HospitalInspections.org

Based on document review and interviews, the hospital failed to ensure 1 of 1 patients (P1) reviewed who was assigned to an employee for 1:1 supervision was kept free from abuse after a staff member, Employee L/behavior health technician, was witnessed by other staff members to push P1. Staff notified the charge nurse but the charge nurse failed to report the witnessed event according to hospital policy and procedure and in accordance with State Statutes. Findings include:

P1 was admitted to the hospital on 2/27/15 due to increased paranoia and delusions. Diagnoses included schizophrenia with possible bipolar affective schizoaffective disorder. P1 had disorganized thoughts, impaired cognition, agitation, and anxiety with compromised judgement and insight.
Progress notes, dated 4/3/15, at 4:54 p.m. noted P1 was agitated, ritualistically turned lights on/off, striking at staff and spitting which required 1:1 supervision. Progress notes, dated 4/3/15 at 9:03 p.m. noted P1 was agitated, attempted to strike staff, spitting, and was very disorganized with a labile mood.

Hospital internal investigation documentation dated 4/8/15, noted on the evening of 4/3/15 Employee I/nurse and Employee K/behavior health technician witnessed Employee L push P1, causing him to fall to the floor. Employee I reported the incident to Employee H/charge nurse who failed to report the event to the supervisor on duty and failed to notify Employee F/nurse manager. Staff schedule for 4/4/15 and 4/5/15 noted Employee L worked from 3:00 p.m. -11:30 p.m. on the Adult Behavior Health Unit.An interview with Employee F/nurse manager was conducted on 6/4/15 at 10:10 a.m. and she stated she received an email from Employee I on 4/6/15 when she returned to work after the weekend. The email explained that Employee L was witnessed to push P1 and P1 fell to the floor. Staff on duty told Employee L that he was being inappropriate. Staff reported the witnessed abuse event to Employee H/registered nurse. Employee L worked the whole shift of the evening of 4/3/15. Employee F followed up with hospital administration and human resources on 4/6/15. An investigation was initiated and Employee L was notified he was suspended pending the investigation. The hospital later terminated Employee L. An interview with Employee G/social worker was conducted on 6/4/15 at 7:40 a.m. and she stated on 4/9/15 she was informed by administration about the witnessed abuse event and directed to notify the state agency.An interview was conducted with Employee J/ behavior health technician on 6/3/15 at 6: 45 p.m. and he stated he responded to P1's room when he heard a noise. Employee J stated he saw P1 lying on the floor. Employee J stated Employee L did not call for assistance despite staff in the vicinity to assist as needed.
An interview with Employee I was conducted on 7/1/15 at 11:40 a.m. and she stated on the evening of 4/3/15, exact time unknown, she witnessed Employee L escort P1 to his room due to some exhibited behaviors on the unit. Employee L stood in the doorway of P1's room. P1 walked toward Employee L. Employee L pushed P1 which caused P1 to fall to the floor. Employee I and Employee K immediately responded to P1's room to assist and assess P1. Employee I stated she told Employee L to go on break and Employee K took over the 1:1 supervision for P1. P1 had no noted injuries. Employee I then informed Employee H that Employee L pushed P1 and caused him to fall to the floor. Employee I stated she sent an email to Employee F to inform her of the witnessed abuse. An interview was conducted with Employee K on 7/1/15 at 1:05 p.m. and he stated on the evening of 4/3/15 he witnessed Employee L waving his arms in an exaggerated manner which agitated P1. Employee K told Employee L that it was inappropriate to taunt P1. Within a minute or so, P1 walked toward Employee L. Employee L then pushed P1, which caused P1 to fall to the floor.

An interview was conducted with Employee H on 6/3/15 at 5:55 p.m. and she verified she was notified of the incident on the evening of 4/3/15 by Employee I who witnessed the incident. Employee H stated she did not notify the administrative representative on duty nor contact the unit nurse manager. Employee H verified she was the charge nurse on duty the evening of 4/3/15. Employee H stated she did not report the incident because Employee I who informed her was also an RN. Employee H verified Employee L worked the entire shift on the evening of 4/3/15. Employee H acknowledged as charge nurse, Employee H was responsible for the unit and patients the evening of 4/3/15.Review of the hospital policy and procedure, Vulnerable Adult, Reporting Maltreatment of, last revised on 1/13, was conducted and noted, "I. Suspected maltreatment of a patient receiving service at any....facility and and....employee is suspected/accused of maltreatment. A. Any employee who witnesses, suspects maltreatment, or is informed of an event involving an....employee immediately report the event to their supervisor. During off shifts/weekends/holidays events are reported to Administrative Representative or designee.....When an internal report is received.......deciding if the report must be forwarded to the Common entry Point. The report must be forwarded within 24 hours."

Based on documentation review and interview, the hospital failed to renew the physician order within four hours of the initiation and continuation of a restraint intervention for 1 of 4 adult patients (P1) reviewed who exhibited violent or self-destructive behavior. Findings include:P1 was a 45 year old man who was admitted to the adult behavioral health unit of the hospital on 2/27/15. P1 exhibited aggressive behaviors, was angry, hallucinating, combative, yelling, screaming, and threatening violence.Documentation flow sheets, dated 3/31/15, noted staff initiated restraints for P1 at 4:10 a.m. due to P1's exhibited behaviors of anger, anxiousness, being combative, disoriented, and threatening violence. Hospital staff contacted the physician who reordered the restraint intervention at 7:07 a.m. for continued thrashing, anger and combative behaviors exhibited by P1. Hospital staff continued the restraint intervention until 12:02 p.m. when the restraints were discontinued for P1. Review of the physician orders revealed the hospital staff failed to receive a physician order for continued restraint use after 11:07 a.m., four hours after the previous physician order for restraint intervention for P1.An interview was conducted with Employee F/nurse manager on 6/3/15 at 1:50 p.m. and she verified staff should have contacted the physician for a restraint renewal order since 4 hours had passed since the previous order and the restraint continued as an intervention for P1.Review of the hospital policy and procedure, Restraint and Seclusion, last revised 5/12, noted "V. Time Limits A. Violent or Self Destructive Restraint Orders. When an order for restraint/seclusion is written for management of violent or self-destructive behavior, it may only be renewed within the following time limits.....Time Limits: 1. 4 hours for adults 18 years of age or older....."

Based on documentation review and interview the hospital failed to ensure a face to face evaluation was completed within one hour after initiation of a restraint intervention for 1 of 4 patient's (P1) reviewed who had a restraint intervention. Findings include:Review of the hospital restraint documentation flow sheet, dated 3/16/15 at 8:20 a.m., noted restraints were initiated for P1 when P1 exhibited behaviors of anger, hallucinating, was delusional, confused, and disoriented. The restraint documentation flow sheet noted there was an in-person face to face evaluation performed within one hour of initiation of the restraint. Review of the progress documentation notes revealed no physician face to face documentation until 10:37 a.m.An interview was conducted with Employee F/nurse manager who verified the restraint order was received on 3/16/15 at 8:30 a.m. but the physician face to face was not completed until 10:37 a.m. which exceeded the one hour time limit for a physician face to face evaluation after a new restraint order or renewal of an order from a physician.
Review of the hospital policy and procedure, Restraint and Seclusion, revised last 5/12, was conducted and noted "XII. Additional Monitoring Requirements-Violent or Self-Destructive behavior..... iv. Document on facility's documentation flow sheet....1. The face to face evaluation 1 hour after initiation of restraint/seclusion by a physician......"