HospitalInspections.org

Based on document review and staff interview, it was determined in 1 of 1 patient (Pt #1) with violent/self destructive behavior the Hospital failed to ensure attending physician was notified of patient abuse per hospital policy.
Findings include:

1. On 7/29/15 at 3:00 PM, the Hospital policy titled, "Abuse of Disabled Adults & Elders; Recognition, Intervention and Reporting" (revised 6/22/15) was reviewed on 7/29/15 at 3:00 PM. It indicated "The director or department equivalent coordinates notifying attending physician, and as needed, will seek necessary order(s) for appropriate consult, treatment or interventions."

2. On 7/29/5/13 at 9:00 AM, the medical record of Pt #1 was reviewed. Pt #1 was admitted to the Hospital with the diagnoses of encephalopathy, confusion, urinary tract infection, hypernatremia and sepsis. Multidisciplinary Notes dated 6/17/15 at 7:45 AM indicated the attending physician (E #6) was notified of injuries to Pt #1 and evaluated the patient, but there is no documentation to indicate E #6 was notified of Pt #1 being slapped by a nurse.

3. On 7/28/15 at 1:40 PM, a phone interview with the attending physician (E #6) was conducted. E #6 stated " I was not aware Pt #1 was hit by a staff member."

4. On 7/29/15 at 2:00 PM the Hospital Complaint Form dated 6/16/15 was reviewed on 7/29/15 at 2:30 PM. It indicated on 6/16/15, registered nurse (E #5) reported to the Nursing Director (E #8) that E #5 witnessed registered nurse (E #4) using unnecessary physical contact to control Pt #1's confused behavior. It was reported E #4 was witnessed holding both of Pt #1's wrists in an attempt to keep E #4 from being injured by Pt #1. During this encounter Pt #1 freed her arm and struck E #4 in the face. E #4 then struck Pt #1 in return making contact with the right side of the Pt # 1's face. Immediately, E #5 stepped in and took over the care of the Pt #1 while E #4 notified the physician (E #6). E #4 reported that a skin tear was received to the right arm of Pt #1during this time of confusion from Pt #1's own fingernails of left hand. E #6 then came to the floor to assess Pt #1 and write new orders. E #6 documented agitation, no distress, and did not notice any suspected harm. It was the end of the night shift and new employees took over care of Pt #1.

5. On 7/29/15 at 3:15 PM, an interview with registered nurse (E #5) was conducted. E #5 indicated E #5 was in the room and witnessed E #4 slap the patient. "I did not say anything to E #4 after the incident, but I did point out the red area on Pt #1's cheek and skin tear on arm. E #4 told me, ' You know I didn ' t mean to hurt Pt #1.'" E #5 verbalized E #5 did not hear the conversation between E #4 and Pt #1's physician (E #6). " I did see E #6 on the floor but don't know if E #6 saw the patient. I don ' t think E #6 knew about the incident. " E #5 indicated E #5 has never witnessed staff verbally or physically abuse patients until this incident.

6. On 7/29/15 at 3:00 PM, an interview with the Patient Safety Quality Director (E #3) was conducted. E #3 stated "You're right, the attending physician (E #6) didn't chart a skin or wound assessment. I assumed that when the nurse (E #4) notified the physician ( E #6) and E #6 came in to examine the patient (Pt #1) that E #6 would have documented the wound on the patient." E #3 agreed there should have been documentation the physician was notified of the patient being slapped and the assessment should have included a wound assessment. E #3 reported that E #4 was terminated due to the nature of the incident, and E #4 had no patient contact after reported incident.

Based on document review and staff interview it was determined in 1 of 10 (Pt #1) patient the facility failed to ensure patient rights and safety by administering medications not standard for treatment which restricted the patient's movement. This failure has the potential to effect all patients exhibiting violent /self harming behavior.

Findings include:

1. The medical record of Pt #1 was reviewed on 7/29/15 at 9:00 AM. Pt #1 was admitted to the hospital on 6/14/15 at 16:13 with diagnoses of Urinary Track Infection and Septicemia. On 6/16/15 an order was received at 8:15 AM for Haldol 1 mg (anti-psychotic) with the indication of use as "Severe Behavioral Problems". The order status indicates the Haldol was administered on 6/16/15 at 9:03 AM. There was no order for a chemical restraint and no diagnosis to indicate the Haldol was standard treatment for Pt #1. Pt #1's routine medication list (from SNF) did not include Haldol.

2. A review of the policy titled "Restraint Utilization (Violent, Self Destructive) revised 7/1/14 was reviewed on 7/28/15 at 10:30 AM. The policy includes on page 10 "Chemical Restraint, 1. Definition: A drug or medication when it is used as a restraint to manage the patient's behavior to restrict the patient's freedom of movement and is NOT standard treatment or dosage for patient condition."

3. An interview was conducted with E# 3 on 7/30/15 at 10:00 AM. E#3 reviewed Pt #1's record and agreed there was no order for the chemical restraint, Haldol.