an assessment or evaluation of the data or the status of the patient's pressure injury.

2- There was no documentation of the patient's Intake and Output (I&O) to assess and evaluate the patient intake and tolerance to the prescribed diet.
3- The patient's estimated nutrient needs were the same from admission to discharge. The additional calories/protein for wound healing was not calculated or added to the Dietitian's recommended diet.

Patient #4
This 37-year-old male was admitted to the hospital on 1/16/21 with shortness of breath. The patient's medical history was significant for Chronic Respiratory Failure and Anoxic Brain Injury. The patient had a tracheostomy tube and a Peg tube in place.
Weights: 3/5/21- 120 pounds, 3/8/21- 126 pounds and on 3/17/21- 113 pounds

On 1/17/21, the initial nutrition screen by the nursing staff on 1/17/21 identified the patient as a high risk due to tube feeding and multiple pressure injuries. The patient had 11 pressure injuries: 5- Stage 4, and 4 unstageable pressure injuries

The initial nutrition assessment on 1/18/21 calculated the patient nutrient needs: 1854-2163 kcal/day, 93-136 gm Protein and Fluid 1854-2163ml/day.
The patient's current prescribed diet: Isosource 1.5 kcal/cc, via g tube, 200 Continuous 40ml/hr via G tube, 200ml free water q4h. Hold free water flushes unless intravenous fluids was reduced.

The dietitian recommends Isosource 1.5, 40ml/hr + Prostat (with intravenous fluids at 100ml/hr = 2148kcal, 116gm Protein and 733ml/day fluid.

Findings:

1- The patient estimated nutrient needs were not updated to reflect the patient's weight loss or his multiple pressure injuries. Ongoing changes in pressure injuries were not reflected in the patient's nutritional reassessment.

2- The intake and output flowsheets were not used to assess the patient's intake of the tube feeding or fluid needs. It was documented that the patient had lost some weight and had multiple pressure injuries; however, none of this important information was addressed in the patient's nutrition reassessments. The patient's tolerance to the feeding was not documented.


Patient #5
Patient #5 is a 55-year-old morbidly obese male admitted to the hospital on 3/8/21 for lethargy. The patient is 6'0" in height and weighs 227 kg (500 pounds). The patient medical history includes diabetes.

The Dietitian Nutritional Assessment on 3/8/21, noted the calculation of the patient nutritional daily needs as: 2065-2754 calories (15-20 kcal/kg) and 110-137gm Protein (0.8-1.0 gm/kg) and fluid needs of 2065-2754ml/day (15-20ml/day). The patient's usual body weight was 480 pounds, but he gained 20 pounds since his last admission. The patient was screened at high risk due to his weight status. The Dietitian's recommended swallow evaluation for consistency in texture and if solids is tolerated, she suggested 2600 "CCMP" therapeutic diet modification. Patient was on an NPO (nothing by mouth) diet order due to his swallowing difficulties.

On 3/12/21, the dietitian nutrition reassessment noted the patient's diet order is Diet Restricted; Texture, "CC", 2 gm Sodium; 2600 kcal; Puree; Nectar Thick Liquids.
Patient tolerating PO (by mouth) intake with assistance.

On 3/13/21, nursing noted revealed the patient developed a pressure injury to the medial buttocks.

On 3/16/21 the dietitian reassessment noted the diet order was changed to NPO due to swallowing difficulty.

Nutrition reassessment on 3/22/21 noted that the diet was changed on 3/20/21 to Clear liquid; Nectar thick Liquid then on 3/22/21 diet order was for NPO.

The nutrition reassessment on 3/28/21 noted the patient was NPO for 5 days- Unable to swallow due to decline in mental status. Current diet order (3/27/20) was Isosource 1.5 kcal/cc, continuous 30 ml/hr and 150 ml of water every six (6) hours.
The dietitian's note did not state how much nutrient will this patient receive from this diet order or if it meets the patient's nutritional needs.

The nutrition reassessment on 4/2/21 noted the patient with pressure injury Stage 3 on both buttocks.
The diet order was NPO, on tube feeding. The dietitian recommended Prostat, a protein supplement.

Findings:
1- There was no evidence in the documentation that the pressure injuries were accounted for in the dietitian's reassessment notes except on 4/2/21 where the Dietitian recommended Prostat, a protein supplement to be added to the tube feeding due to the patient's Stage 3, pressure injury to both buttocks. The calculation for the different stages were not documented in the medical record.


2- Patient's Nutritional Assessment and Reassessment did not address the patient's diabetes
which may have negatively impacted on the healing of pressure injuries.

3- The patient's intake and output was not assessed and his tolerance to the tube feeding was not documented.

On 4/23/21 at approximately 10:30 am, these findings were discussed with Staff E, Clinical Nutrition Manager, who acknowledged findings.