HospitalInspections.org

Based on document review and interview, the facility failed to ensure a safe environment and closer observation of 2 of 10 patients (patient 1 and 2) see tag 144 .

The cumulative effect of this problem resulted in the hospital's inability to ensure that Patients Rights were promoted.

Based on document review and interview, the facility failed to ensure a safe environment and closer observation of 2 of 10 patients (patient 1 and 2).

Findings include:

1. Review of facility policy, AGGRESSIVE BEHAVIORS PROTOCOL, Policy No.: CC80, Issued: 7/2019, indicated the following. To ensure a safe environment from patients that may exhibit aggressive behaviors as well as an environment where other patients and staff can be free of physical attack, injury, or abuse... Line of Sight order, the line of sight (LOS) level of observation involves continuous visual monitoring... One to one order, the patient receives continuous monitoring and physical proximity to the patient by a staff member.

2. Review of patient 1's MR indicated the following. Admitted on 11/21/2019, admitting diagnosis, dementia with behavior disturbance. ... reported increased verbal and physical aggression.
Patient order on LOS 11/28/2019. Medication sheet indicated LOS (Line of Site) for aggressive behaviors. D/C LOS (discontinue line of sight) 12/02/19.
Patient was aggressive as indicated by the following.
11/23/2019...patient hit another patient with closed fist.
11/26/2019, Pt (patient) continues to get in other patient space threatening to fight them.
11/27/2019, Patient got into a fight with another patient.
12/1/2019, patient in altercation with another patient...the other patient ended up on the floor.
12/03/2019, 1830 (hours) patient in altercation (unwitnessed) (with) another patient (patient 2). Patient found laying on back in milieu (environment) with another patient over him....left lower leg ankle discomfort... x-ray ordered...
RADIOLOGY REPORT 12/04/2019 signed at 12:26 hours ...complete oblique fracture involving the distal tibia with modest anterolateral displacement. The joint alignment is maintained. There is associated soft tissue swelling.
Conclusion: Tibial fracture as described above.
MR lacked documentation that patient was placed on closer observation do to aggressive behavior and LOS was discontinued with several episodes of aggressive behavior.

3. Review of patient 2's MR indicated the following. Patient was admitted on 11/15/2019, Dementia with behaviors, increased intrusive behavior. He/She was trying to transfer and lift patients.
No orders for LOS (line of site) or one on one for aggression noted for this admission.
Patient was aggressive as indicated by the following.
11/20/2019... grabbed staff members arm, ...pt pushed other pt in wheelchair...
11/24/201, 0715 (hours) before staff could intervene pt walked up to other patient that had got in an incident and shoved that pt (patient 1) to the ground...
12/03/2019, 1830 (hours), pt voice heard from nurse station. The nurse looked up and saw this pt standing over another patient (patient 1)...

4. Review of facility incident logs included the following. Patient 2 pushed a wheel chair with a patient in it until it fell over on 11/20/2019. Patient 2 pushed patient 1 to the ground on 11/24/2019. Patient 2 and patient 1 incident on 12/03/ 2019, resulting in injury to patient 1.

5. On observation 1/15/2020, at approximately 1600 hours with N2 (Director of Nursing/Registered Nurse) reviewed facility video from 12/03/2020, starting time of 1829 hours. Patient 2 takes cup from table by patient 1. Patient 1 gets up and goes toward patient 2. Patient 1 and patient to are seen pushing each other. Patient 1 hits the floor. Nurses respond 1830 (P1 [Registered Nurse] and P3 [Licensed Practical Nurse]).

6. Interview on 1/15/2020, at approximately 1600 hours with N2 (Director of Nursing/Registered Nurse) confirmed details in video including patients and personnel.

7. Interview on 1/16/2019, at approximately 1225 hours, with N2 (Director of Nursing/Registered Nurse) confirmed incident log indicated, Patient 2 pushed a wheel chair with a patient in it until it fell over on 11/20/2019.

8. Interview on 1/16/2019, at approximately 1227 hours, with N1 (Assistant Director of Nursing) confirmed incident log indicated, patient 2 pushed patient 1 to the ground on 11/24/2019.

9. Interview on 1/15/2020, at approximately 1600 hours, with N2 confirmed incident log indicated, patient 2 and patient 1 incident on 12/03/ 2019 (reviewed on video) resulting in injury to patient 1.

Based on document review and interview facility failed to ensure current Crisis Prevention training for 1 of 6 personnel files reviewed (P6 [Certified Nursing Assistant]).

Findings include:

1, Review of facility policy, Crisis Prevention Intervention, Policy No.: CC.4, last reviewed 9/2018, indicated the following. Purpose: The Nonviolent Crisis Intervention training program focuses on preventative techniques to avoid the use of restraint and seclusion by equipping staff with strategies to intervene through verbal and nonverbal means to create a respectful environment promoting Care, Welfare, Safety, and Security.

2. Review of P6's personnel file indicated Nonviolent Crisis Intervention Training expired on 2/2019.

3. Interview on 01/16/2020, at approximately 1111 hours, with N1 (Assistant Director of Nursing/Registered Nurse) confirmed P6's Nonviolent Crisis Intervention Training expired on 2/2019.