HospitalInspections.org

Based on observations, policy and document review, record reviews, and interviews, the hospital failed to ensure that 3 of 44 patients (Patients #1, #4 and #6) observed received care in a safe setting.

Hospital policy titled "Special Precautions and Patient Level of Observation" stated, " ... 1:1 staff continuous accompaniment at arm's length no more than one arm length away, 24 hours a day to prevent the patient from harm to self or others ...staff shall maintain visual contact of the patient during the patient's use of the bathroom ...staff assigned to observation checks must always visually see the patient ..."

Hospital policy titled "Patient Observation" stated, "...To ensure patient safety...If a patient is in the room [bedroom] during non-hygiene time, the door should be open and unlocked..."

I. Patient #1

A. Review of medical chart revealed:

-Patient #1 was admitted on 09/26/23 at 9:06 PM, status post suicide attempt.
-Psychiatric Evaluation stated, " ...the patient tried to hang herself with two cords and a power cord for the phone ...the patient has a history of multiple suicide attempts, multiple self-harming behaviors and multiple inpatient hospitalizations..."
-"Intake Assessment" described that patient had a total of 6 previous suicide attempts, 2 of which were hangings.
-"Nursing Admission Narrative Summary" stated, " ... positive suicidal ideation with attempts to harm self at the hospital ...patient is 1:1...".
-"Patient Observation Record" dated 9/27/23 indicates that patient was on a 1:1 level of observation.
-"Nursing Progress Note" dated 9/27/23 at 7:00 PM stated, "...At 4 PM patient wrapped paper scrubs around her neck in the shower. Code Blue called."

Document titled "Investigation of Incident on Unit" provided by Employee # 3 revealed:
- "16:23 staff found patient in shower with pants tied around neck when they were about to administer medication".
- "Video review does show that the 1:1 RS (Recovery Specialist) was at the doorway of the room, and self-reported that she was not within arms-reach of the patient while she showered."

During an interview with Employee #2 and Employee #3 it was confirmed that the patient was not visualized during her shower. Employee #3 stated that they reeducated all the 1:1 staff, however no documentation was available to confirm this. It was also stated that leadership was performing checks on each shift to validate that the 1:1 is providing supervision of the patient as outlined in the policy. Documentation provided to confirm this was insufficient.

The hospital staff failed to create a safe environment by not observing the patient in the shower while on 1:1 level of observation, allowing her to be able to tie pants around her neck in an attempt to commit suicide.


II. Patient #3 and #6

During an observation of the Recovery Unit on 10/4/23 between 9:43 and 10:00 AM, 15 patients were observed attending the scheduled Community Group session. Three patients were observed in their bedroom with the doors open. Employee #8 confirmed the unit had a census of 20 patients. When asked which 2 patients were not in their rooms or attending groups, staff was unable to verbalize which patients were unaccounted for. Upon review of the "Patient Observation Records" for the unit, it was determined that Patient #4 and #6 were in their bedrooms. This surveyor went to these patient's rooms and observed the bedroom doors for Patient #4 (room #151) and Patient #6 (room #152) were closed. When the bedroom doors were opened, both patients were observed lying on their bed.

During an interview on 10/4/23 between 9:43 and 10:00 AM, Employee #8 stated that the expectation is for nursing staff to keep patient bedroom doors open when patients are inside. Employee #8 confirmed that Employee #11 did not keep the bedroom doors of room #s 151 and 152 open after completing 9:45 AM observation checks for Patient #s 4 and 6.

Based on medical record review, policy review and staff interview, it was determined that for 3 out of 5 patients (Patient #'s 1, 2, and 4) in the sample, the registered nurse (RN) failed to supervise and evaluate the nursing care. Findings include:

1. Vital Signs

Hospital policy titled "Monitoring Patient Vital Signs" stated, "...All patients admitted to Rockford Center will have vital signs taken twice daily on admission for 3 days and daily thereafter unless ordered more frequently by the physician or warranted by patient's condition..."

I. Patient #1

Medical record review revealed:

A. Patient was admitted on 9/26/23 at 9:06 PM.

B. "Facility Ancillary Orders (non-med)" documented an order dated 9/26/23 at 9:25 PM, for vital signs BID (twice a day) x3 (times 3) days.

C. Electronic medical record review showed no evidence that vital signs were taken appropriately on the following dates:

9/26/23- No evidence of vital signs taken on admission. Patient was admitted after an attempted suicide by hanging.
9/27/23- No evidence of vital signs taken. On this date patient had an incident of a suicide attempt while in the shower. No evidence of vital signs recorded after the incident or upon return of the patient from their emergency room evaluation.
9/28/23- Missing evidence of 1 out 2 sets of ordered vital signs
9/29/23- Missing evidence of 2 out of 2 sets of ordered vital signs
9/30/23- No evidence of vital signs taken
10/01/23- No evidence of vital signs taken
10/02/23- No evidence of vital signs taken

During an interview on 10/05/23 at 3:15 PM, Employee #2 reviewed the electronic record of Patient #1 and confirmed there was no evidence that vital signs were taken on the dates listed.

II. Patient #2

Medical record review revealed:

A. Patient #2 admitted 9/2/23.

B. "Vital Signs Log Sheet" and electronic vital sign document:
- showed no evidence that vital signs were taken on 9/17/23.

During an interview on 10/5/23 between 2:45 3:20 PM, Employee #2 reviewed the electronic record of Patient #2 and confirmed there was no evidence that vital signs were taken on 9/17/23.


III. Patient #4

Medical Record revealed:

A. "Facility Ancillary Orders (non-med)" documented an order dated 9/25/23 at 10:21 PM, for vital signs BID (twice a day) x3 (times 3) days; to start 9/25/23 at 9:00 AM and end on 9/28/23 at 5:00 PM..

B. "Vital Signs Log Sheet" and electronic vital sign document:
- showed no evidence that vital signs were taken on 9/26/23, 9/27/23, or 9/28/23.

During an interview on 10/5/23 between 2:45 3:20 PM, Employee #2 reviewed the electronic record of Patient #4 and confirmed there was no evidence that vital signs were taken on 9/26/23, 9/27/23, or 9/28/23.



2. Charge Nurse verification of patient rounding

Facility policy titled "Patient Observation Policy" stated, " ...Charge Nurse/Nursing Supervisor/Team Leader ...ensures the Patient Observation Rounds are occurring as ordered, 24hrs per day, seven days a week with reviewing the rounding sheet every four hours and then sign, date, and time..."

Facility policy titled, "Charge Nurse Responsibilities" stated, " ...the charge nurse shall ensure staff compliance with the patient observation process ...this should be documented on the Patient Observation Record ..."

I. Patient #1

Medical Record revealed:

A. "Patient Observation Record" was missing a Charge Nurse signature for the following dates and four-hour blocks:
- 9/28/23; 5 out of 6 four-hour blocks ending at 8:00 AM, 12:00 PM, 4:00 PM and 8:00 PM.
- 9/28/23; 3 out of 6 four-hour blocks ending at 12:00 PM, 4:00 PM, 8:00 PM.

During an interview on 10/05/23 at 3:15 PM, Employee # 2 confirmed that the Charge Nurse did not sign the "Patient Observation Records" on the above dates and times.

II. Patient #2

Medical Record revealed:

A. "Patient Observation Record" was missing a Charge Nurse signature for the following dates and four-hour blocks:
- 09/22/23; 3 of 6 four-hour blocks ending at: 4:00 AM, 8:00 AM, and 12:00 AM.
- 9/28/23; 4 of 6 four-hour blocks ending at: 12:00 AM, 4:00 PM, 8:00 PM, and 12:00 AM.
- 9/26/23; 2 of 6 four-hour blocks ending at 8:00 PM and 12:00 AM.
- 10/1/23; 1 of 6 four-hour blocks ending at 12:00 AM.

During an interview on 10/5/23 between 10:42 and 11:18 AM, Employee #4 confirmed a Charge Nurse did not sign the "Patient Observation Records" on the above dates and times.

Based on policy review, record review, and staff interviews, it was determined that for 2 of 5 patients (Patient #'s 1 and 3) in the sample, the Chief Nursing Officer failed to ensure that nursing staff were adhering to the policies and procedures of the hospital.

Hospital policy titled "Emergency Plan Services" stated, "A medical emergency is a medical condition with acute/sever symptoms in which failure to provide immediate medical services could result in one or more of the following outcomes: 1) death; 2) serious health impairment; 3) substantial risk to bodily functions; or 4) serious risk of compromising the function of any body part or organ...A psychiatric emergency is defined as a severe mental debilitation...in which failure to stabilize could result in potential for injury to self or others...The emergency situation should be fully documented in the clinical record in a timely manner by the charge nurse or his/her designee and should include the following: ...signs/symptoms ...treatment interventions and response ...condition at time of transfer...instructions given to patient/family member/guest/employee ..."

I. Patient #1

Medical record review revealed:
-"Nursing Progress Note" dated 9/27/23 stated, "At 4 PM patient wrapped paper scrubs around her neck in the shower. Code blue called."
-No evidence of any other documentation found regarding the incident on 9/27/23 in which the patient attempted suicide. There is no evidence of nursing documentation of an assessment of the patient during the event. No evidence of a transfer note being completed when the patient was taken by EMS from the facility to the hospital.
-During an interview on 10/05/23 at 3:15 PM, Employee #2 stated that a transfer form was completed at the time of the event that would have contained information such as vital signs. No evidence of a completed transfer form was found. Employee #2 confirmed that there was no additional documentation available if it was not found in the patient chart.

II. Patient #3

Medical record review revealed:
- Patient admitted on 10/6/22 at 6:43 PM and discharged 10/9/22 after 11:38 AM.
- No evidence of patient aggression or agitation documented in patient observation records, nursing progress notes, or psychiatrist progress notes during 10/6/22 to 10/9/23 admission.
- "Physician Medication Orders" dated 10/8/22 documented medication order chlorpromazine 50 mg (milligrams) IM (intramuscular) STAT (right away) for aggression at 10:20 PM and diphenhydramine 50 mg IM NOW for agitation at 10:22 PM.
- "Medication Administration Record" documents chlorpromazine 50 mg IM STAT for aggression was administered at 10:21 PM and diphenhydramine 50 mg IM NOW for agitation was administered at 10:22 PM.
- No evidence in patient chart of documentation of signs and symptoms of agitation and aggression, requiring the STAT/NOW IM medication or treatment response.

During an interview on 10/5/23 between 2:45 and 3:20 PM, Employee #2 confirmed that there was no evidence in patient chart of documentation of signs and symptoms requiring the STAT/NOW IM medication or treatment response.

Based on medical record review, policy review, and staff interview, it was determined for 1 of 5 patients (Patient # 2) in the sample, the practitioner failed to sign verbal orders within 48 hours as required by hospital policy and medical bylaws. Findings included:

Hospital policy titled "Verbal/Telephone Orders" stated, "...All orders should be approved by the physician within 48 hours of receipt."

Hospital "Medical Staff Bylaws Rules and Regulation" stated, "...A telephone order shall...be signed and dated by the responsible practitioner within 48 hours..."

Patient #2

1. Medical record review revealed:

Patient #2 admitted on 9/2/23 at 1:41 AM and discharged 10/2/23 at 10:00 PM.

No evidence the following practitioner verbal/telephone orders were signed by Employee #9:
- 9/2/23 at 4:50 AM; Hydroxyzine pamoate 25 mg (milligrams) PO (by mouth) QID (for times a day) PRN (as needed)
- 9/2/23 at 4:50 AM; haloperidol 2 mg PO Q (every) 6 H (hours)
- 9/2/23 at 4:51 AM; bacitracin topical 500 units/g (gram) ointment 1 application BID (twice a day) PRN
- 9/2/23 at 9:13 PM; chloropromazine 25 mg IM (intramuscular) STAT (right away)
- 9/2/23 at 9:15 PM; diphenhydramine 25 mg IM STAT
- 9/2/23 at 9:24 PM; diphenhydramine 25 mg PO Q 6 HR (hour) PRN
- 9/2/23 at 9:30 PM; diphenhydramine 25 mg IM Q 6 HR PRN
- 9/2/23 at 9:32 PM; chlorpromazine PO Q 6 HR PRN
- 9/2/23 at 9:33 PM; chlorpromazine IM Q 6 HR PRN
- 9/3/23 at 9:42 AM; quetiapine 300 mg PO BID
- 9/3/23 at 9:43 AM; quetiapine 300 mg PO ONCE
- 9/8/23 at 10:04 PM; chlorpromazine 25 mg IM NOW
- 9/8/23 at 10:06 PM; diphenhydramine 25 mg IM NOW
- 9/8/23 at 10:07 PM; lorzaepam 1 mg IM NOW

No evidence the following practitioner verbal/telephone orders were signed by Employee #10:
- 9/30/23 at 12:55 PM; ibuprofen 600 mg PO TID (three times a day) PRN

During an interview on 10/5/23 between 10:42 and 11:18 AM, Employee #2 and #4 confirmed the above practitioner verbal orders were not signed by the practitioner.