HospitalInspections.org

Based on interview, record review, observation the hospital failed 1 of 1 Patient (Patient #1) the right to receive care in a safe setting.


Findings Include:

Findings Include:

Based on Record Review Patient #1 had an x-ray completed on The hospital x-ray results 04/04/2024 at 5:08PM, "Radiopaque density in the stomach appears to be a drywall anchor screw. Soft tissue neck x-ray normal..Dr. reviewed x-rays, feels like this should pass on it & it's own."

Based on Interview with hospital Staff #3 on 04/09/2024 at 4:30PM, Patient #1 is being monitored daily to ensure that Patient #1 passes items through stool.

Based on Record Review interivew the hospital Staff #3 reported, "These incidents are happening during the day time and it is unknown what or how the Patients are being monitored during the day shift. We learn of these events when arrive on the night shift.'

Based on Record Review Patient #1 in the hospital Multidisciplinary Progress Notes 04/01/2024, 1:30PM, "Writer was called to patient's room. Patient sitting on her bed calm and shaking. Stating she just 'ate half a bag of the heating pack.' Patient MD was called and ordered to send Patient out for Evaluation."

During Interview with hospital Staff #1 on 04/09/2024 at 10:00AM Patient #1's level of observation did not change when the Patient had the heating pad. 'It appears Patient #1 was in the line of sight reported by staff #1 and not on 1:1 when in the room." The observation sheets reflected Patient #1 was on 10minute observations."

Based on Observation of the Seclusion Room on the unit there were two red in color drywall screw anchors exposed that could be twisted out and digested by Patient. Staff #1 was present and informed. Staff #1 response was 'yes.'

During Interview with hospital Staff #6, on 04/09/2024 at 4:40PM Staff #8 was suspended this morning. There is no fullow-up information available to any investigative work or information related to nursing that this staff can provide now that they have been suspended. Thats why they had been suspended.

Policy

The hospital policy Nursing Services 07/2019, "It is our policy to adhere to the overall hospital mission statement, values and goals of Perimeter Healthcare and various state/federal regulator agencies."


The hospital Policy on Nursing Services Assessment and Reassessment of Patients, 07/2019, reflected, "An accurate record of the patient's condition, care, and treatment is provided throughout the hospital visit. Screening and admission assessments and histories are completed upon arrival to the hospital and during admission process on the inpatient units
The hospital Policy on Nursing Services dated 07/17/2019 reflected, "It is the policy of the Perimeter Healthcare Nursing Services Department to provide the highest attain able quality of nursing care to all patients consistent with the mission, values, vision and goals.

The hospital Policy on Neglect 07/2019, Perimeter Healthcare promotes and requires professional, ethical and legal conduct of staff. The advocacy role of healthcare is maximized when addressing issues of conduct of staff."

The hospital Policy on Incident Reporting 07/2019, "The Incident Report is a mechanism for informing administration of the occurrence of circumstances surrounding individual problematic events. An "Incident" is defined as any happening that is not consistent with the normal or usual operations of the hospital and/or department. Injury does not have to occur. The potential for injury and/or property damage is sufficient for an event to be considered an incident. Incidents are reviewed by the Perimeter Healthcare Performance Improvement Committee and referred to other committees as indicated by hospital policy or legal, regulatory or accreditation requirements."

Based on Observation, Interview and Record Review the hospital failed 1 of 1 Patient (Patient#1). By failing performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. Executive Responsibilities, The hospital's governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following. That clear expectations for safety are established.

Findings Include:

Based on Record Review Patient #1 had an x-ray completed on The hospital x-ray results 04/04/2024 at 5:08PM, "Radiopaque density in the stomach appears to be a drywall anchor screw. Soft tissue neck x-ray normal..Dr. reviewed x-rays, feels like this should pass on it & it's own."

Based on Interview with hospital Staff #3 on 04/09/2024 at 4:30PM, Patient #1 is being monitored daily to ensure that Patient #1 passes items through stool.

Based on Record Review interivew the hospital Staff #3 reported, "These incidents are happening during the day time and it is unknown what or how the Patients are being monitored during the day shift. We learn of these events when arrive on the night shift.'

Based on Record Review Patient #1 in the hospital Multidisciplinary Progress Notes 04/01/2024, 1:30PM, "Writer was called to patient's room. Patient sitting on her bed calm and shaking. Stating she just 'ate half a bag of the heating pack.' Patient MD was called and ordered to send Patient out for Evaluation."

During Interview with hospital Staff #1 on 04/09/2024 at 10:00AM Patient #1's level of observation did not change when the Patient had the heating pad. 'It appears Patient #1 was in the line of sight reported by staff #1 and not on 1:1 when in the room." The observation sheets reflected Patient #1 was on 10minute observations."

Based on Observation of the Seclusion Room on the unit there were two red in color drywall screw anchors exposed that could be twisted out and digested by Patient. Staff #1 was present and informed. Staff #1 response was 'yes.'

During Interview with hospital Staff #6, on 04/09/2024 at 4:40PM Staff #8 was suspended this morning. There is no fullow-up information available to any investigative work or information related to nursing that this staff can provide now that they have been suspended. Thats why they had been suspended.

Policy

The hospital policy Nursing Services 07/2019, "It is our policy to adhere to the overall hospital mission statement, values and goals of Perimeter Healthcare and various state/federal regulator agencies."


The hospital Policy on Nursing Services Assessment and Reassessment of Patients, 07/2019, reflected, "An accurate record of the patient's condition, care, and treatment is provided throughout the hospital visit. Screening and admission assessments and histories are completed upon arrival to the hospital and during admission process on the inpatient units
The hospital Policy on Nursing Services dated 07/17/2019 reflected, "It is the policy of the Perimeter Healthcare Nursing Services Department to provide the highest attain able quality of nursing care to all patients consistent with the mission, values, vision and goals.

The hospital Policy on Neglect 07/2019, Perimeter Healthcare promotes and requires professional, ethical and legal conduct of staff. The advocacy role of healthcare is maximized when addressing issues of conduct of staff."

The hospital Policy on Incident Reporting 07/2019, "The Incident Report is a mechanism for informing administration of the occurrence of circumstances surrounding individual problematic events. An "Incident" is defined as any happening that is not consistent with the normal or usual operations of the hospital and/or department. Injury does not have to occur. The potential for injury and/or property damage is sufficient for an event to be considered an incident. Incidents are reviewed by the Perimeter Healthcare Performance Improvement Committee and referred to other committees as indicated by hospital policy or legal, regulatory or accreditation requirements."