HospitalInspections.org

A. Based on observation, policy review and staff interview, it was determined that for 1 of 1 laundry hamper lined with a plastic liner, the Facility failed to ensure all safety hazards were removed, thus placing all 29 patients on census at risk for harm.

Findings include:

1. An observational tour of the Behavioral Health Unit (4N-W)was conducted on 8/7/12 between 1:00 PM and 1:40 PM. An unattended laundry hamper lined with a plastic bag was in the female hallway in front of room 442. The patients occupying this hallway have diagnoses' of either major depression, schizophrenia, bipolar manic, or psychoses.

2. The Hospital policy titled, " Behavioral Health Unit Contraband" (revised 5/2012) reviewed on 8/7/112, required, "...The purpose of this policy is to create a safe therapeutic environment. In doing so, we must identify items considered "Contraband" on 4 N-W. Contraband is commonly used items that when used for unintended purposes may cause harm to self/others....Items on the attached documents are considered "Contraband" and prohibited from patient access: ...Plastic bags of ANY kind or SIZE...."

3. The DON interviewed on 8/7/12 during the tour confirmed the above finding and stated that the laundry hamper should not be lined with a plastic bag and left unattended in the hallway.


B. Based on reviews of Hospital policy, clinical records, log of incidences, and staff interview, it was determined that for 1 of 2 incidences of alleged staff striking a patient, the Hospital failed to ensure an investigation of the incidence was conducted according to policy. Thus placing all 29 patient on census at risk for harm.

Findings include:

1. The Hospital policy titled, "Incident Reporting: HIPAA and corporate Compliance" (revised 7/07), reviewed on 8/8/12 required, "...This policy describes the process for reporting, documenting and investigating incidents...Review and Investigation... The Compliance Liaison or his/her designee reviews the report. Information for purposes of quality improvement, review of patterns and trends, employee counseling and general risk mitigation is gathered at this time... The Compliance Liaison or his/her designee will investigate the incident...."

2. The clinical record of Pt. #1 was reviewed on 8/7/12.. Pt. #1 was a 21 year old female admitted on 5/25/12 with diagnosis of Episodic Mood Disorder and Autistic Disorder. Admission assessment indicated that Pt. #1 was physically aggressive at home towards mother and sibling, pulled a strangers hair at the mall and punched walls and threw things at home. The clinical record included 2 documentation's (6/5/12 and 6/17/12) of Pt. #1's mother stating Pt. #1 told her that staff hit Pt. #1.

3. The Incident log for 5/1/12-8/5/12, reviewed on 8/8/12 included 2 incident reports with allegation of staff striking Pt. #1. The investigation for the incident report dated 6/17/12, was reviewed on 8/8/12 and included, record review, staff and patient interviews,. However, there was no documentation of an investigation for the 6/5/12 occurrence available.

4. During an interview with the Director of Nursing (DON) on 8/8/12, the DON stated that she did not recall or see the incident report dated 6/5/12 and no investigation occurred. The above finding was confirmed with the DON during the interview.

A. Based on review of Hospital policies, clinical record review and staff interview, it was determined that for 2 of 2 (Pt. #1 & 4) records reviewed for patients sustaining an injury the Hospital failed to ensure the patients were assessed by a registered nurse (RN) after a change in condition, according to policy.

Findings include:

1. The Hospital policy titled, "Medical Record Documentation of Patient Care" (revised 5/2010), reviewed on 8/8/12, required, "Purpose:...to describe daily patient charting and frequency of Nurse/MHC charting to ensure that standards of care and assessment are being met for each patient on the Behavioral Health...."

2. The Hospital policy titled, "Assessment/Reassessment of Patients" (revised 7/2010), reviewed on 8/8/12, required, "1. Patient assessment is completed and patient care needs are prioritized by the Registered Nurse... 3. The Registered nurse is responsible for the reassessment of the patient when there is a change of condition... 8 ...changes in the patient's condiction are assessed and reassessed...document in the Interdisciplinary Progress notes...."

3. The clinical record of Pt. #1 was reviewed on 8/7/12. Pt. #1 was a 21 year old female admitted on 5/25/12 with diagnosis of Episodic Mood Disorder and Autistic Disorder. The Nursing notes dated 6/17/12 at 2:50 PM indicated that Pt. #1 ' s mother pointed to a laceration on Pt. #1's right ear and that the house physician was contacted to assess the ear. However, the record lacked any documentation of an assessment of Pt. #1's ear, by an RN, after it was brought to the RN's attention.

4. The clinical record of Pt. #4 was reviewed on 8/9/12. Pt. #4 was a 44 year old male admitted on 7/20/12 with diagnosis of Schizoaffective disorder. The clinical record contained a Mental Health counselor note dated 7/25/12, indicating Pt. #4 was struck by a peer above the right eye; and a physician evaluation indicated that Pt. #1 sustained a 1/2 inch right orbital laceration. However, the record lacked any documentation of the laceration or an assessment of Pt. #4, by an RN after he sustained the injury.

5. The RN (E #5) staff who was assigned to Pt. #1 on 6/17/12 was interviewed on 8/7/12. E #5 stated that Pt. #1 ' s mother who was visiting on 6/17/12 showed E #5 the small superficial laceration inside Pt. #1's ear. E #5 stated he called the house physician to evaluate Pt. #1, however, E #5 stated he did not assess or document a reassessment of Pt. #1's ear laceration.

6. The above findings were confirmed by the DON during an interviews on 8/7/12 and 8/9/12 at approximately 3:00 PM.