HospitalInspections.org

Based on record review and interview, the governing body failed to:

A. Evaluate the management entity's effectiveness of the behavioral health unit services that resulted in the neglect and deterioration of health of Patient #1 and a potential for deterioration of health for any patient admitted to the behavioral health unit with, or a developed, acute medical condition. Additionally, compromised the safety, limited the right to participate in the care plan, failure to attempt less restrictive interventions prior to utilizing physical holds or drugs to restrict the patient's behavior and/or freedom of movement, which had the potential to cause injuries, and adverse affects for Patient #2. (Refer to A-0083)

B. Ensure an M.D. or D.O. examined, assessed and directed care for patient #1 that resulted in the neglect and deterioration of health of Patient #1 and a potential for deterioration of health for any patient admitted to the behavioral health unit with, or a developed, acute medical condition. (Refer to Tag A-0068)

C. Develop and approve all policies and procedures for the hospital's behavioral health unit.

A review of hospital policies showed the policies were on the letterhead of and signed by the prior governing body and were not reviewed and approved by the current governing body.

On 07/19/17 Staff D stated the policies were the current behavioral health policies because hospital governing body has not gotten to the behavioral health unit yet. [Hospital had undergone a change of ownership on 04/01/17]

Based on record review and interview, the governing body failed to ensure an M.D. or D.O. appropriately examined, assessed, and directed the care for 1 (Patient #1) of 20 records reviewed which resulted in the neglect and deterioration of the health of Patient #1 and a potential for deterioration of health for any patient admitted to the behavioral health unit with, or a developed, acute medical condition.


Findings:


Policy titled "Abuse and Neglect Reporting" defines neglect as the refusal or failure of ...a caretaker to supply the individual with necessary ...treatment ...for any injury, illness or condition of which the individual's physical, mental or emotional health is substantially threatened or impaired. The document further instructs staff to report to the department director. This policy was written on the previous ownerhsip letterhead and had not been approved by the current governing body.


A review of Patient #1 medical record showed the patient was transported to the hospital's emergency room via ambulance from a nursing home for aggressive behavior towards staff on 06/19/17. Patient #1 was 5'8", weighed 204 pounds, in a wheelchair, and was able to move self from chair to bed. The patient was fully alert with limited insight, poor judgment, and poor impulse control. The patient had multiple previous admissions with a history of anxiety, bipolar disorder, depression, and schizophrenia. The patient had secondary diagnoses of hypothyroid, back problems, gout, COPD (chronic obstructive pulmonary disease), GERD (gastroesophageal reflux disease), and non-compliance with medications. Patient #1 was admitted to the hospital's geri-psych unit for further evaluation and care.


On 06/22/17 at 1:59 am, document labeled "Notes" showed the patient was found on the floor laying on his/her right side next to the bed. An x-ray report on 06/22/17 at 8:30 am, showed "dorsal soft tissue contusion".


On 06/22/17 at 1:47 pm (approximately 11.5 hours later), the physician's progress note contained no documentation regarding the injury or the x-ray report. There was no documentation of additional orders noted.


On 06/22/17 at 2:56 pm, the Master Treatment Plan showed no indication of an injury listed in the medical problems section.


On 06/22/17 at 7:00 pm, the nursing assessment noted "Right arm-large hematoma, edema, red in color... wrapped in gauze, C/D/I". There was no indication the physician was contacted; there were no additional indicated actions taken.


On 06/23/17 at 1:02 pm, the physician's progress note showed no documentation regarding the injury or the hematoma; there were no orders related to the injury.


On 06/24/17 at 9:00 am, nursing assessment showed a wound on the right elbow, large bruise "where (patient) fell in the floor" and now had a blister. Patient was referred for wound care and the hospitalist to see.


On 06/24/17 at 2:56 pm, the physician's progress note contained no documentation regarding the deterioration of the wound, no plan to notify the hospitalist; there were no orders related to the injury.


On 06/24/17 at 3:10 pm, the nursing note showed the patient was keeping to self and not talking to peers or staff unless spoken to; stays in room a lot. The nursing note indicates Staff R (a physician) saw the patient and the patient was put on a list for wound care evaluation and notified the hospitalist to see the patient.


On 06/25/17 at 3:51 pm, nursing assessment showed "right upper arm is extremely bruised and deep purple in color, pt lower right arm has scattered bruising with three large open areas, scattered blisters also present."


On 06/25/17 at 4:28 pm, the physician's progress note showed no documentation regarding the wound or change in patient's condition; there were no orders related to the injury.


On 06/25/17 at 9:29 pm, nursing assessment showed the patient's temperature of 103.3°, skin hot to touch, right arm swollen and weeping. The physician was notified and blood cultures were obtained.


On 06/26/17 at 12:45 am, the 15 minute checks showed the patient was on the floor. This documentation continued until 11:00 am on 06/27/17.


On 06/26/17 at 11:26 am, Treatment Team Notes showed no documented assessment of the patient's right arm.


On 06/26/17 at 11:26 am, the Team Notes showed the patient was refusing to get out of bed and had been sleeping on the floor. There were no documented interventions taken to remove the patient from the floor,


On 06/26/17 at 12:00 pm, the physician progress note showed the patient was being considered for discharge to the medical floor for "compartment syndrome".


On 06/26/17 at 3:23 pm, nursing assessment showed the patient's right arm was very swollen from wrist to shoulder. The patient "fell out of bed on the 21st and formed a hematoma and ... arm is very purple and swollen and is weeping in the lower part of the arm from several places." Patient was transferred to the ICU at 4:03 pm.


On 06/26/17 at 4:03 pm, the patient' medical record showed the patient was admitted to ICU with edematous, bruised, bleeding right upper extremity from shoulder to wrist, significant abrasions at elbow and wrist, 3+ edema, and pulse faint status post fall.


Patient #1's condition continued to decline, patient was intubated on 06/27/17 at 9:27 am, he was unresponsive, and was airflighted to another hospital at 11:53 am on 06/27/17. On 06/28/17 at 11:32 pm (approximately 36 hours from arrival), the patient was pronounced deceased.


On 07/19/17 at 11:30 am, Staff J stated on 06/26/17 at 11:00 am, he/she contacted the hospitalist regarding the condition of the patient's right arm; the hospitalist "forgot" about the consult and caused a delay in getting the patient transferred to a medical floor.


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A review of previous 6 months incident reports showed no documentation of this event.


A review of policy and procedures showed the hospital had no governing body approved policy and procedures for the behavioral health unit. (Refer to A-0043)

Based on record review and interview, the governing body failed to ensure the contracted behavioral health services were provided in compliance with the conditions of participation by failing to evaluate the contracted management entity services which resulted in the neglect and deterioration of health of Patient #1 and resulted in no attempts for less restrictive interventions prior to utilizing physical holds or chemical restraints and no monitoring and assessments being conducted during and after restraint interventions for Patient #2. (Refer to A-0395)

Based on record review and interview, the hospital failed to protect and promote patient's rights to be free from abuse, neglect, and restraints as evidenced by:

1. Failing to provide appropriate nursing interventions for patient #1 which resulted in the deterioration of a wound on the patient's right arm and onset of sepsis. (Refer to A-395)

2. Failing to ensure all behavioral health staff had an understanding of the definition of a restraint or utilization of restraint techniques. (Refer to A-0159)

3. Failing to protect Patient #2's right to be free from restraints by restricting the patient's freedom of movement, and failure to attempt less restrictive interventions prior to utilizing a drug to restrict the patient's behavior and/or freedom of movement. (Refer to A-0160)

Based on record review and interview, the hospital failed to ensure staff followed its policies regarding restraints and understood the definition of a restraint for 1 (Patient #2) of 20 records reviewed.

This failed practice compromised Patient #2's safety by staff not understanding or utilizing restraint techniques that minimized risk for musculoskeletal injuries and asphyxiation.

Findings:

A policy titled "Violent Behavior (violent or self destructive) Restraint and Seclusions" defined a Behavioral Health Restraint as the restriction of patient movement for management of behavior that jeopardizes the immediate safety of the patient or other persons; must be initiated in a way that uses the least amount of physical force possible to avoid harm to the patient; and must be discontinued at the earliest possible time.

Patient #2

On 06/07/17, Staff P documented "...had to be held down on her bed briefly to stop her from hitting and kick [sic]..." Documentation showed no description of how the restraint was initiated or implemented (supine or prone position, parts of the patient's body that were restrained, the number of staff involved, the amount of time the patient was restrained, etc.); and documentation showed no assessment of the patient's condition during or following the restraint.

On 07/19/17 at 10:30 am, Staff H stated the staff received annual training in "Secure" (a method of behavioral health restraint).

On 07/19/17 at 11:30 am, Staff J stated "Secure" training was provided annually. When asked to describe physical restraint techniques taught in this training, he/she replied "Try not to do any." Staff J stated if a patient became aggressive and staff were unable to redirect, the patient would be immobilized. He/she described the technique used as "one might grab an arm and one might hold their legs..."; this action was not considered a restraint and no additional monitoring or documentation was required.

On 07/19/17 at 2:15 pm, Staff N stated sometimes patients are "held" but not "held down"; and stated he/she had never used any of the physical restraint techniques taught in the annual training.

On 07/20/17 at 10:35 am, Staff M stated he/she assisted other employees to hold patients down if the nurse requested in order to give the patient an injection; and stated the hold was for the patient's safety and not considered a restraint.

Based on record review and interview, the hospital failed to ensure hospital policy and staff correctly defined a chemical restraint for 1 (Patient #2) of 20 records reviewed.

This failed practice compromised Patient #2's autonomy and dignity by restricting the patient's freedom of movement, and had the potential to adversely affect all patients with behavioral health problems due to failure to attempt less restrictive interventions prior to utilizing a drug to restrict the patient's behavior and/or freedom of movement.

Findings:

A policy titled "Violent Behavior (violent or self destructive) Restraint and Seclusions" defined a drug used for restraint as a medication used to "put a patient to sleep, rendering them unable to function", which was not in keeping with standards of practice. The policy required documentation of the monitoring and care implemented to be documented on the Restraint/Seclusion Flow Sheet.

The APNA definition of a chemical restraint does not include rendering a patient unconscious; the medication is expected to restrict the patient's behavior and decrease the ability to interact with his/her environment.

Patient #2

On 05/31/17 at 8:34 am, Staff Q documented the patient was "placing her hands" on patients and shouting at staff. Staff R ordered Zyprexa 10 MG and Ativan 1 MG PO or IM. Staff Q documented the patient refused to take medications PO. Documentation showed the medications were given as injections at 8:44 am. There was no documentation to show that less restrictive nursing interventions such as offers for quiet room, change of staff and/or 1:1 observation were attempted. There was no assessment of the patient or the patient's situation done prior to or after the administration of the medications. Documentation showed no restraint flow sheet was completed.

On 06/01/17 at 9:18 am, Staff Q documented the patient was threatening staff, also cursing and shouting. Staff R had ordered Zyprexa 10 mg PO or IM. Staff Q documented the patient refused to take the medication. Documentation showed the medication was given as an injection at 9:00 am. There was no documentation to show that less restrictive nursing interventions such as offers for quiet room, change of staff and/or 1:1 observation were attempted. There was no assessment of the patient or the patient's situation done prior to or after the administration of the medications. Documentation showed no restraint flow sheet was completed.

On 06/01/17 at 9:18 am, Staff Q documented the patient was threatening to staff, cursing and shouting; also documented medication ordered "due to pt is a danger to herself and others." Staff R ordered Zyprexa 5 mg and Ativan 1 mg IM. Documentation showed the injections were given at 9:40 am. There was no documentation to show that less restrictive nursing interventions such as offers for quiet room, change of staff and/or 1:1 observation were attempted. There was no assessment of the patient or the patient's situation was done prior to or after the administration of the medications. Documentation showed no restraint flow sheet was completed.

On 06/05/17 at 4:46 pm, Staff Q documented the patient grabbed her shirt and was attempting to tear it when she pulled the nurse on top of her and both fell to the floor. Staff R ordered Zyprexa 10 mg and Ativan 1 mg IM. Documentation showed the injections were given at 5:20 pm. There was no documentation to show that less restrictive nursing interventions such as offers for quiet room, change of staff and/or 1:1 observation were attempted. There was no assessment of the patient or the patient's situation was done prior to or after the administration of the medications. Documentation showed no restraint flow sheet was completed.

On 07/19/17 at 10:30 am, Staff H stated the hospital did not use chemical restraints but was unable to state the definition of a chemical restraint; and was also unable to state the documentation requirements for chemical restraints.

Based on record review and interview, the hospital failed to ensure Registered Nurses accurately assessed and evaluated the care provided by allowing the neglect and deterioration of health of patient #1 when the patient developed an acute medical condition. (Refer to Tag A-0395)

Based on record review and interview, the hospital failed to ensure accurate assessments and interventions for patient #1 which resulted in the neglect and deterioration of health of Patient #1 and by failure to recognize, understand or define a physical or chemical restraint which had to the potential to compromise the safety for Patient #2 who was held down and chemically restrained.

Findings:

Patient #1:

Review of medical records showed Patient #1 was transported to the hospital's emergency room via ambulance from his residence at the nursing home for aggressive behavior towards staff on 06/19/17. Patient #1 was in a wheelchair and was able to move self from chair to bed; patient was fully alert with limited insight, poor judgment, and poor impulse control. He/She has been a patient in this hospital "multiple times" with a history of anxiety, bipolar disorder, depression and schizophrenia with secondary diagnoses of hypothyroid, back problems, gout, COPD (chronic obstructive pulmonary disease), GERD (gastroesophageal reflux disease) and non-compliance with his medications. Patient #1 was admitted to the hospital's geri-psych unit for further evaluation and care.

06/19/17 at 11:15 am, the Nursing Clinical Assessment showed the patient is 5'8" and weighs 204 pounds; his sepsis score/level was noted as negative. The fall risk assessment indicated there were no secondary diagnoses and the patient was on no medications. The Admission History and Physical lists 11 current medications (Allopurinol, Naproxen, Synthyroid, Multivitamin, Depakote, Desryl, Maalox, Milk of Magnesia, Acetaminophen, Zyprexa and Lactolose).

06/19/17 at 12:13 pm, the Comprehensive Nursing Assessment showed upper extremities were equal and strong, full range of motion and muscle tone, no musculoskeletal acute conditions, skin warm and dry and fall risk total score of 60.

06/19/17 at 12:44 pm, Nursing Notes showed suicide risk score as 1 [low risk]; activity risk: chair fast.

06/19/17 at 12:57 pm, the Nursing Notes showed medical concerns as hyperlipidemia, thyroid disorder, arthritis, COPD and hypertension. [different from the 11:15 am assessment]

06/19/17 at 13:38 pm, Nursing Notes showed Vital Signs stable and height as 5'7" and weight at 220 pounds. [a 16 pound difference since 11:15 am]

06/20/17 at 10:00 am, Nursing Notes showed a suicide risk score of 10 [moderate risk, an increase from previous day] and fall risk score of 45 [down from 60 from previous day]. There were no documented interventions.

06/20/17 at 7:19 pm, Nursing Notes showed a suicide risk score of 5 [low risk, a decrease from 10:00am].

06/21/17 at 4:32 pm, Nursing Daily Assessment showed patient was oriented to person/place/time/even/aware of surroundings. Fall risk score is 55.

06/21/17 at 8:00 pm, Nursing Notes showed fall risk score was 70.

06/22/17 at 1:59 am, document labeled "Notes" showed the patient was found on the floor lying on right side next to the bed. At 8:30 am, x-ray report showed "dorsal soft tissue contusion".

06/22/17 at 2:22 pm, Nursing Assessment showed musculoskeletal problem as: Stabilized/Maintained. Falls, Risk documented as: "Maintained or improved through nursing assessment was evidenced by remaining free from falls".

06/23/17 at 10:00 am, Nursing Assessment of skin inspection documented "no skin alterations noted".

06/23/17 at 7:10 pm, Nursing Assessment showed "Right arm-large hematoma, edema, red in color... wrapped in gauze, C/D/I". There were no additional indicated actions or interventions taken.

06/24/17 at 3:10 pm, "7A-7PM Nursing Note" showed "patient has dark hematoma, bruise on right elbow where he fell last weekend...put on list for wound care evaluation."

06/24/17 through 06/25/17, there was no documented "7P-7AM Nursing Note".

06/25/17 at 3:51 pm, Nursing Asseessment showed "right upper arm is extremely bruised and deep purple in color, pt lower right arm has scattered bruising with three large open areas, scattered blisters also present...pt states ... obtained these wounds on previous shift when he was in the floor..."

06/25/17 at 9:29 pm, Nursing Assessment showed the patient's temperature of 103.3°, skin hot to touch, right arm swollen and weeping. The physician was notified and blood cultures were obtained.

06/25/17 through 06/26/17, the 15-minute observations between 12:45 am and 11:00 am, documented the patient was on the floor. There was no documented effort to return the patient to a chair, bed or other position during this 10.25 hours. There was no documented offer of a mattress or the patient was moved to a mattress.

06/26/17 at 5:46 am, Nursing Notes showed vital signs were documented with no indication that the patient remained on the floor.

06/26/17 at 10:45 am, Nursing Note showed patient was "resting with eyes closed". There was no indication the patient was assessed while remaining on the floor.

06/26/17 at 11:26 am, Treatment Team Notes indicated the patient had been sleeping on the floor. There was no indicated interventions taken to remove the patient from the floor and no documented assessment of the patient, specifically the right arm, while the patient remained on the floor for 10.25 hours.

06/26/17 at 3:23 pm, Nursing Notes showed the patient's right arm was very swollen from wrist to shoulder. The patient "fell out of bed on the 21st and formed a hematoma and ... arm is very purple and swollen and is weeping in the lower part of the arm from several places." Patient was transferred to the ICU at 4:03 pm.

06/27/17 at 11:12 am, the Discharge Summary showed the patient was airflighted to a different hospital.

06/28/17 at 11:32 pm (36 hours later), the patient was pronounced deceased by the receiving hospital.

07/19/17 at 10:30 am, Staff H stated they would not let a patient lie on the floor without intervention. No additional documented interventions taken for this patient were provided by Staff H.

07/19/17 at 11:30 am, Staff J, day shift nurse, stated the overnight staff on 06/25/17 to 06/26/17 reported that they were unable to locate the sling to the mechanical lift and were unable to lift the patient from the floor. The patient was too heavy for them to lift manually and the patient was unable to follow directions to lift self from the floor; they did not call other floors for another sling for the lift, they did not call for assistance with lifting. Patient's listed height was 5'8" and weight was documented at 204 pounds on the admission assessment to the hospital. (Patient's height and weight on admission to the receiving hospital was documented at 5'8" and 252 pounds.)


Patient #2:

On 05/29/17, a 72 year old was admitted to the hospital in the manic phase of bipolar disease. The admission history and physical states that she/he was depleted of energy by her/his brain. Patient called 911 stated needed IV vitamins for body and brain. The Police responded and found her/him hitting forehead; abusive and combative with ER staff.

On 05/31/17 at 8:34 am, Staff Q documented the patient was "placing ... hands" on patients and shouting at staff. Staff R ordered Zyprexa 10 MG and Ativan 1 MG PO or IM and Staff Q documented the patient refused to take medications PO. Documentation showed the medications were given as injections at 8:44 am with no attempted interventions such as offers for quiet room, change of staff and/or 1:1 observation documented; no assessment of the patient or the patient's situation was done prior to or after the administration of the medications.

On 06/01/17 at 9:18 am, Staff Q documented the patient was threatening staff, also cursing and shouting. Staff R had ordered Zyprexa 10 mg PO or IM and Staff Q documented the patient refused to take the medication. Documentation showed the medication was given as an injection at 9:00 am with no attempted interventions such as offers for quiet room, change of staff and/or 1:1 observation documented; no assessment of the patient or the patient's situation was done prior to or after the administration of the medications.

On 06/01/17 at 9:18 am, Staff Q documented the patient was threatening to staff, cursing and shouting; also documented medication ordered "due to pt is a danger to herself and others." Staff R ordered Zyprexa 5 mg and Ativan 1 mg IM. Documentation showed the injections were given at 9:40 am with no attempted interventions such as offers for quiet room, change of staff and/or 1:1 observation documented; no assessment of the patient or the patient's situation was done prior to or after the administration of the medications.

On 06/05/17 at 4:46 pm, Staff Q documented the patient grabbed her/his shirt and was attempting to tear it when the patient pulled the nurse on top of her/him and both fell to the floor. Staff R ordered Zyprexa 10 mg and Ativan 1 mg IM. Documentation showed the injections were given at 5:20 pm with no attempted lesser interventions (such as offers for quiet room, change of staff) and/or 1:1 observation documented; no assessment of the patient or the patient's situation was done prior to, during or after the administration of the medications.

On 07/19/17 at 10:30 am, Staff H stated the hospital did not use chemical restraints and was unable to definie a chemical restraint; and was also unable to state the documentation requirements for chemical restraints.