HospitalInspections.org

Based on document review, observation, and interview, it was determined that the Hospital failed to protect and promote each patient's rights by ensuring care in a safe setting. As a result, the Condition of Participation, 42 CFR 482.13 Patient Rights was not in compliance.

Findings include:

1. The Hospital failed to ensure care in a safe setting by failing to ensure the monitoring of patients as ordered. (A-144 A)

A. Based on observation, document review, and interview, it was determined that for 8 of 20 patients (Pts. #3-#10) observed on the Adult Behavioral Health Unit, the Hospital failed to ensure care in a safe setting by failing to ensure the monitoring of patients as ordered.

Findings include:

1. An observational tour of the Adult Behavioral Health Unit was conducted on 1/31/2023, at approximately 10:00 AM. The unit consisted of 20 beds and their were 20 patients on census at the time of the tour. At approximately 10:10 AM, a Mental Health Technician (E#10) was observed with the patient rounding clipboard. The Precaution Flow Sheets from 1/31/2023 were reviewed at that time and indicated that every 15 minute monitoring for 8 patients (Pts. #3-#10) were last completed at 8:45 AM (over 1 hour ago).

2. The clinical records of Pts. #3-#10 were reviewed on 1/31/2023. These records lacked documentation of completion of observation rounds on 1/31/2023 from 8:45 AM through 10:10 AM and included the following:
- Pt. #3 was admitted on 1/27/2023 with a diagnosis of psychosis. Physician orders for suicidal, elopement, and assault precautions were placed on 1/27/2023. The Precaution Flow Sheets dated 1/27/2023, 1/30/2023, and 1/31/2023 did not indicate that Pt. #3 was monitored for elopement precautions as ordered.
- Pt. #4 was admitted on 1/27/2023 with a diagnosis of major depressive disorder. Physician orders for suicidal precautions were placed on 1/28/2023.
- Pt. #5 was admitted on 1/14/2023 with a diagnosis of psychosis. Physician orders for close observation were placed on 1/15/2023 and assault precautions on 1/25/2023. The Precaution Flow Sheet, dated 1/16/2023, lacked documentation that every 15 minute rounding was completed for Pt. #5 between 9:45 PM and 11:45 PM (2 hours). The record did not include any documentation to indicate the patient was off of the unit or why rounds were not conducted on this patient during this time.
- Pt. #6 was admitted on 1/28/2023 with a diagnosis of suicidal ideation. Physician orders for suicidal precautions Q15 (every 15) minutes were placed on 1/28/2023.
- Pt. #7 was admitted on 1/27/2023 with a diagnosis of suicidal ideation. Physician orders for suicidal precautions Q15 minutes were placed on 1/27/2023.
- Pt. #8 was admitted on 1/25/2023 with a diagnoses of suicidal ideation and depression. Physician orders for suicidal precautions Q15 minutes were placed on 1/26/2023.
- Pt. #9 was admitted on 1/26/2023 with a diagnosis of suicidal ideation. Physician orders for suicidal precautions Q15 minutes were placed on 1/26/2023.
- Pt. #10 was admitted on 1/20/2023 with a chief compliant/diagnoses of suicidal ideation and delusions. Physician orders for close observation monitoring (Q15 minutes) were placed on 1/20/2023.

3. The Hospital's policy titled, "Patient Observations and Precautions" (dated 10/2022), was reviewed on 1/31/2023 and required, "The monitoring for safety of patients at risk for harm to self or others is an essential part of the Inpatient Behavioral Health Unit... Precautions are specified by the type of behavior that puts the patient at risk to harm self or others... A patient may be placed on a precaution for suicide, close observation, assault, elopement, sexual acting out, arson, seizures, fall, or other identified risk... The precaution order consists of identification of the potential risk behavior to be observed for and a level of observation.... There are three levels of observation: q15 minutes (every 15 minutes), Line of Sight (LOS), and one to one (1:1)... minimum level of observation, q15 minute checks... Staff will complete the Precaution Flow Sheet as rounds are made, using the coding system described on the form. Staff will observe the patient and note his/her behavior, location... Staff will initial appropriate documentation in the designated areas."

4. An interview was conducted with E#10 on 1/31/2023, at approximately 10:10 AM. E#10 stated that he started rounding at approximately 9:00 AM; however, stated that he was just given the sheets for the 8 patients just a moment ago. E#10 stated that he has not yet completed rounds for these 8 patients and was unsure who conducted rounds prior to now. E#10 stated that the expectation is to complete the rounds every 15 minutes and document in real-time when the rounds are being conducted.

5. An interview was conducted with the Charge Nurse (E#11) on 1/31/2023, at approximately 11:00 AM. E#11 stated that patient observation rounds are conducted minimally every 15 minutes for every patient and stated that rounds should be documented at the time they are being done. E#11 stated that if the patient was off the unit at the time, there should be documentation on the flowsheet to indicate such. E#11 reviewed Pt. #5's medical record and could not determine why Pt. #5's precaution flow sheet on 1/16/2023 was left blank between 9:45 PM to 11:45 PM. E#11 stated that the purpose of doing rounds is for early identification of any changes in a patient's behavior that may pose a risk. E#11 stated that it is important to document the type of precautions a patient is on so that staff know to look for specific behaviors when conducting the rounds. E#11 stated that for example, a patient on elopement precautions should be monitored for lingering around/watching the exits of the unit.


B. Based on document review and interview, it was determined that for 3 of 7 clinical records (Pts. #12, #13, #14) reviewed for incidents of physical assault/combativeness, the Hospital failed to ensure care in a safe setting by failing to implement or increase precautions for patients exhibiting aggressive/assault behaviors.

Findings include:

1. The Hospital's policy titled, "Patient Observations and Precautions" (dated 10/2022), was reviewed on 1/31/2023 and required, "The monitoring for safety of patients at risk for harm to self or others is an essential part of the Inpatient Behavioral Health Unit... Precautions are specified by the type of behavior that puts the patient at risk to harm self or others... A patient may be placed on a precaution for... assault... ASSAULT: Patient expressing ideation of hurting others... Patient has difficulty maintaining control either verbally or physically and has exhibited recent act(s) of physical aggression that could have possibl[y] resulted in serious injury to others... A RN [Registered Nurse] may increase the level of observation if the patient's condition changes. The physician will be notified as soon as possible of the change in condition..."

2. The clinical record of Pt. #12 was reviewed on 2/1/2023. Pt. #12 was admitted on 10/10/2022, with a diagnosis of suicidal ideation. Pt. #12 was on suicide precautions starting 10/10/2022.

Nursing Notes included the following:
10/11/2022 at 12:35 PM: "Patient is labile, anxious and verbally aggressive. Keep coming to the nurses station demanding for different things."
10/11/2022 at 6:31 PM: "Patient is anxious, verbally aggressive, and disrespectful to staff and peers."
10/12/2022 at 11:49 AM: "Pt is agitated, difficult to redirect, constricted affect, inappropriate interactions with staff and other pts, provocative so that he can argue... Pt is unable to follow rules and states that he is going to fight staff and pts. Pt is cursing at staff. Continuing plan of care..."
10/12/2022 at 1:28 PM: "Pt became angry, yelling, and began threatening staff, then began trying to punch staff and shoved staff into wall, pt could not be calmed or redirected, code grey [security alert] called..."

Physician's Orders, Nursing Notes, and Observation/Precaution Sheets from 10/11/2022-10/13/2022 were reviewed and lacked documentation that Pt. #12 was not placed on assault precautions before or after the incident of physical assault on 10/12/2022, at approximately 12:58 PM.

3. The clinical record of Pt. #13 was reviewed on 2/1/2023. Pt. #13 was admitted on 8/30/2022, with a diagnosis of suicidal ideation. The A&R [Assessment & Referral] Assessment, dated 8/30/2022, indicated that Pt. #13 had a history of physical violence towards others, verbal threats towards others, past thoughts of wanting to harm others, engaging in risk taking behaviors, and destruction of property or vandalism. Pt. #13 was on suicide precautions starting 8/30/2022.

Nursing Notes included the following:
9/2/2022 at 2:35 PM: "Patient noted in the day very agitated, cursing, getting in the face of staff and his peers. Staff attempted to redirect patient and patient put his hands on the staff and another patient..."
9/4/2022 at 9:50 AM: "Patient [Pt. #13] verbally threatened two patients while in the day room and got spanked in the face by one of them [Pt. #14]. Small amount of bleeding noted from the nostrils...."

Physician's Orders, Nursing Notes, and Observation/Precaution Sheets from 8/30/2022-9/9/2022 were reviewed and indicated that Pt. #13 was not placed on assault/aggression precautions until 9/4/2022 at 12:47 PM (following the injury from a physical assault), despite exhibiting signs of aggression two days prior on 9/2/2022.

4. The clinical record of Pt. #14 was reviewed on 2/1/2023. Pt. #14 was admitted on 9/3/2022 with diagnoses of depression, suicidal ideation (SI), and auditory hallucinations. The A&R Assessment, dated 9/3/2022, included, "[Pt. #14] here for evaluation due to SI and HI [homicidal ideation]... He also says he wants to 'hurt people.' ... he wants to hurt people because he is 'angry.' When asked what he is angry about he said he does not know he just feels angry. He also endorses auditory hallucinations telling him to hurt other people..." The assessment indicated that Pt. #14 had the following risk factors for violence/homicidal ideation: command hallucinations or delusions, engaging in risk taking behaviors, and having past thoughts of wanting to harm others. Pt. #14 was on suicide precautions starting 9/3/2022.

A Nursing Note, dated 9/4/2022 at 10:34 AM included, "Patient [Pt. #14] got irritated by a male patient [Pt. #13] verbally threatening peers in the Day room and spanked the male patient [Pt. #13] in the face as he walked past him with a book..."

Physician's Orders, Nursing Notes, and Observation/Precaution Sheets from 9/3/2022-9/5/2022 were reviewed and indicated that Pt. #14 was not placed on assault/aggression precautions until 9/4/2022 at 10:26 AM (following the incident of physical assault), despite presenting with homicidal ideation and risk factors for violence upon admission.

5. An interview with the Psychiatrist (MD#1) was conducted on 2/1/2023, at approximately 3:10 PM. MD#1 stated that if a patient is admitted with a history of or current homicidal ideation and is making statements that he/she is angry and wants to hurt others, he/she should be placed on assault precautions upon admission. MD#1 stated that in other cases, if the patient doesn't present with aggressive behaviors/history on admission, but starts to exhibit aggressive behaviors such as making threats to staff and trying to put their hands on them, then assault precautions should be initiated. MD#1 stated that nursing staff are able to initiate precautions as needed and are expected to notify the physician if there are changes to the patient's behavior. MD#1 stated that it is important to put patients on the appropriate precautions so that all staff are aware of what behaviors to monitor for to prevent injuries/incidents between patients and/or staff.

Based on document review and interview, it was determined that for 2 of 2 staff (E#1 and E#15) reviewed for restraint training, the Hospital failed to ensure that staff performing the 1-hour face-to-face evaluation had the required training as specified by Hospital policy associated with the 1- hour face-to-face evaluation.

Findings include:

1. The Hospital's policy titled, "Restraint and Seclusion" (dated 1/2022), was reviewed on 2/1/2023 and required, "Qualified RN [Registered Nurse] (QRN): A licensed RN who has received additional training in performing the required face to face assessment. Qualifications include successful completion of 'Competency Based Training for Conducting the One Hour Face-to-Face Assessment for Patients in Restraints or Seclusion.' American Psychiatric Nurses Association [APNA]... Patients placed in restraint/seclusion for violent or self-destructive behavior, a face-to-face evaluation is performed between the LIP [licensed independent practitioner] or trained, qualified RN (QRN) and the patient..."

2. The clinical record of Pt. #5 was reviewed on 1/31/2023. The record indicated that Pt. #5 was placed in violent/behavioral (4 point = both wrists and both ankles) restraints on 1/23/2023 at approximately 11:00 AM per physician's orders. The One Hour Face to Face Evaluation was completed by RN (E#1) on 1/23/2023 at 11:03 AM.

3. The clinical record of Pt. #11 was reviewed on 1/31/2023. The record indicated that Pt. #11 was placed in 4-point violent/behavioral restraints on 11/27/2022 at 8:00 AM per physician's orders. The One Hour Face to Face Evaluation was completed by RN (E#15) on 11/27/2022 at 8:30 AM.

4. The personnel files of E#1 and E#15 were requested for review. The files lacked documentation of the required APNA training regarding completion of one hour face-to-face evaluation.

5. An interview was conducted with the Chief Nursing Officer (E#4) on 2/2/2023, at approximately 1:45 PM. E#4 stated that they could not find evidence of the required training regarding the one hour face-to-face evaluation in E#1's and E#15's personnel records.