HospitalInspections.org

Based on document review and interview the facility failed to investigate two (2) grievances, failed to keep a patient safe from abuse/neglect, and failed to obtain a physician order for seclusion. See tags A0119, A0145 and A0168.

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review and interview the hospital failed to ensure a patient's verbal/written grievance was submitted for investigation in one (1) instance (Patient # 7), and failed to thoroughly investigate a written grievance in one (1) instance. (Patient # 10)

Findings include:

1. The hospital policy titled, Patient Grievance Procedure, PolicyStat ID 13517667, indicated a patient grievance was a written or verbal complaint by a patient, regarding the patient's care, and/or abuse/neglect. All complaints/grievances may be submitted verbally, in writing to a member of the hospital personnel, by a staff member to whom the complaint/grievance was reported. All verbal or written complaints regarding abuse, neglect, patient harm or hospital compliance, would be considered a grievance that required immediate redress. This policy was last revised in 01/2020.

2. The hospital policy titled, Patient Rights and Responsibilities, PolicyStat ID 13517670, indicated every person who enters the hospital for care, had rights. The rights included that all grievances would be addressed in a timely manner. The patient would receive care in a safe setting, free from verbal abuse and/or harassment. This policy was last revised in 09/2021.

3. Grievance form dated 01/23/2024 indicated that a inpatient, at the hospital, filled out a grievance form related to a staff member P # 5 (Behavioral Health Assistant) had verbally abused patient # 10. The documentation indicated staff and staff member P # 5 stated it didn't happen. Administrative staff member A # 2 (Registered Nurse/Director of Nursing) met with P # 5 for a warning. The grievance lacked documentation related to an investigation (statements/interviews/video detail).

4. Review of patient # 7's medical record (MR) indicated he/she expressed a grievance to staff member P # 4 (Behavioral Health Assistant) on 02/21/2024. Staff member P # 4 wrote the grievance on the grievance form and placed the form in the patient's MR.

5. In interview on 03/12/2024 at approximately 1:45 pm with administrative staff member A # 3 (Director Quality Compliance), confirmed patient # 7's grievance was not investigated and should have been brought to someone's attention, and no other interviews were conducted and/or the video surveillance system reviewed for the grievance related to patient # 10.

6. In interview on 03/12/2024 at approximately 4:00 pm with administrative staff member A # 2, confirmed that A # 3 should have conducted interviews and watched the video surveillance related to the grievance for patient # 10 dated 01/23/2024.

Based on document review and interview, the facility failed to keep a patient free from abuse/neglect in one (1) instance. (Patient # 10)

Findings include:

1. The hospital policy titled, Patient Abuse and Neglect, PolicyStat ID 13034136, indicated abuse was any willful, negligent treatment in a mental health facility. This policy was last revised in 01/2023.

2. The hospital policy titled, Patient Rights and Responsibilities, PolicyStat ID 13517670, indicated every person who enters the hospital for care, had rights. The rights included that all grievances would be addressed in a timely manner. Receive care in a safe setting, free from verbal or physical abuse or harassment. Be free from restraints and seclusion of any form used as a means of coercion, discipline, convenience or retaliation by staff. This policy was last revised in 09/2021.

3. The hospital policy titled, Restraint or Seclusion Use, PolicyStat ID 13483128, indicated monitoring the physical and psychological well-being of the patient who is restrained or secluded, included but not limited to respiratory and circulatory status, skin integrity, vital signs, and the need for personal comfort measures including hydration, feeding and toileting. This policy was last revised in 02/2024.

4. Critical Incident Report (CIR) dated 01/25/2024 was reviewed. Staff reported that patient # 10 had been put in seclusion on 01/18/2024 without a physician order. The investigation found that on 01/18/2024 patient # 10 was placed in seclusion at 10:02 pm by staff members P # 1 (Behavioral Health Assistant-BHA) and P # 2 (Registered Nurse-RN), and was not released until 01/19/2024 at 6:52 am. The patient was in seclusion for 8 hours 50 minutes. The investigation documentation lacked any follow-up education with staff related to abuse/neglect/documentation/patient rights.

5. Patient # 10's medical record (MR) indicated the following:
a. History & Physical indicated the patient was a 70 year/old (y/o) admitted on 12/23/2023 with a diagnosis of dementia, inappropriately sexual behaviors, suicide ideation, and delusions.
b. Patient Safety Observation Rounds dated 01/18/2024 by P # 1 (Behavioral Health Assistant-BHA), indicated the patient was in the milieu from 7:15 pm until 9:15 pm then the patient went to their room from 9:30 pm until 6:15 am on 01/19/2024.
c. The MR lacked a physician order for seclusion dated 01/18/2024 and/or 01/19/2024.
d. The MR lacked documentation related to monitoring the physical and psychological well-being of the patient who was in seclusion.

6. In interview on 03/13/2024 at approximately 2:00 pm with A # 3 (Director Quality Compliance), confirmed the video was reviewed for 01/18/2024 when the patient was in seclusion. The door was shut and locked the entire time.

7. In interview on 03/14/2024 at approximately 1:45 pm with A # 4 (Human Resource Director), confirmed no additional staff education had been conducted by A # 2 (Registered Nurse/Director of Nursing).

Based on document review and interview, the facility failed to ensure the registered nurse obtained an order for seclusion in one (1) instance. (Patient # 10)

Findings include:

1. The hospital policy titled, Restraint or Seclusion Use, PolicyStat ID 13483128, indicated restraint/seclusion may only be utilized upon the written or telephone order of a Licensed Independent Practitioner, Nurse Practitioner, or Physician's Assistant. This policy was last revised in 02/2024.

2. Critical Incident Report (CIR) indicated on 01/25/2024 staff reported that patient # 10 had been put in seclusion on 01/18/2024 without a physician order. The investigation found that on 01/18/2024 patient # 10 was placed in seclusion at 10:02 pm by staff members P # 1 and P # 2, and not released until 01/19/2024 at 6:52 am. The patient was in seclusion for 8 hours 50 minutes.

3. 2. Patient # 10's medical record (MR) indicated the following:
a. History & Physical indicated the patient was a 70 year/old (y/o) admitted on 12/23/2023 with a diagnosis of dementia, inappropriately sexual behaviors, suicide ideation, and delusions.
b. The MR lacked a physician order for seclusion dated 01/18/2024.

4. In interview on 03/13/2024 at approximately 2:00 pm with A # 3, confirmed the video was reviewed for 01/18/2024 when the patient was in seclusion. The door was shut and locked the entire time.

5. In interview on 03/13/2024 at approximately 1:30 pm with administrative staff member A # 4 (Human Resource Director-HRD), confirmed P # 2 (Registered Nurse) did not obtain a physician order for seclusion.

Based on document review and interview the Director of Nursing (DON) failed to ensure an adequate number of personnel were available to provide patient care in three (3) instances. (01/14/2024, 01/19/2024 & 01/20/2024)

Findings include:

1. The hospital policy titled, Clinical Staff (Nurse) Staffing Plan, PolicyStat ID 12279065, indicated the DON was accountable to ensure a sufficient number of staff were on duty at all times. Day shift should have one (1) clinical staff member for every five (5) patients. This policy was last revised in 08/2022.

2. Review of the DON job description dated 06/ 19/1023, indicated the DON was responsible for appropriate staffing levels.

3. Review of the Staffing Pattern Worksheet for the 200 unit, dated 01/14/2024 - 01/27/2024, indicated the unit was short staffed on the day shift on the following dates:
a. 01/14/2024 - the unit census was 26 patients - they should have had five (5) clinical staff members and they were only staffed with four (4).
b. 01/19/2024 - the unit census was 25 patients - they should have had five (5) clinical staff members and they were only staffed with four (4).
c. 01/20/2024 - the unit census was 26 patients - they should have had five (5) clinical staff members and they were only staffed with four (4).

4. In interview on 03/12/2024 at approximately 4:00 pm with administrative staff member A # 2 (Registered Nurse/DON), confirmed the hospital uses patient acuity and the staffing matrix to staff the units.

Based on document review and interview the hospital failed to ensure a policy was followed related to Restraint or Seclusion use in two (2) of eleven (11) medical records reviewed. (Patient # 7 & Patient # 10)

Findings include:

1. The hospital policy titled, Restraint or Seclusion Use, PolicyStat ID 13483128, indicated a face-to-face assessment should be completed within one (1) hour of seclusion. All nursing assessments should be documented using the restraint/seclusion packet, and all documentation should include date, time and staff signature/initials. The nurse present at the episode would arrange a patient debriefing. All debriefing forms should be forwarded to the Director of Nursing (DON).

2. The Restraint/Seclusion Packet for Patient # 7's MR indicated the following:
a. An order dated 02/13/2024 at 7:40 pm, indicated the MR lacked debriefing documentation, staff signature, date, and time.
b. An order dated 02/15/2024 at 12:30 pm, indicated the MR lacked debriefing documentation, staff signature, date, and time.

3. The Restraint/Seclusion Packet for Patient # 10's MR indicated the following:
a. An order dated 01/01/2024 at 2:00 pm, indicated the MR lacked debriefing documentation, staff signature, date, and time.
b. An order dated 01/17/2024 at 8:45 pm, indicated the MR lacked debriefing documentation, staff signature, date, and time.
c. An order dated 01/20/2024 at 11:10 pm, indicated the lacked debriefing documentation, staff signature, date, and time.
d. All debriefing forms were still in the chart and not forwarded to the DON for review.

4. In interview on 03/12/2024 at approximately 1:45 pm with administrative staff member A # 3 (Director Quality Compliance), confirmed staff should follow the hospital's policies and procedures.

Based on document review and interview the facility failed to ensure an employee was qualified by education/experience in one (1) instance. (A # 2 - Director of Nursing-DON)

Findings include:

1. Review of Director of Nursing (DON) job description, indicated the educational requirements to be a Master's Degree in Psychiatric or Mental Health Nursing, or its equivalent education in acute care behavioral health. Job description was signed by A # 2 (DON) on 06/19/2023.

2. Review of the personnel file for A # 2, indicated he/she lacked the required education/documentation (Master's Degree in Psychiatric or Mental Health Nursing).

2. In interview on 03/13/2024 at approximately 1:30 pm with administrative staff member A # 4 (Human Resource Director-HRD), confirmed A # 2's personnel file had an Associates Degree in Nursing. The file lacked any documentation related to a Master's Degree and/or experience in mental health nursing.