HospitalInspections.org

Based on document review, video review, policy review, record review and interview, the hospital failed to ensure all Patients Rights were promoted and patients received care in a safe setting for 2 of 2 (Patient #1, and #2) patients who sustained injuries while in the care of staff.

The findings included:

1. Review of Hospital Policies included the following:
The Organization Plan for Patient Safety with a revised date of 09/2011 and a last approved date of 03/2021 detailed the hospital's guidance for ensuring the well-being of patients.
The Patient Observation Guidelines with a revised date of 06/2021 and last approved date of 06/2021 detailed the hospital's guidance for ensuring the safety of all patients by routinely observing them and documenting the observations.
The Patient Abuse or Neglect Policy with a revised date of 12/2015 and a last approved date of 02/2021 detailed the expectation of staffs treatment toward patients, reporting of incidents and examples of abuse and neglect.
The Alleged Patient Abuse, Neglect, Exploitation Policy with a revised date of 19/2021 and a last approved date of 11/2021 which detailed definitions, reporting, consequences for not following the policy and details for the investigation including the components and documentation to be maintained in a file.

Review of the Handle With Care Instructor Manual with a last copyright date of 2006 is the hospital's choice for training behavior management, proper personal-defense releases, blocks, restraint techniques, escort techniques and detailed post crisis de-briefing

2. Medical Record Review revealed Patient #1 was involuntarily admitted to the hospital on 2/28/22 with diagnoses which included Schizoaffective Disorder - Bipolar type. Patient #1 was well known to this hospital with a history of thirteen (13) past inpatient hospitalizations. Patient #1 was 59 years old and lived in a group home.

Review of the Medical Screening Exam dated 2/28/22 revealed Patient #1 was alert and oriented.

Review of the Nursing Admission Assessment dated 3/1/22, revealed Patient #1 was independent with eating, bathing, dressing/grooming, toileting, ambulation and transferring.

The Mental Status Assessment revealed Patient #1 was alert and oriented to person, place, time and situation and well-groomed.
Patient #1 scored 71 and was not considered a fall risk.(A score of 90 or greater was considered a fall risk).

A Nursing Admission Narrative Summary dated 3/1/22 revealed Patient #1 was admitted for delusions and aggression at the group home.

On 3/5/22, Patient #1 complained of hip pain that had started the evening before on 3/4/22. The patient stated she was pushed by staff while her bed was being changed. Patient #1 reported the staff picked her up and put her back in bed. There was no documentation of this incident in patient #1's medical record.

Patient #1 was transferred to an acute care hospital 2 days later and diagnosed with a hip fracture.

3. Medical Record Review revealed Patient #2 was involuntarily admitted to the hospital on 4/20/22 with diagnoses to include Psychosis, Bipolar Disorder, Intellectual Disability. Patient #2 was 22 years old and lived in a group home.

Review of the Medical Screening Exam dated 4/20/22 revealed Patient #2 was alert, cooperative and oriented. The patient's significant medical history included Autism,
Post Traumatic Stress Syndrome (PTSD), Attention-deficit/Hyperactivity disorder (ADHD) and Schizophrenia. Patient #2 denied thoughts of suicide, and homicide.

Review of the Standardized Intake Assessment dated 4/20/22 revealed Patient #2 was brought to this hospital by police after making suicidal threats and, "pt [Patient
#2] made a suicidal statement after becoming angry. Staff reports pt has been making suicidal threats for the past week. Pt. denies current SI [Suicidal Ideation] ...Pt denies current SI but appears to display poor impulse control ...Pt has hx [history] of assaultive behaviors ...Pt ran away from GH [Group Home] yesterday ...HISTORY OF TRAUMA ...mother shot pt's older brother in front of him ...additional comments ...Pt jumped out of a moving car last night & was banging his head on a tractor ...Adoptive parents stated pt has a hx of violence and does not like authority or women ...Group home manager stated pt has been verbally aggressive towards staff & this was the first time he assaulted a staff member. Pt was on his way to get booked for a vandalism charge when this episode occurred today. Pt is IDD [Intellectual Disability Disorder] moderate level per GH staff manager ..."

Review of the Nursing Admission Assessment dated 4/20/22 revealed, " ...I got mad I wanted to go home and could not - so I threw and broke something. I have not been taking my medication and some girl has been bothering me. Denies hallucinations. Given verbal plan of safety. Pt autistic ...noise and people easily upset him ..."

On 4/22/22 Patient #2 was on 1:1 observation. Staff interviews revealed Patient #2 had allegedly grabbed a bedsheet and quickly wrapped it around his neck. The two Care Coordinators (CC) who were with the patient at the time (CC #2 and CC #3)stated they immediately removed the sheet from around the patient's neck. There was no report of the patient's attempt to injure himself. After the incident, Patient #2's shoulder appeared to be drooping. Patient #2 was not assessed following the alleged incident with the sheet for greater than 12 hours. On 4/23/22, Patient #2 was assessed by an oncoming nurse who transferred the patient to an acute care hospital where the patient was diagnosed with a fractured clavicle.

4. Review of a video dated 5/5/22 of the East Womens Day Room revealed CC #10 had left a rolling office chair in the Day Room. Patient #4 was agitated and grabbed the chair. CC #10 attempted to get the chair from Patient #4. Patient #4 pulled herself away from CC #10 and fell to the floor. There was no documentation that Patient #4 was injured. By leaving a rolling chair in reach of an agitated patient put patients and staff in danger of injury and was not a safe environment for patients.

5. Review of a video dated 5/5/22 of the East Womens Day Room revealed CC #13 pushed a female patient by the neck which caused the patient to fall backwards into a chair. This incident was not reported and was not identified for investigation. The patient was not physically injured in the video. The patient's identity is unknown but viewed on the video and identified as Patient #14.

6. Review of a video dated 5/7/22 of the East Cafeteria revealed CC #13 threw a clipboard at a female patient. This incident was reported to administration on 5/10/22. The patient was not physically injured in the video. The patient's identity is unknown but viewed in the video and identified as Patient #15. This incident was verbally reported to this surveyor during a telephone interview with the complainant (Complaint #57571) on 5/13/22.

CC #13 was terminated on 5/12/22 for the above incidents.

Refer to A-0144

Based on document review, policy review, record review and interview, the hospital failed to ensure patients received care in a safe setting for one (1) of one (1) (Patient #1) patients who sustained a hip fracture while being cared for by hospital staff and failed to ensure patients who exhibited self-injurious behaviors were closely monitored to prevent injuries for one (1) of (1) (Patient #2) sampled patients sustaining a fracture to the left clavicle after allegedly attempting to injure himself.

The findings included:

1. Review of the hospital's policy titled, Organization Plan for Patient Safety with a revised date of 09/2011 and a last approved date of 03/2021 revealed, " ...When actual or potential undesirable conditions or events occur, we respond immediately to assure the safety and well- being of patients, visitors and staff ...When sentinel events occur, or conditions are discovered that may contribute to such events, leaders and staff most knowledgeable about the process or system contributing to the event or condition, participate in conducting a root cause analysis to determine the underlying case ..."

2. Review of the hospital's policy titled, Patient Observation Guidelines with a revised date of 06/2021 and a last approved date of 06/2021 revealed, " ...All patients will be routinely observed in compliance with physician orders and prescribed protocols ...Observe patient on bedrest or when sleeping by ...making sure that the patient has moved from his/her previous sleeping position ...Staff will document the client's location on the observation sheet at a minimum, every 15 minutes ...1:1 Observation ...Guidelines for implementation of this level of observation include ...1 [one] staff member assigned to 1 [one] patient ...Staff should attempt to interact or otherwise engage the patient when assigned to 1:1 ...Medical Record documentation for this level of observation includes ...AA progress note entry by a nurse should be documented in the medical record at least every shift reflecting the patient's condition and/or changes in patient status ..."

3. Review of the hospital's policy titled, Patient Abuse or Neglect with a revised date of 12/2015 and a last approved date of 2/2021 revealed, " ...PURPOSE To foster professional responsibility on the part of the employee ...POLICY ...Staff member will demonstrate kindness, empathy and acceptance of each current and former patient regardless of the patient's behavior, needs or problems. Inappropriate staff conduct is not tolerated ...PROCEDURE ...Inappropriate staff conduct may include, but is not limited to ...Any physical violence which may result in injury such as ...rough handling ...Yelling, threatening remarks ...Not performing duties safely, omitting needed care and treatment ...Repeatedly failing to respond to patient's request ...Failing to report a patient's request or complaints ...Performing any type of physical contact with a patient, which is not specifically within the context of clinical therapeutic activities ...Not being aware of patient needs ...Reporting of Incidents The patient or anyone aware may report incidents of inappropriate staff conduct to ...Any staff member ..."

4. Review of the hospital's policy titled, Alleged Patient Abuse, Neglect, Exploitation with a revised date of 1/2021 and a last approved date of 11/2021 revealed, " ...It is the policy of [Named Hospital] to report all incidents of patient abuse, neglect, and exploitation by a caregiver as soon a possible to appropriate agencies ...The definition for "Abuse" includes ...Any act or failure to act by an employee of a hospital which was performed or which was failed to be performed knowingly, recklessly, or intentionally and which caused or may have caused, injury ...to a patient by a caregiver, and includes such acts as ...the striking of a patient ...the use of excessive force when placing a patient in bodily restraints ...The definition for "Neglect" includes: An act or omission by an individual responsible for providing services in a hospital which caused or may have caused injury ...by a caregiver and includes an act or omission such as ...The failure to provide adequate ...health care to a patient ...The failure to provide a safe environment for a patient ...There is a duty to report incidents that occur at a facility when one "reasonably believes or who knows of information "that would reasonably cause a person to believe such abuse or neglect by a caregiver, has or would occur ...The following action shall be taken if any staff member identifies or suspects patient abuse, neglect or exploitation ...Report allegations immediately to the Director of Nursing and the Nurse Executive ...Document information on an Incident Report Form ...Assessment ...Continuous support and monitoring of alleged victim ...A Nursing assessment/reassessment post incident will be completed ...Internal Medicine will be notified of the incident and perform an assessment/reassessment ...Investigation ...An internal investigation shall be conducted by DRM [Director of Risk Management] ...and a written report of findings will be documented. Documentation of all investigations shall be maintained to include: written statements surveillance/security tape, as available copies of external reports, and secure crime scene if applicable ...Should the internal investigation substantiate patient abuse, neglect, or exploitation, disciplinary action shall be implemented with Hospital policy ...Failure to comply with these requirements may be grounds for revocation of a facility's license ..."

5. Review of the hospital's policy titled, Reassessment with a revised date of 03/2014 and a last approved date of 03/2021 revealed, " ...Reassessment is conducted by a Registered Nurse every 24 hours at a minimum. Additionally, reassessment occurs in the following circumstances ...Change in the patient's condition ... physical complaint ...Allegations of Abuse and Neglect ...Patient injuries ...R.N. findings from the reassessment are documented in the patient's chart..."

6. Medical Record Review revealed Patient #1 was involuntarily admitted to the hospital on 2/28/22 with diagnoses which included Schizoaffective Disorder-Bipolar type. Patient #1 was well known to this hospital with a history of 13 past inpatient hospitalizations. Patient #1 was 59 years old and lived in a group home.

Review of the Medical Screening Exam dated 2/28/22 revealed Patient #1 was alert and oriented.

Review of the Nursing Admission Assessment dated 3/1/22 revealed Patient #1 was independent with eating, bathing, dressing/grooming, toileting, ambulation and transferring.

The Mental Status Assessment revealed Patient #1 was alert and oriented to person, place, time and situation and well-groomed. Patient #1 scored 71 and was not considered a fall risk. (A score of 90 or greater was considered a fall risk).

Review of Nursing Flow Sheet Progress Record dated 2/28/22 through 3/2/22 revealed Patient #1 voided self. No assistance needed.

Review of Nursing Flow Sheet Progress Record dated 3/3/22 revealed Patient #1 voided and had a bowel movement by self with no assistance needed.

Review of Nursing Flow Sheet Progress Record dated 3/4/22 at 5:00 AM revealed, " ...Pt up and down throughout night ...Removing clothes frequently ..."

Review of Nursing Flow Sheet Progress Record dated 3/5/22 at 4:15 PM revealed, " ...Lying in bed. Has urinated on self ...Changed clothes and transferred to clean bed, in process pt c/o [complained of] pain in hip ...States it has been hurting since last night [3/4/22] ...Will notify MD of status per charge nurse ..." The physician ordered a portable xray of the patient's hip. There was no documentation the portable xray was performed. There was no documentation of other assessments of the patient's hip pain.

Review of a Patient Observation sheet dated 3/6/22 documented Patient #1 was "Walking/Pacing" in her room at 4:30 PM. (The patient was unable to get out of bed and walk due to the hip pain noted on 3/5/22. The Patient Observation entry was inaccurate).

Review of a Patient Observation sheet dated 3/6/22 documented Patient #1 was walking/pacing in the hall at 6:00 PM, sitting in the hall at 6:15 PM and walking in the hall at 6:30 PM. Review of the hospital's video footage for 3/6/22 from 6:00 PM to 7:00 PM revealed Patient #1 did not come out of her room and walk or sit in the hallway. The Patient Observation entries were inaccurate.

On 3/7/22 Emergency Medical Services (EMS) was called to transport Patient #1 to an acute care hospital.

Review of the EMS Incident Report dated 3/7/22 revealed, " ...ES [EMERGENCY SERVICES] CALLED BY HEALTHARE PROVIDER ...FOR HIP PX [PAIN] X [TIMES] 3 DAYS. PTS [PATIENT'S] L [LEFT] HIP IS OBVIOUSLY CONTORTED/TWISTED WITH SWELLING NOTED. PT. LAYING IN URINE SOAKED BED. FACILITY STAFF COULD NOT EXPLAIN TO EMS HOW OR WHEN INJURY OCCURRED. PT IN OBVIOUS PX [PAIN]. 20G INT [20 GAUGE INTERMITTENT NEEDLE THERAPY] EST [ESTABLISHED] R [RIGHT] FOREARM ...25MCG [25 MICROGRAMS] FENTANYL IV [INTRAVENOUS] FOR PX ...PT PLACED ON A SCOOP STRETCHER AND PLACED ONTO EMS COT ...PT MOVED TO EMS UNIT. V/S [VITAL SIGNS] MONITORED AND PT TRANSPORTED ..."

Patient #1 was transported via ambulance to an Acute Care Hospital on 3/7/22 at 10:37 AM. Patient #1 was admitted and had surgery to repair the Left hip fracture.

During an interview on 4/28/22 at 2:45 PM, the Director of Process Improvement was asked about Patient #1's injury and how it occurred. The Director of Process Improvement stated that Patient #1 had changed her story multiple times and after their investigation it could not be determined how the injury occurred.
A copy of the Facility investigation was requested, however only an undated "Investigation Summary Form" was submitted with 3/7/22 documented as the date of the incident. The summary did not contain all the components of a complete investigation as outlined in the Hospital's Alleged Patient Abuse, Neglect, Exploitation Policy. The saved video footage submitted to this State Agency began on 3/5/22 at approximately 12:00 AM, however, a nursing note dated 3/5/22 revealed Patient #1 stated the pain began sometime the evening of 3/4/22. The video did not contain footage of staff or patients entering and exiting Patient #1's room on the evening of 3/4/22. There was no documentation the video was watched beginning on the afternoon/evening of 3/4/22. There was no documentation that Nursing was re-educated regarding assessments for potential injuries and pain assessments following a report of an altercation, incident or accident. There was no documentation regarding Patient #1 complaining of pain on 3/5/22 but no pain medication was administered until 3/6/22. There was no documentation the Hospital was aware the x-ray order that was written on 3/5/22 was not called in to the x-ray company until 3/7/22 (2 days later). There was no documentation Nursing was re-educated on timely follow-up with MD orders. The Hospital investigation provided to this surveyor was not a thorough investigation for Patient #1.

7. Medical Record Review revealed Patient #2 was involuntarily admitted to the hospital on 4/20/22 with diagnoses which included Psychosis, Bipolar Disorder, Intellectual Disability. Patient #2 was 22 years old and lived in a group home.

Review of the Medical Screening Exam dated 4/20/22 revealed Patient #2 was alert, cooperative and oriented. The patient ' s significant Medical History included Autism, PTSD (Post Traumatic Stress Syndrome) ADHD (Attention-deficit/Hyperactivity disorder) and Schizophrenia. The Medical Exam documented that Patient #1 denied thoughts of suicide, and homicide.

Review of the Standardized Intake Assessment dated 4/20/22 revealed Patient #2 was brought to this hospital by police after making suicidal threats, "pt made a suicidal statement after becoming angry. Staff reports pt has been making suicidal threats for the past week. Pt. denies current SI [Suicidal Ideation] ...Pt denies current SI but appears to display poor impulse control ...Pt has hx [history] of assaultive behaviors ...Pt ran away from GH [Group Home] yesterday ...HISTORY OF TRAUMA ...mother shot pt's older brother in front of him ...additional comments ...Pt jumped out of a moving car last night & was banging his head on a tractor ...Adoptive parents stated pt has a hx of violence and does not like authority or women ...Group home manager stated pt has been verbally aggressive towards staff & this was the first time he assaulted a staff member. Pt was on his way to get booked for a vandalism charge when this episode occurred today. Pt is IDD [Intellectual Disability Disorder] moderate level per GH staff manager ..."

Review of the Nursing Admission Assessment dated 4/20/22 revealed, " ...I got mad I wanted to go home and could not - so I threw and broke something. I have not been taking my medication and some girl has been bothering me. Denies hallucinations. Given verbal plan of safety. Pt autistic ...noise and people easily upset him ..."

Review of a Nursing Flow Sheet/Progress Report dated 4/21/22 at 1:30 PM revealed, "pt has been sleeping, but is now walking in the hall. Calm and cooperative Medication compliant. Denies SI. On one to one observation ..."

Review of a Psychiatric Progress Note dated 4/22/22 at 6:15 AM revealed, " Pt has been aggressive and agitated Required PRN [as needed] meds yesterday and was placed on 1:1 ..." He denied suicidal and homicidal ideation.

Review of a Nursing Flow Sheet/Progress Report dated 4/22/22 at 10:00 AM revealed, " ...Calm and cooperative at this time-medication compliant. Denies SI. Remains in his room on one to one observation ...11:30 Pt [Patient] acting bizarre, talking to wall-trying to escape one to one tech. MD notified and order received ...12:50 Pt came to med window for meds. States he feels calm now ..." There were no further nursing notes for 4/22/22.

Review of a Daily Suicide Risk Assessments dated 4/21/22, and 4/22/22 revealed Patient #2 had no thoughts of suicide and no newly identified triggers. There was no documentation of self injurious attempts.

On 4/22/22 Patient #2 was on 1:1 observation. Based on staff interviews, Patient #2 allegedly grabbed a bedsheet and quickly wrapped it around his neck. The two (2) Care Coordinators (CC), identified as CC#2 and CC #3, who were in the room stated they had immediately removed the sheet from around the patient's neck.
There was no documentation of the patient's attempt to injure himself in the patient's medical record. Patient #2 was not assessed for the self-injurious behavior or assessed for injuries or pain following the alleged incident for greater than 12 hours.

A nursing progress record dated 4/23/22 at 08:40 AM revealed, "At or around 08:20 a.m. nurse went to patient's room to assess left arm due to patient complaining of pain and discomfort. Left arm was observed to be swollen and bruised. Pt. was unable to raise arm or extend left arm. Pt. complained of pain when touching the left shoulder area and was unable to squeeze the nurse's hand w/ his left hand without pain. Per pt he didn't fall or injure his arm himself ...". There was no documentation of Patient #2 allegedly wrapping a sheet around his neck the evening before. The nurse called Emergency Medical Services (EMS) and Patient #2 was transferred by ambulance to an Acute Care Hospital on 4/23/22 at 9:40 AM where the patient was diagnosed with a fractured clavicle.

Review of a Bartlett Police Department Incident Report dated 4/23/22 at 11:57 AM revealed, " ...Officer ...responded to ...[Named Acute Care Hospital] emergency room regarding an assault complaint. Upon arrival, I spoke with RN ...who stated the victim, [Named Patient #2] was transported from [Named Behavioral Hospital] for injuries sustained at ...East Unit. [Named RN] stated the victim was being treated for a broken left collar bone and bruising/abrasions associated with choking on the victim's neck. I then spoke with [Named Group Home house manager] who stated the victim is a resident of an assisted group home, is autistic and is currently diagnosed with schizophrenia, PTSD, and ADHD ...The complainant stated she received a call around 0830 from the victim on today's date, saying sometime the previous night. At the same time, in the East Unit of [Named Behavioral Hospital], he was assaulted by three unknown [Named Behavioral Hospital] staff members. When she called [Named Behavioral Hospital] concerning the incident, the complainant stated she spoke with [Named Staff Nurse] who advised the victim did sustain injuries and was being transported to [Named Acute Care Hospital] for treatment. [Named Behavioral Hospital] staff could not provide any other information at that time. At the time of the report, the only information the victim could provide was that two of the suspects were male black and one was male white, and the assault happened sometime during the evening on 04/22/22. The complainant ...contacted Adult Protective Services concerning the incident ..."

Review of the hospital's video recordings for 4/22/22 revealed the following:
6:19 PM to 6:28 PM - Patient is out on the smoker's patio. He is pacing back and forth, moving both arms and shoulders without any difficulty.

6:32 PM: Patient #2 goes into his room with linens and a food box in his hands with CC #2 (1:1).

6:51 PM: CC #3 watches from the doorway then goes into the room

6:53 PM - 6:55 PM: CC #3 threw linens and towels out into the hall multiple times.

6:55 PM: CC #3 leaves the room.

6:57 PM: CC #4 enters the room the door closes.
6:58 PM: the door opens and CC #4 leaves the room.

7:00 PM: CC #4 and CC #1 come to the door and stop. CC #3 comes to the door. CC #1 goes in room, CC #3 and CC #4 are in the doorway. CC #2 is still in the room.

7:01 PM: CC #3 walks down the hall. CC #1 walks down the hall. CC #4 is in the doorway.

7:06 PM: Patient #2 and CC #2 come out of the room and walk down the hall. Patient #2's left shoulder is drooping at an angle arm is hanging by his side. He is not moving his left arm.

7:07 PM: Patient #2 was holding his left shoulder/clavicle area with his right hand and his left arm was hanging by his side.

Based on the video footage detailed above, Patient #2 sustained an injury to his left shoulder/clavicle area while in his room between 6:32 PM and 7:06 PM. Staff Members CC #1, CC #2, CC#3, and CC#4 were each in Patient #2's room at some time on 4/22/22 between 6:32 PM and 7:06 PM (34 minutes).
There was no documentation staff had assessed the patient's shoulder/clavicle area on 4/22/22.

Review of CC #1, CC #2, CC#3, and CC#4's personnel file confirmed each of them had been through and passed the Handle With Care Behavior Management System and were trained in proper hold techniques.

A copy of the Facility investigation was requested, however only an undated "Investigation Summary Form" was submitted with the date of the incident documented as "4/26/22 ?" Review of the Hospital's Investigation Summary Form did not contain al the components of a complete investigation as outlined in the Hospital's Alleged Patient Abuse, Neglect, Exploitation Policy and revealed no report of findings, no written statements of any witnesses, no copies of any external reports (i.e. Acute Care ER documentation). No documentation that any staff were relieved of duty pending the outcome of the investigation. The investigation did not reveal any findings as to whether there was any substantiated or unsubstantiated abuse, neglect or exploitation regarding Patient #2's injuries. There was no documentation of a physical review of any holds that were placed on Patient #2 during the incident were done inappropriately. There was no documentation any staff were re-trained in "Handle With Care" Behavioral Management System. There was no documentation that Nursing was re-educated regarding assessments for potential injuries and pain assessments following a report of an altercation. The Hospital investigation provided to this surveyor was not a thorough investigation for Patient #2.

Review of a Progress Record dated 4/26/22 at 6:00 PM revealed, " ...Late Entry On 4/22/22 @ [at] approx. 1907 [7:07 PM] staff walked [Named Patient #2] to nurses station and reported to nurse that [Named Patient #2] attempted to harm himself by wrapping his sheet around his neck. Staff reports taking sheet from around [Named Patient #2] neck without incident. Staff placed sheets outside [Named Patient #2's] door and walked him to nurse to report incident. No injury noted to [Named Patient #2] and he denied pain at that time. 1:1 for safety ...Continue to monitor for mood and behavioral changes ..."
This "late entry" was written 4 days after the incident occurred and is the only documentation in the medical record of Patient #1 allegedly attempting to harm himself.

During an interview on 5/4/22 at 10:45 AM, CC #5 was asked about the incident with Patient #2, and CC #5 stated, " ...He was laying on his right side facing me. He was laying and breathing. No physical interaction on the morning he reported to the nurse. He told her he had some pain ..."
CC #5 was asked if Patient #2 ever got up during that night after the altercation and CC #5 stated, "Possibly could have gotten up. I don't remember. [named CC #7] relieved me some during the night. I don't remember if he was wearing a hat that night ..."

During an interview on 5/4/22 at 11:00 AM, the Nurse Practitioner (NP) was asked about the incident with Patient #2. NP stated he met with Patient #2 alone in his room after he returned from the acute hospital emergency department. The NP stated, " ...The nurse was adamant that I come to see him".
The NP stated that Patient #2 told him that he was in the bathroom and a staff member told him to get out of the bathroom. The patient stated they [unknown who "they" are] were yelling at him to come out of the bathroom; and said that he was probably in the bathroom too long because he was taking a shower. The NP was asked if Patient #2 was scared and the NP stated that Patient #2 said he wanted to go home. The NP stated Patient #2 seemed preoccupied with the doorway and the patient kept looking over the NP's shoulder towards the door. The NP stated Patient #2 did not want anyone touching his arm. The NP stated Patient #2 was, " ...like a 10 year old. I never saw an aggressive side. He was a happy guy. Sometime he would get excited about what he was trying to say and get loud and I would just remind him that I was right there and not to talk so loud and he was always receptive to my re-direction and he would say ok, ok and lower his voice."

During an interview on 5/4/22 at 12:29 PM, Nurse #1 was asked to describe her involvement with Patient #2 regarding his injury and Nurse #1 stated, " ...When I walked down there [Patient #2's room], [named CC #5] the 1:1 was in the chair and blocking the door. No covers were on his [Patient #2's] bed... I asked [CC #5] "What's going on" and [CC #5] said "He's [Patient #2] not talking about anything". The Nurse then stated that Patient #2 jumps out of bed when he saw me and grabbed his left arm and said, "My arm, my arm"... I asked [CC #5] again "what's going on" and he said "nothing". [CC #5] kept brushing [Patient #2] off saying to [Patient #2] "sit down and shut up"...[Patient #2] said, "that guy in the black hat", he said it 2 times ..."
Nurse #1 then stated the staff member who was wearing a black hat was down the hall and when Patient #2 saw that staff member the patient ran towards his bed.
Nurse #1 stated that CC#5 told the patient to "sit down". Nurse #1 stated that she approached the staff member who was wearing the black hat and it was CC #7. The nurse stated that CC #7 said, "I don't want any part of this, people are confusing me with [named someone else]. Nurse #1 confirmed the Chief Nursing Officer (CNO) called her that morning and asked her to interview the patient. Nurse #1 went to assess and interview the patient in his room. Nurse #1 Stated, " ...I asked Patient #2 what had happened. Patient #2 stated it happened yesterday evening and he started getting scared and started crying. I left the room and called the CNO to notify her of my assessment of the injury. She advised me to call the Physician. I called the Nurse Practitioner and orders were given to send [named Patient #2] to [Named Acute Care Hospital]. I went back in the room and [named Patient #2] stated he was in the shower for 3 minutes and the white staff told me to get out of the shower. "They threw me on the bed and put my head in the mattress. The guy in the hat pulled my arm and I heard it pop". Then Patient #2 started crying and hollering "I want to get out of here. I don't feel safe". He had repeated that earlier also. I asked him where are your covers - He said "They took it from me". I asked him if the staff knew they hurt his arm. He said "they told me to get up off the floor before they beat my ass". I asked him if his arm just started hurting this morning or did he tell someone last night and he said, "I told the nurse last night" pointing toward the med room and "she laughed at me". I reported to the CNO that [named CC#5] was blocking the door like he didn't want me to come in".

During an interview on 5/4/22 at 1:54 PM CC #1 was asked about his involvement with Patient #2. CC #1 said he took over 1:1 observations from 11:00 PM to 3:15 AM on 4/23/22. CC #1 stated Patient #2 slept on his back the whole entire time and he never got up out of the bed or woke up. CC #1 stated he didn't notice anything about the patient's arm but Patient #2 was upset but not crying. CC #1 stated the patient was yelling. CC #1 stated he saw no one put their hands on him.

During an interview on 5/4/22 at 2:09 PM, CC #2 was asked about the incident with Patient #2. CC #2 stated " ...He [Patient #2] took a shower ...I remember [CC #3] entering the room to see if I needed a break. [Patient #2] was talking to me. He [Patient #2] ran to the bed by himself and tied the sheet around his neck... [CC #3] was new and started talking to me and I guess since the attention was off [Patient #2], I guess he decided to act out. We rushed over there and got it [the sheet] off him and put everything in the hallway. He didn't say anything - he was mad and said "I'm going to kill you." I waited for him to calm down and took him to smoke. On the way out I took him to the nurses' station and told 2 nurses. They told me to take him to get his meds. I took him to get his meds".
CC #2 was asked if he noticed anything different with Patient #2 after the incident and CC#2 stated, "I might have seen him rubbing his shoulder but I don't know. I don't recall if the nurses came out and assessed him ...He is an attention seeker. He was trying to blame his injury on any staff ...He told me a bald guy did it ...if it did happen while we were trying to keep him from harming himself - it really wasn't intentional."

During an interview on 5/4/22 at 3:05 PM, CC # 3 was asked about the incident with Patient #2. CC #3 stated, "I went in to talk to [Named CC #2] to see if he needed a break. [Patient #2] is always trying to run out of the room. I was in front of him and [named CC #2] was to my right [the patient's left]. We were trying to get the sheet off so he wouldn't hurt himself. We took all the linens out of his room. He sat on his bed the whole time, he was yelling. The whole time he was yelling that staff were abusing him but I know for a fact that didn't happen - he just wanted to get out of there. I remember he got mad at us. He just wanted to go home. He was on the smokers patio and apologizing to the techs [CCs] and giving us fist bumps on the patio. He never mentioned he was hurting that whole time. I never saw him rubbing his shoulder. I was never on his 1:1 so he never was in the shower when I was helping out the other techs [CCs] only that one time I was there in his room ..."

During an interview on 5/4/22 at 3:17 PM, Nurse #3 confirmed she was the charge nurse on 4/22/22 for the 3:00 PM to 11:00 PM shift. Nurse #3 confirmed CC #2 stated Patient #2 tried to wrap the sheet around his neck and he and CC #3 got it off of him. Nurse #3 stated, " ...Then they [CC #2, #3] walked him to the nursing desk and told me. I spoke to [Patient #2] through the nursing window and he was asked if he was in pain. He said no. I asked him what happened and he looked at me and said he wanted to go home. He did not say why. I did not see anything through the window that made me think he was guarding anything ...I did not see him again until Med [medication] pass that next morning and at the med window he walked up with his 1:1. [CC #6] asked me if I had seen his shoulder. I looked at it and his shirt was stretched down and I saw the swelling and bruising ..."

During an interview on 5/4/22 at 4:03 PM, CC #4 was asked about any involvement he had with Patient #2. CC #4 stated, "He was my 1:1 a couple of days before and I never had that experience with him. I had a good rapport with him. He was always relaxed - He was autistic - I had to remind him of like social space for example ... I recall no issues with him. I have never seen him get aggressive. He would get excited from time to time like with comics ...He is real bubbly - happy - relaxed ..."

8. Review of a video dated 5/5/22 of the East Womens Day Room revealed CC #10 had left a rolling office chair in the Day Room. Patient #4 was agitated and grabbed the chair. CC #10 attempted to get the chair from Patient #4. Patient #4 pulled herself away from CC #10 and went to the floor. Patient #4 was not injured. By leaving a rolling chair in reach of an agitated patient put patients and staff in danger of injury and was not a safe environment for patients.

During an interview on 5/13/22 beginning at 4:15 PM, the CEO stated the staff must not leave chairs or Dinamaps (Vital Sign Machines on a rolling pole) or any other equipment out where patient can get them. The CEO confirmed that is not a safe practice. The CEO stated they would make sure that is addressed with the staff.

During an interview on 5/17/22 beginning at 1:50 PM, CC #10 stated, " ...The chair technically should not be out. I should have put the chair up I should have put it away ..."

9. Review of a video dated 5/5/22 of the East Womens Day Room revealed CC #13 pushed a female patient (identified as Patient #14) backwards into a chair. This incident was not reported to anyone and was identified during the complaint investigation. The Hospital had begun training on Abuse and Neglect on 5/4/22. The patient was not physically injured in the video. During the review of a video on 5/12/22, the video dated 5/5/22 for Complaint #57571, this incident was observed for the first time by Hospital Administration during the viewing with this surveyor.

During an interview on 5/13/22 beginning at 4:15 PM, the CEO and Director of Risk each verified that was the first time they had seen this incident in the East Womens' Day Room with CC #13. They verified that CC #13 had been terminated earlier in the week for another incident that had occurred in the Cafeteria and been reported to them on 5/10/22. The CEO verified CC #13 did not work after 5/7/22 at the facility.

10. Review of a video dated 5/7/22 of the East Cafeteria revealed CC #13 threw a clipboard with papers at a female patient identified as Patient #15. This incident was reported to administration on 5/10/22. The Hospital had begun training on Abuse and Neglect on 5/4/22. The patient was not physically injured in the video. This incident was also verbally reported to this surveyor during a telephone interview with the complainant on 5/13/22.

During an interview on 5/13/22 beginning at 4:15 PM, the CEO confirmed CC #13 was terminated on 5/12/22 for both incidents. CC #13 will be reported to the abuse registry.

Based on document review, policy review, record review and interview, the hospital failed to ensure nursing services followed physician orders for Xrays, performed nursing assessments and reassessments and identified patients' needs for 2 of 2 (Patient #1, and #2) patients who sustained fractures while in the care of hospital staff.

The findings included:

1. Review of the hospital's policy titled, Reassessment with a revised date of 03/2014 and a last approved date of 03/2021 revealed, " ...Reassessment is conducted by a Registered Nurse every 24 hours at a minimum. Additionally, reassessment occurs in the following circumstances ...Change in the patient's condition ... physical complaint ...Allegations of Abuse and Neglect ...Patient injuries ...R.N. findings from the reassessment are documented in the patient's chart..."

Review of the hospital's policy titled, Patient Abuse or Neglect with a revised date of 12/2015 and a last approved date of 2/2021 revealed, "...The following action shall be taken if any staff member identifies or suspects patient abuse, neglect or exploitation ...Assessment ...Continuous support and monitoring of alleged victim ...A Nursing assessment/reassessment post incident will be completed ...Internal Medicine will be notified of the incident and perform an assessment/reassessment..."

2. Medical Record Review revealed Patient #1 was involuntarily admitted to the hospital on 2/28/22 with diagnoses to include Schizoaffective Disorder, Bipolar type. Patient #1 was well known to this hospital with a history of 13 past inpatient hospitalizations. Patient #1 was 59 years old and lived in a group home.

A nursing narrative note revealed Patient #1 was admitted for delusions and aggression at the group home.

On 3/5/22, Patient #1 complained of hip pain that had started the evening before 3/4/22.

Review of the medical record revealed no assessments were performed and no pain medication was given to the patient for greater than 12 hours.

A physician order for an x-ray was written on 3/5/22 but was not called in to the x-ray company until 3/7/22. (A two (2) day delay).

On 3/7/22, Patient #1 was transferred to an acute care hospital and diagnosed with a fractured hip.

3. Medical Record Review revealed Patient #2 was involuntarily admitted to the hospital on 4/20/22 with diagnoses to include Psychosis, Bipolar Disorder, Intellectual Disability and was autistic. Patient #2 was 22 years old and lived in a group home.

On 4/22/22 Patient #2 was on 1:1 observation. Patient #2 allegedly grabbed a bedsheet and quickly wrapped it around his neck. Two (2) Care Coordinators (CC) who were in the room with the patient stated they immediately removed the sheet from around his neck. There was no documentation of the allegedly self injurious behavior in the patient's medical record and no documentation the patient was assessed following the alleged incident.

Patient #2 was transferred to an acute care hospital the following day and diagnosed with a clavicle fracture.

Refer to A144 and A395.

Based on document review, policy review, record review and interview, the hospital failed to ensure nursing services identified patient needs, performed assessments and followed physician orders for 2 of 2 (Patients #1 and #2) patients who sustained injuries while in the care of hospital nursing staff.

The findings include:

1. Review of the hospital's policy titled, Reassessment with a revised date of 03/2014 and a last approved date of 03/2021 revealed, " ...Reassessment is conducted by a Registered Nurse every 24 hours at a minimum. Additionally, reassessment occurs in the following circumstances ...Change in the patient's condition ... physical complaint ...Allegations of Abuse and Neglect ...Patient injuries ...R.N. findings from the reassessment are documented in the patient's chart..."

2. Review of the hospital's policy titled, Patient Abuse or Neglect with a revised date of 12/2015 and a last approved date of 2/2021 revealed, "...The following action shall be taken if any staff member identifies or suspects patient abuse, neglect or exploitation ...Assessment ...Continuous support and monitoring of alleged victim ...A Nursing assessment/reassessment post incident will be completed ...Internal Medicine will be notified of the incident and perform an assessment/reassessment..."

3. Medical Record Review revealed Patient #1 was involuntarily admitted to the hospital on 2/28/22 with diagnoses to include Schizoaffective Disorder, Bipolar type. Patient #1 was well known to this hospital with a history of 13 past inpatient hospitalizations. Patient #1 was 59 years old and lived in a group home.

Review of the Medical Screening Exam dated 2/28/22 revealed Patient #1 was alert and oriented.

Review of the Nursing Admission Assessment dated 3/1/22, the functional assessment revealed Patient #1 was independent with eating, bathing, dressing/grooming, toileting, ambulation and transferring. The Mental Status Assessment revealed Patient #1 was alert and oriented to person, place, time and situation and well-groomed.

The nursing progress notes from 3/1/22 - 3/4/22 revealed Patient #1 ambulated per self without difficulty and was independent with activities of daily living (ADLs).

Review of Nursing Flow Sheet Progress Record dated 3/5/22 at 4:15 PM revealed, " ...Lying in bed. Has urinated on self ...Changed clothes and transferred to clean bed, in process pt c/o [complained of] pain in R hip ...States it has been hurting since last night [3/4/22] ...Will notify MD of status per charge nurse ..." The physician ordered a portable Xray of the patient's hip due to hip pain. There was no documentation the Xray was done as ordered until 2 days later on 3/7/22. There was no documentation of other assessments of the patient and the patient's complaints of hip pain. There was no documentation of nursing investigation of how the patient sustained hip pain and was no longer ambulatory.

On 3/6/22 Patient #1 received Naproxen 500 milligrams per physician order for complaint of moderate pain. There was no reassessment following the pain medication to determine if the pain medication had relieved the patient's pain. There were no other interventions for the patient's pain.

On 3/7/22, nursing called emergency Medical Services (EMS) to transport Patient #1 to an acute care hospital. Review of the EMS Incident Report dated 3/7/22 revealed, " ...ES [EMERGENCY SERVICES] CALLED BY HEALTHCARE PROVIDER ...FOR HIP PX [PAIN] X [TIMES] 3 DAYS. PTS [PATIENT'S] L [LEFT] HIP IS OBVIOUSLY CONTORTED/TWISTED WITH SWELLING NOTED. PT. LAYING IN URINE SOAKED BED. FACILITY STAFF COULD NOT EXPLAIN TO EMS HOW OR WHEN INJURY OCCURRED. PT IN OBVIOUS PX [PAIN]. 20G INT [20 GAUGE INTERMITTENT NEEDLE THERAPY] EST [ESTABLISHED] R [RIGHT] FOREARM ...25MCG [25 MICROGRAMS] FENTANYL IV [INTRAVENOUS] FOR PX ...PT PLACED ON A SCOOP STRETCHER AND PLACED ONTO EMS COT ...PT MOVED TO EMS UNIT. V/S [VITAL SIGNS] MONITORED AND PT TRANSPORTED ..."

Patient #1 was admitted to the acute care hospital for surgical repair of a fractured hip.

During a telephone interview on 5/9/22 at 2:33 PM, Nurse #4 was asked if she wrote the X-ray order for patient #1 on 3/5/22 and did she call the order in to the X-ray company. Nurse #4 confirmed she did write the order for the X-ray, but she stated she was putting it in the computer for another nurse who was at the bedside of Patient #1. She further stated that she did not think she called the X-ray company to place the order. She revealed, "...We have an x-ray line, I didn't call them..." Nurse #4 stated that she was in the room assisting the other nurse when the patient was wet in the bed. She stated she did not see any bruising, or swelling. Nurse #4 stated, "...We couldn't decide, the hip was slightly larger on the outside..."

3. Medical Record Review revealed Patient #2 was involuntarily admitted to the hospital on 4/20/22 with diagnoses to include Psychosis, Bipolar Disorder, Intellectual Disability. Patient #2 was 22 years old and lived in a group home. Patient #2 was placed on 1:1 observation.

Review of a Nursing Flow Sheet/Progress Report dated 4/22/22 at 10:00 AM revealed, " ...Calm and cooperative at this time-medication compliant. Denies SI (Suicidal Ideation). Remains in his room on one to one observation ...1130 [11:30 AM] Pt [Patient] acting bizarre, talking to wall-trying to escape one to one tech. MD notified and order received ..." There was no documentation of other nursing assessments of the patients behavior.

On 4/22/22 at 12:50 PM, " Pt came to med window for meds. States he feels calm now ..." There were no nursing assessments or reassessments following this nursing note.

Review of a Daily Suicide Risk Assessment sheets dated 4/21/22, 4/22/22, and 4/23/22 revealed Patient #2 had no thoughts of suicide and no newly identified triggers.

Review of the hospital's video recordings of Patient #2 on 4/22/22 revealed the following:
6:19 PM to 6:28 PM - Patient is out on the smoker's patio. He is pacing back and forth, moving both arms and shoulders without any difficulty.

6:32 PM: Patient #2 goes into his room with linens and a food box in his hands with Care Coordinator (CC) #2 (1:1 observations).

6:51 PM: CC #3 watches from the doorway then goes into the room

6:53 PM - 6:55 PM: CC #3 threw linens and towels out into the hall multiple times.

6:55 PM: CC #3 leaves the room.

6:57 PM: CC #4 enters the room the door closes.
6:58 PM: the door opens and CC #4 leaves the room.

7:00 PM: CC #4 and CC #1 come to the door and stop. CC #3 comes to the door. CC #1 goes in room, CC #3 and CC #4 are in the doorway. CC #2 is still in the room.

7:01 PM: CC #3 walks down the hall. CC #1 walks down the hall. CC #4 is in the doorway.

7:06 PM: Patient #2 and CC #2 come out of the room and walk down the hall. Patient #2's left shoulder is drooping at an angle arm is hanging by his side. He is not moving his left arm.

7:07 PM: Patient #2 was holding his left shoulder/clavicle area with his right hand and his left arm was hanging by his side.

Based on the video footage detailed above, Patient #2 sustained an injury to his left shoulder/clavicle area while in his room between 6:32 PM and 7:06 PM. Staff Members CC #1, CC #2, CC#3, and CC#4 were each in Patient #2's room at some time on 4/22/22 between 6:32 PM and 7:06 PM (34 minutes).
There was no documentation nursing assessed the patient's shoulder/clavicle area on 4/22/22 following a change in the patient's status. Patient #2 remained in his room the remainder of 4/22/22. There was no documentation nursing performed an assessment of the patient until 4/23/22.

Review of a Progress Record dated 4/23/22 at 08:40 AM revealed, "At or around 08:20 a.m. nurse went to patient's room to assess left arm due to patient complaining of pain and discomfort. Left arm was observed to be swollen and bruised. Pt. was unable to raise arm or extend left arm. Pt. complained of pain when touching the left shoulder area and was unable to squeeze the nurse's hand w/ his left hand without pain. Per pt he didn't fall or injure his arm himself ...1720 [7:20 PM] ...Pt AAO [Awake, Alert and Oriented] x [times] 3. Pt. intellectually delayed. Compliant with meds ...1:1 observation ...Pt. calm/cooperative ..." The nurse contacted EMS to transport the patient to an acute care hospital where Patient #2 was diagnosed with a fractured clavicle.

This action by the nurse at 8:40 AM on 4/23/22 was the first nursing assessment of Patient #1 since the patient's change in status occurred on 4/22/22 between 6:34 PM - 7:06 PM.

During an interview on 5/4/22 at 3:17 PM, Nurse #3 confirmed she was the charge nurse on 4/22/22 for the 3:00 PM to 11:00 PM shift. Nurse #3 stated, " ...they [CCs]walked him [Patient #2] to the nursing desk and told me [that the patient was complaining of shoulder pain]. I spoke to [Patient #2] through the nursing window and he was asked if he was in pain. He said no. I asked him what happened and he looked at me and said he wanted to go home. He did not say why. I did not see anything through the window that made me think he was guarding anything ...I did not see him again until Med [medication] pass that next morning and at the med window he walked up with his 1:1. [CC #6] asked me if I had seen his shoulder. I looked at it and his shirt was stretched down and I saw the swelling and bruising ..."

Refer to A144.