HospitalInspections.org

Based on interview and record review, it was determined that the hospital failed to promote and protect each patients' rights.

On 3/21/19, a finding of Immediate Jeopardy (IJ) was identified in the area of Patient Rights. The hospital was notified of this finding on 3/21/19, at 10:41 AM. The Hospital submitted an IJ removal/abatement plan on 3/21/19, at 2:17 PM, alleging removal of the IJ as of 3/21/19, at 2:15 PM. The plan was accepted and the hospital was notified at 2:45 PM on 3/21/19. Surveyors were on site and reviewed for IJ removal. It was determined that IJ had been removed on 3/21/19, but at 7:00 PM rather than 2:15 as they had alleged. The hospital was notified of the IJ removal at 7:05 PM on 3/21/19.

Findings include:

1. The hospital did not provide patients with written information for lodging a grievance with the state agency including the address and telephone number of the agency. (Refer to tag A-115)

2. The hospital did not provide patients with written information for lodging a grievance with the state agency including the address and telephone number of the agency. (Refer to tag A-118)

3. The hospital did not obtain an informed consent to treat for 3 of 30 sampled patients. Specifically, the hospital did not obtain written or verbal consent to treat for patients who were incapacitated or otherwise unable to consent to treatment upon admission. (Refer to tag A-131)

4. The hospital failed to ensure each patient was free from all forms of abuse or harassment. Specifically, for 1 of 30 sampled patients an allegation of sexual abuse was not investigated until the next morning and the patient was not afforded sufficient protection to ensure the incident would not happen again.
(Refer to tag A-145)

Based on interview and record review, it was determined that the hospital did not provide patients with written information for lodging a grievance with the state agency including the address and telephone number of the agency.

Findings include:

On 3/19/19, review of the admission packet and paperwork was completed.

There was no documented evidence that the hospital had provided patients with written information for lodging a grievance with the state agency including the address and telephone number of the agency.

On 3/19/19 at 4:00 PM, an interview was conducted with the chief nursing officer (CNO). The CNO stated that the information regarding filing a grievance with the state agency must have been missed when the patient rights and responsibilities pamphlet was printed.

Based on interview and record review, it was determined that the hospital did not obtain an informed consent to treat for 3 of 30 sampled patients. Specifically, the hospital did not obtain written or verbal consent to treat for patients who were incapacitated or otherwise unable to consent to treatment upon admission. (Patient identifiers: 4, 11, and 17.)

Findings include:

1. Patient 4 was admitted to the hospital on 3/17/19, with an admitting diagnosis of urosepsis.

Patient 4's medical record was reviewed on 3/25/19. A review of the consent to treat revealed patient 4 was unable to sign the consent. The consent was signed by the admission person and co-signed by another staff member. No documentation could be located to indicate that a consent to treat had been completed by the patient or the patient's representative, prior to the patient being discharged from the hospital.

2. Patient 17 was admitted to the hospital on 3/6/19, with an admitted diagnosis of an epidural abscess.

Patient 17's medical record was reviewed on 3/25/19. Patient 17's medical record was reviewed on 3/25/19. A review of the consent to treat revealed patient 4 was unable to sign the consent. The consent was signed by the admission person and co-signed by another staff member. No documentation could be located to indicate that a consent to treat had been completed by the patient or the patient's representative, prior to the patient being discharged from the hospital.

On 3/25/19, at 2:15 PM, an interview was conducted with the chief nursing officer (CNO). The CNO called the admission office and spoke with an admissions staff person to ask for clarification of what the hospital process was when a patient was unable to sign the consent to treat on admission. The staff person told her that if the patient cannot sign on admission they would have another staff person witness and sign the admission paperwork indicating that the patient was unable to sign. The staff person stated they did not follow up with the patient or the patient's representative to obtain a signed consent to treat.

During the interview, the CNO contacted the corporate person over the admissions department. The corporate person stated that if the patient was unable to sign the consent form upon admission, the admission staff were to go to the patient room at a later time and attempt to get a signed consent from the patient or the patient's representative. If the patient was still unable to sign the consent and there is no patient representative present, the admissions person was to contact the patient's representative by telephone and obtain a verbal consent to treat.

3. Patient 26 was admitted to the hospital on 5/24/18, with an admitting diagnosis of shock.

Patient 26's medical record was reviewed on 3/26/19. No documentation could be located to indicate that a consent to treat had been completed by the patient or the patient's representative, prior to the patient being discharged from the hospital.

On 3/26/19 at 8:46 AM, an interview was conducted with the quality director (QD). The QD stated that the hospital was unable to locate the consent forms for patient 26.

Based on observation, interview, and record review it was determined the hospital failed to ensure each patient had the right to be free from all forms of abuse or harassment. Specifically, for 1 of 30 sampled patients an allegation of sexual abuse was not investigated until the next morning and the patient was not afforded sufficient protection to ensure the incident would not happen again. (Patient identifier: 16.)

On 3/21/19 a finding of Immediate Jeopardy (IJ) was identified in the area of Patient Rights. The hospital was notified of this finding on 3/21/19 at 10:41 AM. The Hospital submitted an IJ removal/abatement plan on 3/21/19 at 2:17 PM alleging removal as of 3/21/19 at 2:15 PM. The plan was accepted and the hospital was notified at 2:45 PM on 3/21/19. Surveyors were on site and reviewed for IJ removal. It was determined that IJ had been removed on 3/21/19, at 7:00 PM, based on the steps the hospital had taken. The hospital was notified of this finding at 7:05 PM on 3/21/19.

Findings include:

Patient 16 was admitted to the hospital on 3/6/19 with suicidal ideation.

1. A review of patient 16's electronic medical record was completed on 3/26/19.

On 3/7/19 at 3:06 AM, registered nurse (RN) 1 entered the following note in patient 16's electronic medical record, "...During her assessment she mentioned how she felt that another pt (patient) was watching her from the hallway. She rated her mood moderate...About 45 min (minutes) later she ran up to me in distress and said that this other pt had been in her room and walked u pto (sic) her bed and possibly touched her. She became extremely agitated and distrustful. She began saying she wanted to be discharged and that she didn't feel safe. There was no evidence to support that another pt was in her room. She started to pound on the door and demand to leave and that she would be filling (sic) a law suit. I was able to calm her eventually but it took a couple hours. She eventually fell asleep. Will continue to monitor." Note: No further information regarding this incident was placed in patient 16's electronic medical record by RN 1.

On 3/7/19 at 10:12 AM, RN 2 entered the following note in patient 16's electronic medical record, "At approximately 0835 (8:35 AM) patient brought concern to this writer about another male patient entering her room last night. Escalated this issue to unit director at approximately 0845. Police notified."

Additionally, when hospital staff contacted her husband after her discharge he informed staff, "She is struggling ... We would like to see the video ... (name of patient 16) is concerned she may not know exactly what happened because she had been given a sleeping pill that night."

2. On 3/19/19 the survey team reviewed the hospital incident log, and found one incident recorded on 3/7/19 by RN 2, no incident was found to be reported by RN 1. The survey team requested this incident report to review.

The incident report submitted by RN 2 on 3/7/19 at 10:32 AM revealed that on 3/6/19 at 10:00 PM an event occurred. RN 2 documented the following, "Pt alerted RN at0835 (sic), an uninvited male patient came into her room last night and 'touched my butt'. She states she told night shift, but was not satisfied with their response. Now asked me about speaking with the director or 'Security Director' today. She said 'A guard came and walked the halls for just 20 minutes, that's it, then no one'. Pt stated she does not feel safe. I notified unit director and unit manager of situation immediately following her request at 0845 this morning."

The incident report also included a note from the behavioral health unit director (BHUD) placed in the incident report on 3/7/19 at 11:01 AM and revealed the following, "I was notified of this incident upon arrival to the unit at approximately 0700 (7:00 AM). I immediately alreated (sic) the other staff about the incident and ensured that a staff member was stationed in the hallway at all time (sic). I reviewed video footage from 1800-2300 (6:00 PM to 11:00 PM). Upon review of video footage I did witness a male patient enter (name of patient 16)'s room at approximately 2238 (10:38 PM), he was in her room for approximately 35 seconds at which point I saw him exit the room quickly followed by (name of patient 16) approximately 3 seconds later. She alerted nursing staff of the incident, they followed up with her, ensured that the q(every)15 minute checks were completed and documented on time and allowed patient to keep her door shut after the incident. I interviewed the patient at approximately 0830 with the safety director. During her interview she stated ' I was given medicine to help me sleep and went to sleep at approximately 2130 (9:30 PM), around 1030 I felt a brushing sensation on my leg, I awoke and thought I saw a short overweight black male quickly leaving my room. It felt like he just touched my thigh and butt. I quickly went to the nursing station and told staff.' She stated during the interview that she would like to (sic) police contacted and that she wanted to press charges. PD (police department) was contacted and arrived to the unit at approximately 1000, they took statements from (name of patient 16) and the male suspect. They stated that there was not enough evidence to charge anyone with a crime at this time...Both patient are being assessed at this time 1100 3/7/2019 by their MD's (medical doctors) to decide appropriate level of monitoring and placement. A staff member will be stationed in the hallway at all times while male suspect is on the unit."

Lastly, the incident report included a note from the patient safety and risk manger (PSRM) dated 3/7/19 at 3:45 PM which read, "The male patient who entered (name of patient 16)'s room was discharged today and (name of patient 16) will be discharged later today. This was discussed with facility CNO (chief nursing officer) and CEO (chief executive officer), and will now be a police matter for any further investigation and follow up."

3. On 3/20/19 at 9:13 AM, an interview was conducted with the BHUD and hospital quality director (QD). The BHUD stated the incident involving patient 16 had been reviewed by him and was closed. The BHUD further stated his staff did everything they should have, including notifying him immediately. When asked when he was notified the BHUD stated "at about 7 (AM)" on 3/7/19. The BHUD stated he was aware that patient 16 reported the incident to the night shift staff on 3/6/19 and that staff continued to perform visual checks of each patient every 15 minutes and, "kept someone in the hall most of the night" to ensure "nothing else happened." The BHUD stated the night shift staff should have completed an incident report and informed the next shift during report. The BHUD confirmed an incident report had not been completed by night shift staff. The BHUD further stated the night shift staff performed increased monitoring by, "watching monitors" which were at the nurses station but that "they didn't do a great job documenting." The BHUD stated when a patient reported an allegation, as patient 16 had, the staff were to immediately contact him and ensure the patient was safe. The BHUD stated hospital security should also be informed. The BHUD stated because this incident happened on the night shift the house supervisor should have been notified of the incident. The BHUD stated he was not sure if the house supervisor or hospital security had been notified of the alleged incident on 3/6/19. The BHUD further stated they were having an in-service tonight to discuss incidents and what the expectations of the staff were. The BHUD stated he had not talked with RN 1, who was patient 16's nurse on the night of 3/6/19 "yet". The QD stated she would find out if the house supervisor and/or security was informed of the incident.

4. On 3/20/19 at 10:14 AM, the QD provided the survey team with two incident reports from the hospital security regarding patient 16. The QD stated that when security was initially contacted, on 3/6/19, it was called in as "man-power" needed because patient 16 "was agitated". The QD stated when security was notified it was a possible "sexual assault" a new incident report was completed. The QD further stated she had reviewed the house supervisor logs and could not find that they had been notified of the incident.

The incident reports were reviewed on 3/20/19.

The first incident report dated 3/6/19 at 10:38 PM revealed the following information, "I was called by RN (name of RN 3) to the Adult Behavioral Unit at 2238 (10:38 PM) when a problematic patient was asking to review footage of her room ((407)). (Name of RN 3) asked be to do a walk through of the unit just to calm the patient down. When I arrived (name of RN 3) told me the patient was claiming that another male patient had entered her room, and left. I walked down the hall, and the patient approached me asking if I could help her get out of the unit so she could contact a lawyer. She accused the patient in the room across from her of entering her room while she was sleeping and wanted to review footage of her room. I told her I can't show her footage, but I could keep an eye on the cameras to make sure that didn't happen. The patient got angry with me that I didn't do as she asked, and stormed off down the hall. I went to the nurses station, and RN (name of RN) told me that it was her who had entered the patients room to do her regular Q-15's, and that she had already tried telling this to the patient but the patient wouldn't listen. We then heard the patient tapping on the glass on the doors entering the unit trying to get the Ortho(orthopedic)/Spine staff's attention. I approached her and told her she wasn't allowed past the red line and that she shouldn't be tapping the glass. She argued with me that security was useless since I wouldn't let her out, and started to change her story about what the other patient had done while in her room, now saying he was 'tapping her shoulder', even though this wasn't initially told to us. RN (name of RN) assured the patient that it was her who had entered the room and even showed her the Q-15 log. The patient wasn't happy, but eventually stormed off to her room. The nurses told me the patient was most likely trying to be manipulative in order to get herself out of the unit, and that reviewing camera footage probably wasn't needed. I left the adult BHU (behavioral health unit) when everything calmed down at 2315 (11:15 PM)."

The second incident report dated 3/7/19 at 8:30 AM, revealed the following information, "At approximately 0800 (8:00 AM) hours, I was notified by BHU Director (name of the BHU director) that an incident had occurred last night on adult psych. I responded to adult psych with security manager (name of security manager). While enroute to adult psych, I told (name of security manager) that security officer (name of security officer) had told me about the incident that occurred on adult psych last night where a female patient stated that a male patient had entered her room. I was informed that the patient was demanding to see security video footage and was making threats about suing the hospital. (Name of security officer) told me that they could not confirm that the male patient had entered her room. He told me that staff had showed the female patient the Q 15 report after the patient had demanded to see it".

...I spoke with (name of the BHUD and the PSRM) and they confirmed that the male patient had entered the female patient's room They said that the female patient wanted to report the incident to Bountiful police and press charges...Bountiful police officer (name of officer) arrived and interviewed the female patient in the conference room outside the adult psych unit.. The female patient said that she was sleeping and she was awaken (sic) when she felt something touch her on her upper thigh below her buttocks...She stated when she woke up, the patient from across the all in room 406 was in her room. She stated that he immediately ran out of her room and began walking the hallway like nothing had happened. She stated that she immediately reported the incident to staff and that security arrived on the floor. She stated that she was told by staff that nobody entered her room. She stated that security stayed on the floor for approximately 30 minutes and then left...

...The male patient from room 406 was also interviewed by officer (name of officer). He stated that he did not enter the female patient's room to his knowledge. He stated he is a paranoid schizophrenic and that he could have entered the room but that he didn't think he did... Officer (name of officer) stated that he did not have enough information to file any criminal charges and would file the report for informational purposes only...

... A plan was put in place to have hospital staff do a line of sight on the male patient until they can figure out what to do with both patients."

5. On 3/20/19 at 10:20 AM, the camera footage of the psychiatric unit hallway from 3/6/19 at 10:30 PM to 3/7/19 at 9:07 AM was reviewed with the security manager (SM) and QD. The following was observed:

a. At 10:31 PM, a male patient, patient 28, was observed to walk in front of the doorway to patient 16's room and look into her room for approximately 2 to 3 seconds. He was observed to look up and down the hallway multiple times prior to and after looking into patient 16's room.

b. At 10:35 PM, patient 28 was again observed outside patient 16's room looking up and down the hallway multiple times. Patient 28 then appeared to step just inside the doorway of patient 16's room for approximately 2-3 seconds and again walk away.

c. At 10:37 PM, patient 28 was observed to enter patient 16's room and remain in her room for 34 seconds. Patient 28 was then observed to quickly exit her room and enter the room directly across the hall. Per the QD, the room patient 28 entered was his assigned room. As soon as patient 28 entered the room across the hall, patient 16 was observed to quickly exit her room and walk towards the nurses station at the front of the unit. A nurse, RN 1 per interview with QD, was then observed to follow patient 16 back to her room. RN 1 was observed in patient 16's room for approximately 5-10 seconds, he then went back to the front nurses station.

d. From 10:38 PM to 10:43 PM, patient 16 was observed to be in and out of her room multiple times, as well as looking out from her doorway up and down the hall on multiple occasions.

e. At 10:43 PM, RN 1 was observed to walk back to patient 16's room with patient 16 from the front nurses station.

f. At 10:45 PM, a security officer was observed to enter the unit and begin walking the hall.

g. At 10:49 PM, RN 1 was observed to exit patient 16's room. Shortly, after patient 16 was observed to be talking with the security officer near the entrance of the unit. After talking with the officer, patient 16 was observed to be at the doors to the unit.

h. At 10:55 PM, patient 16 was observed to enter her room and the nurse is observed locking the door to her room. The QA director stated staff locked her door for her safety, but that she could exit anytime. The QA director further stated anyone entering patient 16's room would need a key to enter.

Note: Throughout this time patient 28 was observed to enter his room, leave his room, walk the halls, and then re-enter his room multiple times.

i. At 10:56 PM, patient 28 was observed to be talking with an aide, RN, and security officer in the hallway near the front nurses station.

j. At 10:57 PM, patient 16 was observed to exit her room and walk down the hallway to the area outside the front nurses station. The security officer and RN 1 are observed to be in the hallway outside of the front nurses station. Patient 28 is observed to be on the opposite side of the hall in the area outside of the front nurses station.

k. At 11:02 PM, patient 16 was observed to walk back to her room and enter her room.

l. At 11:03 PM, patient 28 was observed to walk back down to his room and enter his room.

m. At 11:08 PM, the security officer was observed to leave the unit.

Note: The security officer was on the unit for approximately 23 minutes.

n. At 11:09 PM, patient 28 was observed to exit his room and walk down the hall to the area outside of the front nurses station. No staff members were observed in the hallway. Patient 28 walked back to his room at 11:10 PM, again no staff were present in the hallway.

o. At 11:20 PM, during what appeared to be a 15 minute visual check of each patient, a nurse is observed to unlock patient 16's door and perform a visual check, the nurse did relock her door.

Note: Patient 16's door was locked for 25 minutes.

p. At 11:43 PM, during what appeared to be a 15 minute visual check of each patient, RN 3 was observed to unlock patient 16's door and perform a visual check, RN 3 was not observed to relock patient 16's door.

q. From 11:51 PM to 12:00 AM, a hospital technician stood in the hallway outside of the front nurses station.

r. At 11:57 PM, RN 1 was observed to enter patient 16's room without having to unlock the door.

s. At 12:03 AM, RN 1 was observed to exit patient 16's room without locking her door as he left.

t. At 12:04 AM, RN 1, RN 3, and the technician were observed to exit the nurses station at the front of the unit and go to the nurses station at the back of the unit.

At 10:55 AM, during the review of the camera footage, the BHUD entered the security office. The BHUD stated unit staff had locked patient 16's door to ensure her safety. When the surveyor informed the BHUD that per hospital camera footage patient 16's door had only been locked for 25 minutes he responded, "O, really?".

At 10:56 AM, during the review of the camera footage the QD stated the hospital had actually not closed out the incident yet. The QD further stated, "we have 60 days per the PSO (contract with the patient safety organization) to investigate". When the surveyor asked how during that 60 day review period they were protecting patients to ensure this did not happen again the BHUD stated he had "talked" with staff about the incident but could not provide evidence of this. The BHUD then stated he had talked to staff about reporting incidents to him "immediately" and "more thorough assessments". When asked what was meant by more thorough assessments the BHUD stated, "If they would have called me I would have come in and figured out an appropriate plan."

Note: When the BHUD was interviewed earlier in the day, he did not inform the surveyor that staff education had occurred. In fact he stated training would be completed tonight (3/20/19).

At 11:00 AM, the QD stated she had reviewed the house supervisor logs and could not find that they had been notified of the incident. The QD confirmed the house supervisor should have been informed of the incident on 3/6/19.

u. From 12:17 AM to 5:25 AM, approximately every 15 minutes staff were observed to perform visual checks of each patient. The QD confirmed during this time patient 16's door was not locked and staff were not observed to remain in the hallway. The QD stated staff were watching the monitors in the nurses station which gave them a visual of the hallway and each patient room. The QD confirmed this could not be verified because there were no cameras in either of the nurses station.

v. From 5:25 AM to 6:19 AM, unit staff were not observed to complete 15 minute visual checks on each patient. The QD and SM confirmed during this timeframe staff were not observed to complete visual rounds on each patient. The QD confirmed patient rounding should have been completed during this timeframe. The QD also confirmed staff were not observed to be stationed in the hallway to observe patients.

At 11:38 AM, the SM stated he was informed by his security officer who was on shift during the night of 3/6/19 that he had been called up to the psychiatric unit, but that he was called up for an agitated patient not a possible sexual assault.

w. At 7:20 AM, the BHUD was observed to enter the unit and talk with the day shift technician in the hallway.

x. At 7:32 AM, patient 16 was observed to exit her room and go down the hallway to the area outside of the front nurses station.

y. From 7:32 AM to 8:32 AM, patient 16 was observed to enter and exit her room on multiple occasions. Staff members were observed to be in the hallway at all times during this time. At 8:32 AM, patient 28 was observed in the hallway at the same time as patient 16. Patient 16 was observed to quickly walk past him.

z. At 8:33 AM, RN 2 was observed to enter patient 16's room.

aa. At 9:04 AM, the SM was observed to enter the unit.

bb. At 9:06 AM, the BHUD, the PSRM, and a security officer were observed to enter the unit.

cc. At 9:07 AM, the BHUD and the PSRM were observed to enter patient 16's room.

6. On 3/20/19 at 4:40 PM, an interview was conducted with RN 3. RN 3 confirmed she was working on the BHU on the night of 3/6/19. RN 3 stated that patient 16 came out of her room and said a patient, patient 28, came into her room. RN 3 stated that she did not remember patient 28 being around the patient 16's room. RN 3 stated the patient 28 usually hung out around the nurses' station and she did not remember him leaving his usual spot. RN 3 stated that she told patient 16 she would not let it happen again and "I'd keep her safe". Then patient 16 told RN 3 that she was touched by patient 28. RN 3 stated she asked what patient 16 meant by that and stated, "you know touched me". RN 3 again stated she informed patient 16 she would not let that happen and she would keep her safe. RN 3 stated that they kept patient 16 safe by completing 15 minute checks and watched patient 28 closely. RN 3 stated security talked to patient 16. RN 3 stated that patient 16 thought security was going to be there all night be he could not do that because he was the only security officer on that night. RN 3 was not positive if patient 16 reported to security that she had been touched. RN 3 stated that patient 16 mostly talked to RN 1. Security filed a report but RN 3 did not know if RN 1 had filed one.

On 3/20/19 at approximately 4:40 PM, an interview was conducted with RN 2. RN 2 confirmed she worked the day shift on 3/7/19. RN 2 stated patient 16 came to her when she woke up around 8:30 AM, and was very upset and distressed. RN 2 stated patient 16 did not make a lot of sense because she was so upset, but stated that a large black shadow entered her room and touched her butt. RN 2 stated she told her supervisor and that her supervisor was reviewing the tapes at that time. RN 2 stated that patient 16 stated that she may have had a sleep pill that night so it was all fuzzy to her.

7. Patient 28 was admitted to the hospital on 3/5/19

A review of patient 28's medical record was completed on 2/26/19.

On 3/7/19 at 3:06 AM, RN 1 entered the following note in patient 28's electronic medical record, "Pt has been walking the hallway most of the evening. He was watched carefully as he had a history of wandering into others rooms. But no behavior like that was seen...His interaction with another pt in which he was accused of going into her room did add uneeded (sic) stress to him. But he handled it well. He was concerned about legal issues if he were 'targeted' by these problems and if he would be in legal trouble. I alleviated his concerns and he went to slee (sic) well..."

Based on interview and record review it was determined that the Hospital did not ensure that certified registered nurse anesthetists (CRNAs) were under the supervision of the operating practitioner or an anesthesiologist who was immediately available.

Findings include:

On 3/20/19 at 8:15 AM, an interview was conducted with the chief nursing officer (CNO) concerning the hospital oversight and supervision of the CRNAs. The CNO stated that the hospital has anesthesiologists on call each day and most would be available to come in to assist within 5 minutes if there was a need.

The CNO stated that the hospital only used the CRNAs in labor and delivery. The CNO stated that the obstetrician would normally be the one to supervise the CRNA. The CNO further stated that the hospital did not have a policy or procedure concerning the supervision of the CRNAs nor did they have signed documentation to indicate that the physicians agreed to supervise the CRNAs and assist as necessary.