HospitalInspections.org

Based on record reviews and interviews, the facility failed to ensure that nursing staff documented accurate assessments and events that occurred for 2 of 8 patients (#2 and #8) reviewed. This deficient practice placed all patients in the facility at high risk for undetected, untreated serious illness and/or injury.
Findings included:

Patient#2:
Record review of the facility in-patient geriatric psychiatric unit records revealed the following information:
- Patient #2 was a 69-year-old male who presented to the emergency room under emergency detention on 08/13/2021 for mental decompensation. Further review revealed that he was nonverbal except for saying his name and was catatonic.

- Record review of the Physician's History and Physical, dated 08/16/2021 revealed the following:
-Patient is a 69-year-old-male, history of depression and dementia who was brought to the hospital under emergency detention due to patient not being able to care for self. Wife brought the patient in given that she was concerned for his safety. Emergency detention explains that the patient was taken to his primary care doctor and upon evaluation it was determined that his mental health is declining. Patient was non-verbal except for saying his name ... Patient was initially started on low dose Risperdal for dementia related perceptual disturbances. Patient only able to reply to his name. Severe, advanced dementia, catatonic, total care.

- Record review of the Braden Skin Assessments for Patient #2 revealed the following:
-08/13/2021 at 07:26 am: Physical Condition: N/A, Mobility: Very Limited, Activity: Bedfast, Sensory Perception: Slightly Limited, Friction and Sear: Potential Problem, Nutrition: Adequate. (Score 14)
-08/13/2021 at 08:00 pm: Physical Condition: N/A, Mobility: Very Limited, Activity: Bedfast, Sensory Perception: Slightly Limited, Friction and Sear: Potential Problem, Nutrition: Adequate. (Score 14)
-08/14/2021 at 12:57 pm: Physical Condition: N/A, Mobility: Very Limited, Activity: Bedfast, Sensory Perception: Slightly Limited, Friction and Sear: Potential Problem, Nutrition: Adequate. (Score 14)
-08/15/2021 at 02:45 am: Physical Condition: N/A, Mobility: Very Limited, Activity: Bedfast, Sensory Perception: Slightly Limited, Friction and Sear: Potential Problem, Nutrition: Adequate. (Score 13)
-08/15/2021 at 09:40 am: Physical Condition: N/A, Mobility: Very Limited, Activity: Chairfast, Sensory Perception: Slightly Limited, Friction and Sear: Potential Problem, Nutrition: Adequate. (Score 15)
-08/15/2021 at 08:06 pm: Physical Condition: N/A, Mobility: No Limitations, Activity: Walks frequently, Sensory Perception: No Impairment, Friction and Sear: No apparent problem, Nutrition: Adequate. (Score 22)
-08/16/2021 at 07:49 am: Physical Condition: N/A, Mobility: Completely Limited, Activity: Bedfast, Sensory Perception: Completely Limited, Friction and Sear: Problem, Nutrition: Probably Inadequate. (Score 7)

- Further review of the facility medical record revealed no evidence that nursing staff notified Patient #2's physician of his high risk for skin breakdown, and/ or enacted any nursing interventions (nursing care plan) in regard to skin breakdown.

In an interview conducted on 11/08/2022 at 1:00 PM, facility Nursing administrative staff confirmed the inconsistences in nursing documentation for patient #2, and the lack of documentation regarding nursing follow-up and skin care interventions/ care planning.

Patient #8:
Record review of emergency department records revealed the following:
A.) Patient #8 was a 62-year-old female who presented to the emergency room under emergency detention for mental decompensation.
B.) Physician #1 documented on 04/05/2021 at 04:50 that Behavior Assessment Team agrees with inpatient hospitalization. Awaiting Covid-19 results. While obtaining Covid-19 test, patient had refused and required more force than expected. She has left forearm pain. Will obtain an X-ray of the forearm. Time: 04/05/2021 at 06:50: Assessment: Forearm X-ray is negative.
C.) Nurse #1 documented on 04/05/2021 at 04:38 that patient #8 became physically aggressive while performing Covid test.

Review of emergency department documentation failed to reveal how facility staff were able to obtain a Covid test since patient #8 became physically aggressive while facility staff obtained the Covid test.
Review of Patient #8's medical record revealed a restraint/seclusion episode on 04/7/2021 at 2300. The restraint lasted 2 minutes and the seclusion was documented as lasting 20 minutes. Documentation of the face-to-face nurse evaluation after the restraint/seclusion was done on 04/08/2021 at 0048 did not reveal any injuries to patient #8.
Review of facility incident report dated 04/13/2021 at 11:41 revealed the following documented by the Nursing Director of Geri-Psych Unit: Patient (#8) report injury because of being placed in seclusion. While in seclusion, staff reports patient physically attacked spit on RN; Patient has bruises to both lower right and left wrist and some bruising to upper right arm; patient (#8) placed in seclusion for approximately 20 minutes. Security also involved with event and assistance with emergency medication.
Interview on 11/08/2022 at 1:35 PM with facility administrative staff confirmed there was no documentation of Security being involved with patient #8 receiving a Covid test or Security assisting with giving her emergency medication after being placed in seclusion on 04/07/2021.
Interview on 11/10/2022 at 1:20 PM with Nursing Director of Geri-Psych Unit revealed but was not limited to the following: "If Patient #8 had been restrained at any point during her emergency department/inpatient admission, it should have been documented."