HospitalInspections.org

Based on facility policy review, facility document review, medical record review, and interview, the facility failed to ensure patients' rights were promoted to receive care in a safe setting for two of five (Patient #1 and Patient #5) sampled patients.

The findings included:

1. Review of the facility's "SAFETY SEARCHES" dated ""3/2020" and "Contraband" dated "11/2020" policies revealed all patients would be searched and wanded in the intake department using an electronic device to ensure patients do not have potentially hazardous weapons or metal objects. A body search should be conducted for contraband once the patient is admitted inpatient and arrives on the unit.

Review of the facility's "PLAN OF CARE" policy revised "11/2020" revealed, " ... PURPOSE: To assure care is based on problems identified through assessment ... The plan is updated as indicated by patient need ... "

Review of the facility's "FALL PRECAUTIONS AND PREVENTION" policy dated "4/2020" revealed, " ... In order to reduce the risk of patient injuries as a result of a fall, nursing staff will assess and re-assess the patient's level of risk for fall and implement appropriate interventions...All patients admitted to the hospital will be assessed using the MORSE Falls Assessment as part of the Nursing Assessment...Risk of Falls will be included in the Interdisciplinary Treatment Plan and updated as needed...."

2. Medical record review revealed on 6/19/2022 police were called to Patient #1's residence when the patient starting exhibiting threatening behaviors and had not been taking medications. The patient was arrested by police for emergency detention and taken to the Crisis Assessment Center (CAC). The patient had a history of Schizophrenia.

Review of the CAC assessment revealed Patient #1 presented to CAC via police department due to suicidal ideations, the patient was off her medications and was actively trying to hurt herself. Per police report the patient was actively suicidal and put a sharp object to her head. The patient reported self-harming behaviors and showed superficial cuts up and down her left arm. The patient had an extensive history of physically aggressive behaviors.

Review of the Certificate of Need for Involuntary Admission dated 6/19/2022 revealed, " ... Patient presents as manic and threatening to harm herself and others ... Patient presents as a poor historian, racing thoughts, over talkative, heightened energy and reports hx [history] of previous suicide attempts and aggressive behavior ... Patient is too high risk to self to be released back into the community. Patient is involuntary ... " The Basis for admission revealed, " ... stating that she put various items 'up in my private parts' including a knife and screwdriver ..."

The patient was transferred to the Intake Department at Delta Specialty Hospital on 6/19/2022.

Medical record review and documents review at the hospital revealed Patient #1 was not appropriately checked for weapons or harmful objects when in the hospital's Intake Department or when admitted to the hospital inpatient unit.

On 6/20/2022 at approximately 10:00 AM it was discovered that Patient #1 had a knife concealed in her clothing.

The facility failed to ensure procedures were followed to prevent Patient #1 from harming herself or others.


3. Medical record review revealed Patient #5 was admitted to the facility on 6/1/2022 with Schizoaffective Disorder. The patient was on Eliquis for Pulmonary Embolus and Chronic anticoagulation, putting the patient at increased risk for bleeding.

The patient had a fall on 6/1/2022 related to behaviors. The patient had a fall on 6/2/2022, sustaining an injury to the side of his face/head and was sent to the emergency department (ED). The patient had a fall on 6/4/2022, sustaining an injury to the side of his face/head.

Review of the 6/4/2022 hospital report revealed the patient had a seven to eight millimeter acute right frontal lobe bleed and was admitted to the hospital in ICU for 2 days.

There was no documentation the facility had developed and implemented an action plan in order to prevent the patient from falls and provide safety interventions for the patient.

The facility nursing staff failed to accurately develop and implement a care plan for falls and in accordance with the facility's policies.

Refer to 0144.

Based on facility document review, facility policy review, medical record review, and interview, the facility failed to ensure all patients received care in a safe setting for two of five (Patient #1 and Patient #5) sampled patients.

The findings included:

1. Review of the facility's "SAFETY SEARCHES" policy dated "3/2020" revealed, "Delta Specialty Hospital strives to maintain a safe and therapeutic environment for patients, visitors and staff. In order to achieve this, routine searches should be conducted on all patients on admission ... Other searches (patient, room, unit) may be conducted when there is reasonable cause to believe a patient may possess and item which is potentially hazardous...
PROCEDURE...
Electronic Search ... Electronic Searches will be conducted in the Intake area for direct admissions during the admission process to assure that a patient is free of weapons or any metal objects that could be used for harm before entering the unit. The patient will be scanned over the entire body by a wand metal detector ...
Belongings search ... All patients should have their belongings searched for potentially hazardous items by facility staff on admission ... Remove any items deemed hazardous for patient to keep in room ... Dangerous weapons are to be turned over [to] Nursing Supervisor ...
Patient Search ... All patients should have a routine patient search conducted by intake staff on admission ... All new admissions should remain separated from other patients until the completion of a patient search ... "

Review of the facility's contraband policy dated "11/2020" revealed patients are to be scanned or wanded for contraband in the intake department and a body search for contraband once they arrive on the unit.

Review of the "PLAN OF CARE" policy revised "11/2020" revealed, " ... PURPOSE: To assure care is based on problems identified through assessment ... A plan of care is established at the time of admission and a problem list developed ... The plan of care is reflected daily in the nursing notes ... POLICY ... A problem list is initiated by the RN utilizing nursing diagnosis statements ... The plan is updated as indicated by patient need ... "

Review of the "FALL PRECAUTIONS AND PREVENTION" policy dated "4/2020" revealed, " ... In order to reduce the risk of patient injuries as a result of a fall, nursing staff will assess and re-assess the patient's level of risk for fall and implement appropriate interventions through the following procedures. A fall is defined as a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor or the ground, other than the consequence of overwhelming external force ...
PROCEDURE ... All patients admitted to the hospital will be assessed using the MORSE Falls Assessment as part of the Nursing Assessment. Based on this assessment, each patient will be placed in a risk category ...Nursing shall place the patient on fall precautions when indicated and ensure the practitioner is notified and orders the level of observation and precautions consistent with the assessed level of risk ... Risk of Falls will be included in the Interdisciplinary Treatment Plan and updated as needed.
...Falls Prevention Interventions ...

...Standard Falls Prevention Interventions - apply to all patients ... Orient patient to surroundings ... Keep room free from clutter ... Ensure patient has proper fitting, non-skid footwear ... Provide patient with ability to contact nursing staff at night for assistance ... Leave bathroom door ajar ... Routine q [every] 15 minute observations ...

...0-24: Low Risk for Falls ... Standard interventions ... Assess for environmental obstacles ...

...25-44: Medium Risk for Falls ... All standard and low risk precautions ... Perform gait assessment ... Review medications ... If applicable, insure patient is wearing his/her eyeglasses and/or hearing aid when awake ... monitor patient gait after receiving sedating medications, diuretics and laxatives ...Interventions Post Fall ... Patient is assessed/reassessed after any fall ... The medical practitioner will be contacted by the Charge Nurse to determine course of treatment after a patient has fallen ...Patient falls risk reassessed and appropriate interventions implemented ... "

2. Review of the police report filed in the hospital's medical record revealed, " ...On 6/19/2022 at 08:31 hours, [Name of Police Officer] responded to a Emergency Commitment at [address]. Officers met with complainant [Name of Patient #1's boyfriend] who stated that his girlfriend, suspect [Name of Patient #1] is diagnosed with paranoid Schizophrenia, bipolar and depression and off her meds.." The patient was arrested for Emergency Detention and taken to the Crisis Assessment Center (CAC).

Review of the CAC assessment revealed Patient #1 presented to CAC via police department due to suicidal ideations, the patient was off her medications and was actively trying to hurt herself. Per police report the patient was actively suicidal and put a sharp object to her head. The patient reported self-harming behaviors 3-4 months ago and showed superficial cuts up and down her left arm. The patient has an extensive history of physical aggressive behaviors.

Review of the Certificate of Need for Involuntary Admission dated 6/19/2022 revealed, " ... Patient presents as manic and threatening to harm herself and others ... Patient presents as a poor historian, racing thoughts, over talkative, heightened energy and reports hx [history] of previous suicide attempts and aggressive behavior ... Patient is too high risk to self to be released back into the community. Patient is involuntary ... " The Basis for admission revealed, " ... stating that she put various items 'up in my private parts' including a knife and screwdriver ..." The patient was transferred to Delta Specialty Hospital.

Medical record review revealed Patient #1 was admitted to the hospital on 6/19/2022 with the diagnoses of Schizoaffective Disorder, Bipolar Type.

Review of the "Intake Assessment" dated 6/19/2022 with no time noted, revealed the patient had active suicidal ideations with a plan and put a sharp object to her head. Patient reports a history of self-harm and cutting. The patient was reported to have been banging her head on the wall at the CAC. The patient was disoriented and lethargic during intake due to being sedated at the CAC.

Review of the "High Risk Notification Form" revealed Intake Nurse #1 documented every 15 minute observations were ordered by the practitioner. The "Contraband Check via Wanding/Metal Detector?" section was not completed. The patient was handed off to the admitting unit on 6/19/2022 at 23:00.

Review of the Nurse Admit Assessment, completed by RN #4, dated 6/19/2022 at 23:38 revealed the time of arrival to unit was 23:00. The section titled "Body - Safety Search" documented "Performed by ... [Name of Behavioral Health Assistance (BHA) #1 and #2] ..."

Review of the Psychiatric Evaluation dated 6/20/2022 at 08:15 revealed the physician documented, " ... Reporting SI [Suicidal Ideations] with plan to stab self in the head. Held a sharp object to her head in front of [Name of Police Department]. History of self harm via cutting and often bangs head against the wall. Labile and agitated. Preoccupied with internal stimuli. Reports seeing 'monsters like cyclops' and hearing voices. Paranoid. Mood is elevated. Rambling speech with loose association. Delusional and bizarre, stating that she puts various items 'up my private parts' including a knife and screwdriver ..."

Review of a "Late entry for June 20, 2022 @ [at] 10:00" titled "NURSE PROGRESS NOTE" dated 7/8/2022 at 13:02 revealed, " ... Late entry for June 20, 2022 @ 10:00, BHA reported patient approached him and stated she did not get checked well the night before and handed him a pocketknife. He thanked the patient and took the knife to the CNO for processing." The note was electronically signed by the CNO on 7/8/2022 at 13:06, after the complaint investigation was initiated.

Review of the 6/21/2022 "BH [Behavioral Health] Daily Progress Note" at 06:47 revealed, " ... Pt up in hallway pacing. Mood is labile, elevated. Speech is rapid and rambling, Responding to IS [Internal Stimuli]. Remains paranoid and guarded. States SI with plan to 'Do anything.' Hearing voices and seeing 'monsters.' Impulsive and intrusive ..."

Review of the facility's incident investigation provided by the Risk Manager, revealed the following timeline:
6/20/2022- Contraband on the unit, staff retrieved.
6/20/2022- The RM immediately followed up, obtained statements from staff.
6/20/2022- Nursing leadership made aware of contraband incident.
6/21/2022- Unit Nurse Manager spoke with Patient #1.
6/21/2022- Nursing staff re-educated staff involved.
6/23/2022- RM spoke with lead techs to ascertain contraband issue, systemic.
6/24/2022-ongoing- Risk flash meetings are held to discuss contraband/searches.
6/30/2022- Contraband meeting scheduled.
7/5/2022- Contraband meeting held.
7/6/2022- Nursing educator to educate house wide as it relates for staff involved in searches.

In an interview on 7/19/2022 at 9:45 AM, in the conference room, the CNO was asked about Patient #1's knife. The CNO stated the knife had been turned over to her. The CNO stated it was a pocket knife, was unopened and about 6 inches long and the blade was just under 6 inches.

In an interview on 7/19/2022 at 10:00 AM, in the conference room, BHA #3 was asked about the knife that Patient #1 had. BHA #3 stated the blade was approximately 6 inches, like a hunting knife.

In an interview on 7/19/2022 at 11:25 AM, in the conference room, the COO stated the facility met and developed an action plan on 7/5/2022. The COO stated on 7/6/2022 in-services were started to address the incident.

In an interview on 7/19/2022 at 1:14 PM, in the conference room, the COO stated all contraband training will be completed by 7/31/2022.

In an interview on 7/19/2022 at 1:45 PM, in the conference room, the COO was asked why the facility waited from 6/20/200 to 7/5/2022 to develop and implement an action plan. The COO stated The Joint Commission was here.

In a telephone interview on 7/20/2022 at 10:00 AM RN #4 was asked why the body search was not conducted for Patient #1 upon admission to the unit. RN #4 stated, " ... I don't do searches on females. I let the female techs do them."

In a telephone interview on 7/20/2022 at 10:10 AM BHA #2 was asked why an appropriate body search was not conducted on Patient #1. BHA #2 stated, " ... I ' m not sure why it wasn't done. We are under the supervision of the nurse."

In a telephone interview on 7/20/2022 at 10:15 AM BHA #1 was asked why an appropriate body search was not conducted on Patient #1. BHA #1 stated, " ... I'm not sure of this patient." BHA #1 verified they had an in-service for contraband on 7/17/2022.

In an interview on 7/20/2022 at 11:03 AM Intake Nurse #1 was asked why Patient #1 was not checked for contraband. Intake Nurse #1 stated, " ... can't recall that patient." Intake Nurse #1 was unable to answer why she didn't conduct a contraband check in the Intake Department.

3. Medical record review revealed Patient #5 was 82 years old and Involuntarily admitted to the hospital on 6/1/2022 with diagnoses that included Dementia, Schizoaffective Disorder-Bipolar Type, Hallucinations, and Homicidal Ideations.

Review of the Intake Assessment dated 6/1/2022 at 14:45 revealed Patient #5 thought people were trying to break into his home, and had homicidal thoughts towards those people. The patient had visual and audible hallucinations, was paranoid and delusional, had racing thoughts, agitated, impulsive and threatened to kill his daughter and son.

Review of the High Risk Notification form dated 6/1/2022 at 15:15 revealed the patient was admitted with every 15 minute observations for assault precautions.

Review of the Morse Fall Assessment dated 6/1/2022 at 17:55 revealed a fall score of 15, "No or Low Risk."

Review of the "Nurse Progress Note" dated 6/1/2022 at 19:55 revealed Patient #5 was in the hallway confused and trying to get into another patient's room. " ... Pt [Patient] observed BHA [Behavioral Health Assistant] performing Q [every] 15 min check becomes angry when tech [BHA] attempts to lock female pt's door to prevent [Name of Patient #5] from entering. Pt difficult to redirect. Pt grabs BHA behind the neck cursing and pushes him into room. BHA pushes pt off him and back, pt holding onto BHA. Pt falls on bottom and back against wall."
At 20:12 the practitioner was notified for sedative for verbal and physical aggression. Haldol 5 mg and Ativan 1 mg ordered. The medication was administered to Patient #5 with 3 caregivers assisting.

Review of the Morse Fall Assessment dated 6/1/2022 at 20:00 revealed a fall score of 40, "Moderate Risk" due to the recent fall earlier in the shift while having a behavior.

Review of the "Nurse Progress Note" dated 6/2/2022 at 02:00 revealed RN #1 documented, " ...pt [patient] found lying on floor with pants at his feet. Noted vomit on floor ... Pt assessed and noted red abrasion near rt eyebrow and cheek ..." RN #1 documented at 02:45, 02:48, and 03:00 a practitioner was called.
There was no documentation by the RN that a practitioner was contacted and gave specific orders for Patient #5's fall with injury to the eyebrow and cheek area.

Review of a note documented by the Nurse Practitioner that was called for the 6/2/2022 fall, dated 6/3/2022 at 14:20 revealed, "I was notified by staff yesterday morning (6/3/22) [6/2/2022] pt [patient] was found lying on the floor in his room, RN said she was unsure if pt hit his head, pt was in NAD [no acute distress], VS [vital signs] stable, neuro assessment WNL [within normal limits]. when I saw patient later in the day he was resting in the bed, sedated from medication given earlier, awake to voice, follows commands, pupils equal, round, reactive, confused (baseline), small superficial abrasion noted above left eyebrow with bruising. Patient sent out to hospital to rule out any injury that might have occurred-pt high risk for bleeding, hx [history] chronic anticoagulation with eliquis."
The note was electronically signed by the Nurse Practitioner on 6/3/2022 at 14:28.

Review of the Morse Fall Assessment dated 6/2/2022 at 09:33 revealed a fall score of 15, having no falls and was "No or Low Risk."
The fall assessment failed to reflect the patient falling on 6/1/2022 and 6/2/2022.

Review of the "Nurse Progress Note" dated 6/2/2022 revealed that RN #2 documented at 1:45 PM, "Received a call from previous shift nurse checking on patient and stated that patient had hit his head. 1:50 pm Called to inform NP [Nurse Practitioner]. New orders received to send him out to [Name of Hospital #1] for CT [computerized tomography - a test that reveals abnormalities] of the head. Patient is also on Eliquis. 2 pm [2:00 PM] Called [Name of Hospital #1], report given to [Name of Nurse at Hospital #1] ..." The patient left the facility at 3:00 PM and taken to Hospital #1.
The patient was transferred to the hospital approximately 13 hours after he was found on the floor with an abrasion near the right eyebrow and cheek.

Review of Hospital #1's ED Provider Notes dated 6/2/2022 revealed Patient #5 arrived in the ED and was seen by the physician at 15:58. The physician documented, " ... 82 year-old with history of schizoaffective disorder, hypertension, on Eliquis for unknown reason presents from [Name of Facility] where he is involuntarily committed ... after he is sustained a fall last night. Per EMS [emergency medical services] reported he rolled out of bed overnight. They state the nursing staff wanted him evaluated for potential head bleed as he is on anticoagulation ... The EMS crew pointed out an abrasion on the right side of the patient's face. The patient states he does have some mild pain there ..."
Review of the CT of the head revealed there was no evidence of acute hemorrhage. The patient was discharged back to the facility.

Review of the "Nurse Progress Note" dated 6/2/2022 at 21:50 revealed, "NOTED PATIENT RETURNED FROM [Name of Hospital #1] E.R. [emergency room] F/U [follow-up] FALL CT DONE NO NEW ORDERS NOTED ..."

Review of the Morse Fall Assessment dated 6/3/2022 at 07:30 revealed a fall score of 15, "No or Low Risk."
The assessment revealed "No" the patient had not had any falls during the present hospitalization.
The fall assessment failed to reflect the patient's falls on 6/1/2022 and 6/2/2022.

Review of the Morse Fall Assessment dated 6/4/2022 at 07:40 revealed a fall score of 15 (No or Low Risk). The assessment revealed the patient had not had any falls during this hospitalization.
The fall assessment failed to reflect the patient's falls on 6/1/2022 and 6/2/2022.

Review of the "Nurse Progress Note" dated 6/4/2022 at 19:20 revealed RN #3 documented, "Pt. confused, aaox self, believes staff is in his home. Agitated, combative, striking staff x2 [times 2] ... Unable to redirect. Refusing PO [by mouth] medications ... Going into peers rooms ... Received phone order for Haldol 2.5 mg [milligrams]... and Benadryl 25 mg IM [intramuscular]...
Discussed monitoring patient closely for high fall risk ... Administered [IM medication] to patient."

Review of the "Patient Observations" forms dated 6/2/2022, 6/3/2022, and 6/4/2022 revealed the patient remained on every 15 minute observations for "Assault" precautions only, the "Fall" section was not indicated. There was no documentation of additional "monitoring patient closely for high fall risk."

Review of the "Nurse Progress Note" dated 6/4/2022 revealed, "6/4/2022 @ approx. 2200, RN notified by BHT pt had experienced an unwitnessed fall in pts room by doorway. Pt. found lying on floor, awake, alert, and responsive to nurse. No loss of consciousness, no change in mental status. AAOx [awake, alert and oriented] self-only- at baseline. Pt. assisted back to bed x2 staff members. Assessed for injuries, golf ball size hematoma above R [right] eyebrow found. No external bleeding or abrasions ... Notified [Name of Practitioner] of fall and anticoagulation status ... received phone order to transfer pt to ED [emergency department at Hospital #2] ... EMS notified." The note revealed the patient was transferred to the hospital at 22:45 with a BHT/BHA sitter.

Review of the physician's orders dated 6/4/2022 at 23:53 revealed an order to place the patient on 1 to 1 observation, after the patient had already transferred to Hospital #2's ED.

Review of Hospital #2's medical records revealed Patient #5 presented to the ED on 6/4/2022 at 23:16 via EMS. The ED physician documented at 01:06, " ... history of mental illness and dementia on Eliquis presents from [Name of facility] after he fell and hit his head tonight after he got a haldol and benadryl injection ... IMPRESSION/PLAN ... Intracranial hemorrhage ... "
Review of the Head CT revealed, " IMPRESSION ... There is a 7-8 mm [seven to eight milliliters] acute bleed within the medial aspect of the right frontal lobe ... no epidural or subdural bleed... There is soft tissue swelling/hematoma ... no evidence of skull fracture ..."

Patient #5 was admitted to Hospital #2's ICU [intensive care unit] for 2 days and was discharged home on 6/6/2022 in stable condition with Home Health services.

In an interview on 8/2/2022 at 2:30 PM, in the lobby conference room, the Risk Manager stated the patient care plans are included in the patient assessment reports.

In a telephone interview on 8/4/2022 at 9:00 AM the Risk Manager stated there were no videos of Patient #5's falls.

In a telephone interview on 8/4/2022 at 10:09 AM the Risk Manager stated they had spoken with the NP regarding the 6/2/2022 fall. The NP did not recall the notification time for the patient's fall.

Based on hospital policy review, medical record review, and interview, the hospital failed to ensure all nursing staff developed and implemented accurate nursing care plans in accordance with patient needs in order to promote safety and prevent falls; and failed to ensure safety searches were conducted upon admission on all new patients to ensure harmful contraband was not in possession of patients for two of five (Patients #1 and #5) sampled patients

The findings included:

1. Review of the facility's "SAFETY SEARCHES" dated ""3/2020" and "Contraband" dated "11/2020" policies revealed all patients would be searched and wanded in the intake department using an electronic device to ensure patients do not have potentially hazardous weapons or metal objects. A body search should be conducted for contraband once the patient is admitted inpatient and arrives on the unit.

Review of the facility's "PLAN OF CARE" policy revised "11/2020" revealed, " ... PURPOSE: To assure care is based on problems identified through assessment ... The plan is updated as indicated by patient need ... "

Review of the facility's "FALL PRECAUTIONS AND PREVENTION" policy dated "4/2020" revealed, " ... In order to reduce the risk of patient injuries as a result of a fall, nursing staff will assess and re-assess the patient's level of risk for fall and implement appropriate interventions...All patients admitted to the hospital will be assessed using the MORSE Falls Assessment as part of the Nursing Assessment...Risk of Falls will be included in the Interdisciplinary Treatment Plan and updated as needed...."

2. Medical record review revealed on 6/19/2022 police were called to Patient #1's residence when the patient starting exhibiting threatening behaviors and had not been taking medications. The patient was arrested by police for emergency detention and taken to the Crisis Assessment Center (CAC). The patient had a history of Schizophrenia.

Review of the CAC assessment revealed Patient #1 presented to CAC via police department due to suicidal ideations, the patient was off her medications and was actively trying to hurt herself. Per police report the patient was actively suicidal and put a sharp object to her head. The patient reported self-harming behaviors and showed superficial cuts up and down her left arm. The patient had an extensive history of physically aggressive behaviors.

Review of the Certificate of Need for Involuntary Admission dated 6/19/2022 revealed, " ... Patient presents as manic and threatening to harm herself and others ... Patient presents as a poor historian, racing thoughts, over talkative, heightened energy and reports hx [history] of previous suicide attempts and aggressive behavior ... Patient is too high risk to self to be released back into the community. Patient is involuntary ... " The Basis for admission revealed, " ... stating that she put various items 'up in my private parts' including a knife and screwdriver ..."

The patient was transferred to the Intake Department at Delta Specialty Hospital on 6/19/2022.

Medical record review and documents review at the hospital revealed Patient #1 was not appropriately checked for weapons or harmful objects when in the hospital's Intake Department or when admitted to the hospital inpatient unit.

On 6/20/2022 at approximately 10:00 AM it was discovered that Patient #1 had a knife concealed in her clothing.

The facility failed to ensure procedures were followed to prevent Patient #1 from harming herself or others.
Refer to A0395

3. Medical record review revealed Patient #5 was admitted to the facility on 6/1/2022 with Schizoaffective Disorder. The patient was on Eliquis for Pulmonary Embolus and Chronic anticoagulation, putting the patient at increased risk for bleeding.

The patient had a fall on 6/1/2022 related to behaviors. The patient had a fall on 6/2/2022, sustaining an injury to the side of his face/head and was sent to the emergency department (ED). The patient had a fall on 6/4/2022, sustaining an injury to the side of his face/head.

Review of the 6/4/2022 hospital report revealed the patient had a seven to eight millimeter acute right frontal lobe bleed and was admitted to the hospital in ICU for 2 days.

There was no documentation the facility had developed and implemented an action plan in order to prevent the patient from falls and provide safety interventions for the patient.

The facility nursing staff failed to accurately develop and implement a care plan for falls and in accordance with the facility's policies.
Refer to A0396

Based on facility policy review, medical records review and interview, the hospital failed to ensure adequate supervison of the nursing staff and ensure the staff followed facility policeis and searched each patient arriving to the nursing unit for harmful contraband for one of five (Patient #1) sampled patients.

The findings included:

1. Review of the facility's "SAFETY SEARCHES" policy dated "3/2020" revealed, "Delta Specialty Hospital strives to maintain a safe and therapeutic environment for patients, visitors and staff. In order to achieve this, routine searches should be conducted on all patients on admission ... Other searches (patient, room, unit) may be conducted when there is reasonable cause to believe a patient may possess and item which is potentially hazardous...
PROCEDURE...
Electronic Search ... Electronic Searches will be conducted in the Intake area for direct admissions during the admission process to assure that a patient is free of weapons or any metal objects that could be used for harm before entering the unit. The patient will be scanned over the entire body by a wand metal detector ...
Belongings search ... All patients should have their belongings searched for potentially hazardous items by facility staff on admission ... Remove any items deemed hazardous for patient to keep in room ... Dangerous weapons are to be turned over [to] Nursing Supervisor ...
Patient Search ... All patients should have a routine patient search conducted by intake staff on admission ... All new admissions should remain separated from other patients until the completion of a patient search ... "

Review of the facility's contraband policy dated "11/2020" revealed patients are to be scanned or wanded for contraband in the intake department and a body search for contraband once they arrive on the unit.

2. Review of the police report filed in the hospital's medical record revealed, " ...On 6/19/2022 at 08:31 hours, [Name of Police Officer] responded to a Emergency Commitment at [address]. Officers met with complainant [Name of Patient #1's boyfriend] who stated that his girlfriend, suspect [Name of Patient #1] is diagnosed with paranoid Schizophrenia, bipolar and depression and off her meds.." The patient was arrested for Emergency Detention and taken to the Crisis Assessment Center (CAC).

Review of the CAC assessment revealed Patient #1 presented to CAC via police department due to suicidal ideations, the patient was off her medications and was actively trying to hurt herself. Per police report the patient was actively suicidal and put a sharp object to her head. The patient reported self-harming behaviors 3-4 months ago and showed superficial cuts up and down her left arm. The patient has an extensive history of physical aggressive behaviors.

Review of the Certificate of Need for Involuntary Admission dated 6/19/2022 revealed, " ... Patient presents as manic and threatening to harm herself and others ... Patient presents as a poor historian, racing thoughts, over talkative, heightened energy and reports hx [history] of previous suicide attempts and aggressive behavior ... Patient is too high risk to self to be released back into the community. Patient is involuntary ... " The Basis for admission revealed, " ... stating that she put various items 'up in my private parts' including a knife and screwdriver ..." The patient was transferred to Delta Specialty Hospital.

Medical record review revealed Patient #1 was admitted to the hospital on 6/19/2022 with the diagnoses of Schizoaffective Disorder, Bipolar Type.

Review of the "Intake Assessment" dated 6/19/2022 with no time noted, revealed the patient had active suicidal ideations with a plan and put a sharp object to her head. Patient reports a history of self-harm and cutting. The patient was reported to have been banging her head on the wall at the CAC. The patient was disoriented and lethargic during intake due to being sedated at the CAC.

Review of the "High Risk Notification Form" revealed Intake Nurse #1 documented every 15 minute observations were ordered by the practitioner. The "Contraband Check via Wanding/Metal Detector?" section was not completed. The patient was handed off to the admitting unit on 6/19/2022 at 23:00.

Review of the Nurse Admit Assessment, completed by RN #4, dated 6/19/2022 at 23:38 revealed the time of arrival to unit was 23:00. The section titled "Body - Safety Search" documented "Performed by ... [Name of Behavioral Health Assistance (BHA) #1 and #2] ..."

Review of the Psychiatric Evaluation dated 6/20/2022 at 08:15 revealed the physician documented, " ... Reporting SI [Suicidal Ideations] with plan to stab self in the head. Held a sharp object to her head in front of [Name of Police Department]. History of self harm via cutting and often bangs head against the wall. Labile and agitated. Preoccupied with internal stimuli. Reports seeing 'monsters like cyclops' and hearing voices. Paranoid. Mood is elevated. Rambling speech with loose association. Delusional and bizarre, stating that she puts various items 'up my private parts' including a knife and screwdriver ..."

Review of a "Late entry for June 20, 2022 @ [at] 10:00" titled "NURSE PROGRESS NOTE" dated 7/8/2022 at 13:02 revealed, " ... Late entry for June 20, 2022 @ 10:00, BHA reported patient approached him and stated she did not get checked well the night before and handed him a pocketknife. He thanked the patient and took the knife to the CNO for processing." The note was electronically signed by the CNO on 7/8/2022 at 13:06, after the complaint investigation was initiated.

Review of the 6/21/2022 "BH [Behavioral Health] Daily Progress Note" at 06:47 revealed, " ... Pt up in hallway pacing. Mood is labile, elevated. Speech is rapid and rambling, Responding to IS [Internal Stimuli]. Remains paranoid and guarded. States SI with plan to 'Do anything.' Hearing voices and seeing 'monsters.' Impulsive and intrusive ..."

Review of the facility's incident investigation provided by the Risk Manager, revealed the following timeline:
6/20/2022- Contraband on the unit, staff retrieved.
6/20/2022- The RM immediately followed up, obtained statements from staff.
6/20/2022- Nursing leadership made aware of contraband incident.
6/21/2022- Unit Nurse Manager spoke with Patient #1.
6/21/2022- Nursing staff re-educated staff involved.
6/23/2022- RM spoke with lead techs to ascertain contraband issue, systemic.
6/24/2022-ongoing- Risk flash meetings are held to discuss contraband/searches.
6/30/2022- Contraband meeting scheduled.
7/5/2022- Contraband meeting held.
7/6/2022- Nursing educator to educate house wide as it relates for staff involved in searches.

In an interview on 7/19/2022 at 9:45 AM, in the conference room, the CNO was asked about Patient #1's knife. The CNO stated the knife had been turned over to her. The CNO stated it was a pocket knife, was unopened and about 6 inches long and the blade was just under 6 inches.

In an interview on 7/19/2022 at 10:00 AM, in the conference room, BHA #3 was asked about the knife that Patient #1 had. BHA #3 stated the blade was approximately 6 inches, like a hunting knife.

In an interview on 7/19/2022 at 11:25 AM, in the conference room, the COO stated the facility met and developed an action plan on 7/5/2022. The COO stated on 7/6/2022 in-services were started to address the incident.

In an interview on 7/19/2022 at 1:14 PM, in the conference room, the COO stated all contraband training will be completed by 7/31/2022.

In an interview on 7/19/2022 at 1:45 PM, in the conference room, the COO was asked why the facility waited from 6/20/200 to 7/5/2022 to develop and implement an action plan. The COO stated The Joint Commission was here.

In a telephone interview on 7/20/2022 at 10:00 AM RN #4 was asked why the body search was not conducted for Patient #1 upon admission to the unit. RN #4 stated, " ... I don't do searches on females. I let the female techs do them."

In a telephone interview on 7/20/2022 at 10:10 AM BHA #2 was asked why an appropriate body search was not conducted on Patient #1. BHA #2 stated, " ... I ' m not sure why it wasn't done. We are under the supervision of the nurse."

In a telephone interview on 7/20/2022 at 10:15 AM BHA #1 was asked why an appropriate body search was not conducted on Patient #1. BHA #1 stated, " ... I'm not sure of this patient." BHA #1 verified they had an in-service for contraband on 7/17/2022.

In an interview on 7/20/2022 at 11:03 AM Intake Nurse #1 was asked why Patient #1 was not checked for contraband. Intake Nurse #1 stated, " ... can't recall that patient." Intake Nurse #1 was unable to answer why she didn't conduct a contraband check in the Intake Department.

Based on facility policy review, medical record review, and interview the hospital failed to ensure the nursing care plan was revised and updated to reflect fall interventions for one of five (Patient #5) sampled patients reviewed.

The findings included:

1. Review of the "PLAN OF CARE" policy revised "11/2020" revealed, " ... PURPOSE: To assure care is based on problems identified through assessment ... A plan of care is established at the time of admission and a problem list developed ... The plan of care is reflected daily in the nursing notes ... POLICY ... A problem list is initiated by the RN utilizing nursing diagnosis statements ... The plan is updated as indicated by patient need ... "

2. Review of the "FALL PRECAUTIONS AND PREVENTION" policy dated "4/2020" revealed, " ... In order to reduce the risk of patient injuries as a result of a fall, nursing staff will assess and re-assess the patient's level of risk for fall and implement appropriate interventions through the following procedures. A fall is defined as a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor or the ground, other than the consequence of overwhelming external force ...

PROCEDURE ... 1. All patients admitted to the hospital will be assessed using the MORSE Falls Assessment as part of the Nursing Assessment. Based on this assessment, each patient will be placed in a risk category. 2 ...Nursing shall place the patient on fall precautions when indicated and ensure the practitioner is notified and orders the level of observation and precautions consistent with the assessed level of risk ... 3. Risk of Falls will be included in the Interdisciplinary Treatment Plan and updated as needed.
4. Falls Prevention Interventions ...

a. Standard Falls Prevention Interventions - apply to all patients ... Orient patient to surroundings ... Keep room free from clutter ... Ensure patient has proper fitting, non-skid footwear ... Provide patient with ability to contact nursing staff at night for assistance ... Leave bathroom door ajar ... Routine q [every] 15 minute observations ...

b. 0-24: Low Risk for Falls ... Standard interventions ... Assess for environmental obstacles ...

c. 25-44: Medium Risk for Falls ... All standard and low risk precautions ... Perform gait assessment ... Review medications ... If applicable, insure patient is wearing his/her eyeglasses and/or hearing aid when awake ... monitor patient gait after receiving sedating medications, diuretics and laxatives ...

5. Interventions Post Fall ... Patient is assessed/reassessed after any fall ... The medical practitioner will be contacted by the Charge Nurse to determine course of treatment after a patient has fallen ...Patient falls risk reassessed and appropriate interventions implemented ... "

3. Medical record review revealed Patient #5 was 82 years old and Involuntarily admitted to the hospital on 6/1/2022 with diagnoses that included Dementia, Schizoaffective Disorder-Bipolar Type, Hallucinations, and Homicidal Ideations.

Review of the Intake Assessment dated 6/1/2022 at 14:45 revealed Patient #5 thought people were trying to break into his home, and had homicidal thoughts towards those people. The patient had visual and audible hallucinations, was paranoid and delusional, had racing thoughts, agitated, impulsive and threatened to kill his daughter and son.

Review of the High Risk Notification form dated 6/1/2022 at 15:15 revealed the patient was admitted with every 15 minute observations for assault precautions.

Review of the Morse Fall Assessment dated 6/1/2022 at 17:55 revealed a fall score of 15, "No or Low Risk."

Review of the "Nurse Progress Note" dated 6/1/2022 at 19:55 revealed Patient #5 was in the hallway confused and trying to get into another patient's room. " ... Pt [Patient] observed BHA [Behavioral Health Assistant] performing Q [every] 15 min check becomes angry when tech [BHA] attempts to lock female pt's door to prevent [Name of Patient #5] from entering. Pt difficult to redirect. Pt grabs BHA behind the neck cursing and pushes him into room. BHA pushes pt off him and back, pt holding onto BHA. Pt falls on bottom and back against wall."
At 20:12 the practitioner was notified for sedative for verbal and physical aggression. Haldol 5 mg and Ativan 1 mg ordered. The medication was administered to Patient #5 with 3 caregivers assisting.

Review of the Morse Fall Assessment dated 6/1/2022 at 20:00 revealed a fall score of 40, "Moderate Risk" due to the recent fall earlier in the shift while having a behavior.

Review of the "Nurse Progress Note" dated 6/2/2022 at 02:00 revealed RN #1 documented, " ...pt [patient] found lying on floor with pants at his feet. Noted vomit on floor ... Pt assessed and noted red abrasion near rt eyebrow and cheek ..." RN #1 documented at 02:45, 02:48, and 03:00 a practitioner was called.
There was no documentation by the RN that a practitioner was contacted and gave specific orders for Patient #5's fall with injury to the eyebrow and cheek area.

Review of a note documented by the Nurse Practitioner that was called for the 6/2/2022 fall, dated 6/3/2022 at 14:20 revealed, "I was notified by staff yesterday morning (6/3/22) [6/2/2022] pt [patient] was found lying on the floor in his room, RN said she was unsure if pt hit his head, pt was in NAD [no acute distress], VS [vital signs] stable, neuro assessment WNL [within normal limits]. when I saw patient later in the day he was resting in the bed, sedated from medication given earlier, awake to voice, follows commands, pupils equal, round, reactive, confused (baseline), small superficial abrasion noted above left eyebrow with bruising. Patient sent out to hospital to rule out any injury that might have occurred-pt high risk for bleeding, hx [history] chronic anticoagulation with eliquis."
The note was electronically signed by the Nurse Practitioner on 6/3/2022 at 14:28.

Review of the Morse Fall Assessment dated 6/2/2022 at 09:33 revealed a fall score of 15, having no falls and was "No or Low Risk."
The fall assessment failed to reflect the patient falling on 6/1/2022 and 6/2/2022.

Review of the "Nurse Progress Note" dated 6/2/2022 revealed that RN #2 documented at 1:45 PM, "Received a call from previous shift nurse checking on patient and stated that patient had hit his head. 1:50 pm Called to inform NP [Nurse Practitioner]. New orders received to send him out to [Name of Hospital #1] for CT [computerized tomography - a test that reveals abnormalities] of the head. Patient is also on Eliquis. 2 pm [2:00 PM] Called [Name of Hospital #1], report given to [Name of Nurse at Hospital #1] ..." The patient left the facility at 3:00 PM and taken to Hospital #1.
The patient was transferred to the hospital approximately 13 hours after he was found on the floor with an abrasion near the right eyebrow and cheek.

Review of Hospital #1's ED Provider Notes dated 6/2/2022 revealed Patient #5 arrived in the ED and was seen by the physician at 15:58. The physician documented, " ... 82 year-old with history of schizoaffective disorder, hypertension, on Eliquis for unknown reason presents from [Name of Facility] where he is involuntarily committed ... after he is sustained a fall last night. Per EMS [emergency medical services] reported he rolled out of bed overnight. They state the nursing staff wanted him evaluated for potential head bleed as he is on anticoagulation ... The EMS crew pointed out an abrasion on the right side of the patient's face. The patient states he does have some mild pain there ..."
Review of the CT of the head revealed there was no evidence of acute hemorrhage. The patient was discharged back to the facility.

Review of the "Nurse Progress Note" dated 6/2/2022 at 21:50 revealed, "NOTED PATIENT RETURNED FROM [Name of Hospital #1] E.R. [emergency room] F/U [follow-up] FALL CT DONE NO NEW ORDERS NOTED ..."

Review of the Morse Fall Assessment dated 6/3/2022 at 07:30 revealed a fall score of 15, "No or Low Risk."
The assessment revealed "No" the patient had not had any falls during the present hospitalization.
The fall assessment failed to reflect the patient's falls on 6/1/2022 and 6/2/2022.

Review of the Morse Fall Assessment dated 6/4/2022 at 07:40 revealed a fall score of 15 (No or Low Risk). The assessment revealed the patient had not had any falls during this hospitalization.
The fall assessment failed to reflect the patient's falls on 6/1/2022 and 6/2/2022.

Review of the "Nurse Progress Note" dated 6/4/2022 at 19:20 revealed RN #3 documented, "Pt. confused, aaox self, believes staff is in his home. Agitated, combative, striking staff x2 [times 2] ... Unable to redirect. Refusing PO [by mouth] medications ... Going into peers rooms ... Received phone order for Haldol 2.5 mg [milligrams]... and Benadryl 25 mg IM [intramuscular]...
Discussed monitoring patient closely for high fall risk ... Administered [IM medication] to patient."

Review of the "Patient Observations" forms dated 6/2/2022, 6/3/2022, and 6/4/2022 revealed the patient remained on every 15 minute observations for "Assault" precautions only, the "Fall" section was not indicated. There was no documentation of additional "monitoring patient closely for high fall risk."

Review of the "Nurse Progress Note" dated 6/4/2022 revealed, "6/4/2022 @ approx. 2200, RN notified by BHT pt had experienced an unwitnessed fall in pts room by doorway. Pt. found lying on floor, awake, alert, and responsive to nurse. No loss of consciousness, no change in mental status. AAOx [awake, alert and oriented] self-only- at baseline. Pt. assisted back to bed x2 staff members. Assessed for injuries, golf ball size hematoma above R [right] eyebrow found. No external bleeding or abrasions ... Notified [Name of Practitioner] of fall and anticoagulation status ... received phone order to transfer pt to ED [emergency department at Hospital #2] ... EMS notified." The note revealed the patient was transferred to the hospital at 22:45 with a BHT/BHA sitter.

Review of the physician's orders dated 6/4/2022 at 23:53 revealed an order to place the patient on 1 to 1 observation, after the patient had already transferred to Hospital #2's ED.

Review of Hospital #2's medical records revealed Patient #5 presented to the ED on 6/4/2022 at 23:16 via EMS. The ED physician documented at 01:06, " ... history of mental illness and dementia on Eliquis presents from [Name of facility] after he fell and hit his head tonight after he got a haldol and benadryl injection ... IMPRESSION/PLAN ... Intracranial hemorrhage ... "
Review of the Head CT revealed, " IMPRESSION ... There is a 7-8 mm [seven to eight milliliters] acute bleed within the medial aspect of the right frontal lobe ... no epidural or subdural bleed... There is soft tissue swelling/hematoma ... no evidence of skull fracture ..."

Patient #5 was admitted to Hospital #2's ICU [intensive care unit] for 2 days and was discharged home on 6/6/2022 in stable condition with Home Health services.

In an interview on 8/2/2022 at 2:30 PM, in the lobby conference room, the Risk Manager stated the patient care plans are included in the patient assessment reports.

In a telephone interview on 8/4/2022 at 9:00 AM the Risk Manager stated there were no videos of Patient #5's falls.

In a telephone interview on 8/4/2022 at 10:09 AM the Risk Manager stated they had spoken with the NP regarding the 6/2/2022 fall. The NP did not recall the notification time for the patient's fall.