HospitalInspections.org

Based on policy review, medical record review and interview, the facility failed to ensure the family/Power of Attorney (POA) was notified of a change in condition for 1 of 3 (Patient #1) sampled patients reviewed with changes in condition.

The findings included:

1. Review of the facility's "Precautions, Sexual Acting Out" policy (approved 8/22) revealed, "...Provision of a safe, therapeutic environment of care includes the prevention of patient to patient sexual incidents. Patients shall not have sexual contact with one another...If the hospital determines that there has been an allegation of sexual familiarity (contact) between patients, an immediate investigation must take place...Risk of sexual acting out behaviors will be addressed in the Interdisciplinary Treatment Plan. Treatment plan will be updated as needed..."

2. Review of the facility's "Risk Management Incident Reporting Policy" (approved 1/22) revealed, "The Incident Report enables the facility to manage risk, increase safety, and improve the quality of health care provided in the facility through risk control intervention and monitoring the effectiveness of the interventions and corrective action plan...If the incident involves a patient, staff must chart relevant factual information in the patient's medical record..."

3. Medical record review revealed Patient #1 was admitted to the facility on 8/17/22 with diagnoses that included Schizoaffective Disorder, Bipolar Type.

Review of the facility's incident report dated 9/1/22, with the time documented as "evening" revealed, "...During observation checks, [Patient #2] was found in [Patient #1] room by staff. Both patients were naked from the waist down, laying on the bed, touching each other...Was family or others notified...[named Patient #2's mother]..."

There was no documentation on the incident report that Patient #1's family/POA was notified of the incident.

Further review of Patient #1's medical record revealed no documentation that the family/POA was notified of the incident.

In an email interview on 9/12/22 with Patient #1's POA the POA stated he found out about the incident from Patient #1. The facility never contacted him to report the incident.

Based on policy review, medical record review and interview, the facility failed to ensure all patients received care in a safe setting by changing safety observations from every 5 minutes to every 15 minutes without a physician's order for 1 of 7 (Patient #5) patients receiving observations by staff.

The findings included:

1. Review of the facility's "OBSERVATIONS, PATIENT" policy (approved 12/21) revealed, "...In order to maintain patient safety the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and/or confirmed with the DON [Director of Nursing] or AOC [Administrator on Call]...A psychiatric practitioner is the only person that can decrease the level...The physician will order one of three levels of observation at time of admission and as the patient's condition warrants a change: 1. 15 Minute 2. Q5 [every 5] Minute 3. One-to-One...Patient is placed on Q5 minute observations if their behavior is unpredictable and there is potential risk for harm to self or others yet behavior is not at the point requiring constant 1:1 observation...The nurse will contact the attending physician/designee if the nurse assessment indicates continued Q5 minute observations may not be necessary...The attending physician/designee will then order a continuation of Q5 minute observations or provide an order for a different level of observation..."

2. Medical record review for Patient #5 revealed an admission date of 8/20/22 with diagnoses that included Depressive Disorder, Severe with Psychosis.

Review of Patient #5's Admission Order, dated 8/20/22, documented, "...Level of Observation: Q 5 minutes..."

Review of a physician's order dated 8/21/22 documented, "...continue Q 5 min [minute] monitoring for high suicide risk..."

Review of "Patient Observation" flowsheets beginning upon admission on 8/20/22, revealed the level of observation was Q 5 minutes. Beginning on 8/27/22, observations were then performed every 15 minutes.

There was no documentation of a physician's order to change the level of observations from Q 5 minutes to every 15 minutes on 8/27/22.

During an interview on 9/21/22 at 11 AM, the facility's Risk Manager verified there were no additional orders.

Based on policy review, medical record review and interview, the facility failed to ensure an organized nursing service notified the physician of incomplete ordered lab tests, and failed to document patient incidents in the patient's medical record for 4 of 7 (Patients #1, 2, 3, and 4) sampled patients.

The findings included:

1. Review of the facility's "NOTING ORDERS" policy (approved 12/21) revealed, "...Practitioner orders shall be noted by the nurse as soon as possible for timely implementation..."

2. Review of the facility's "Risk Management Incident Reporting Policy" (approved 1/22) revealed, "...An "incident" is an unanticipated event which results in, or nearly causes, a negative impact on patient care or visitor safety...If the incident involves a patient, staff must chart relevant factual information in the patient's medical record..."

3. Medical record review for Patient #1 revealed an admission date of 8/17/22 with diagnoses that included Schizoaffective Disorder, Bipolar type.

Review of an incident report dated 9/1/22 revealed Patient #1 was involved in a patient to patient "Misconduct-Body Exposure" incident. The incident report documented, "During observation checks [Patient #2] was found in [Patient #1's] room by staff. Both patients were naked from the waist down, laying on the bed, touching each other...conversations with both [Patient #2 and Patient #1] when event was reported, both patients stated sexual intercourse did not occur as [Patient #1's] penis was not erect. [Patient #1] stated [Patient #2] came into his room and asked him to take off his pants. Both stated they had exposed their genitals to each other while [Patient #1] was laying on top of [Patient #2]...NP [named Nurse Practitioner] was notified on 9/2/22 with orders to complete and STD [Sexually Transmitted Disease] panel on [Patient #1] due to complaints of painful urination that had started before his admission..."

Review of the "Nursing Reassessment" notes and progress notes dated 9/1/22, 9/2/22 and 9/3/22 revealed no documentation of the patient to patient body exposure misconduct incident in the patient's medical record.

Review of a physician order dated 9/2/22 revealed an order for a STD panel.

Review of lab test results in Patient #1's medical record revealed the STD panel was not obtained until 9/15/22. There was no documentation of why the lab test was not obtained when ordered, and no documentation the physician was notified of the delay in obtaining the test.

In an interview on 9/20/22 beginning at 11:00 AM, the facility's Risk Manager (RM) verified the incident should be documented in the medical record. The RM verified all lab test results were in the record and up to date.

4. Medical record review for Patient #2 revealed an admission date of 12/1/21 with diagnoses that included Suicidal Ideation and Schizoaffective Disorder.

Review of an incident report dated 9/1/22 revealed Patient #1 was involved in a patient to patient "Misconduct-Body Exposure" incident. The incident report documented, "During observation checks [Patient #2] was found in [Patient #1's] room by staff. Both patients were naked from the waist down, laying on the bed, touching each other...conversations with both [Patient #2 and Patient #1] when event was reported, both patients stated sexual intercourse did not occur as [Patient #1's] penis was not erect. [Patient #1] stated [Patient #2] came into his room and asked him to take off his pants. Both stated they had exposed their genitals to each other while [Patient #1] was laying on top of [Patient #2]..."

Review of the "Nursing Reassessment" notes and progress notes dated 9/1/22, 9/2/22 and 9/3/22 revealed no documentation of the patient to patient body exposure misconduct incident in the patient's medical record.

In an interview on 9/20/22 beginning at 11:00 AM, the RM verified the incident should be documented in the medical record.

5. Medical record review for Patient #3 revealed an admission date of 8/30/22 with diagnoses that included Schizoaffective Disorder, Bipolar Type.

Review of an incident report dated 8/30/22 revealed "Patient attacked another patient...[Patient #3] was aggressive/agitated and started hitting patient [Patient #6]. PRN [as needed] medication given to [Patient #3]...no injuries..."

Review of the "Nursing Reassessment" notes and progress notes dated 8/30/22 revealed no documentation of the incident in the patient's medical record.

In an interview on 9/20/22 beginning at 11:00 AM, the RM verified the incident should be documented in the medical record.

6. Medical Record review for Patient #4 revealed an admission date of 8/2/22 with diagnoses that included Schizoaffective Disorder, Bipolar Type.

Review of a physician's order dated 8/9/22 documented "HIV [Human Immunodeficiency Virus] test (HIV Panel), Hepatitis panel"

Review of Patient #4's lab test results revealed no documentation of a Hepatitis Panel test, and no documentation the physician was notified that the test was not obtained.

In an interview on 9/20/22 beginning at 11:00 AM, the RM verified all lab test results were in the medical record.