HospitalInspections.org

The facility failed to protect and promote the rights of patients by:

---Failing to provide a clean, sanitary physical environment (A-0144)

---Failing to identify, investigate and respond to reports of patient abuse (A-0145)

---Failing to obtain physician's orders for the use of restraint and seclusion (A-0168)

Based on observation and interview, the facility failed to provide a clean, sanitary environment to patients on the 4 North and 3 North Units. Findings include:

On 9/1/11 at approximately 0930 the 4 North Unit was toured with the CEO. Debris ( paper scraps and dust primarily) was found on both day room floors and on the kitchen floor. Both floors appeared to be dirty in spots. One of two patient rooms (#N404-1) with a newly admitted patient (admission 8/31/11) had a soiled bathroom floor, especially along the edges. Patient #2's room floor was littered with debris and appeared to be soiled in places. In the refrigerator, both patient and staff food was stored in the same refrigerator and cupboards. An undated sandwich, which the CEO acknowledged appeared to come from the facility's kitchen, was found in the refrigerator. The CEO was unable to explain how staff would know when it was no longer safe for consumption. The CEO stated that he did not know of any facility policy against storing patient and staff food together and that facility prepared food should be dated.

On 9/1/11 at approximately 1215 the Chief Nursing Officer (CNO) accompanied the surveyor to the 3 North Unit but assigned MHA #1 to the tour. The kitchen floor appeared to be soiled and felt sticky in places. MHA #1 stated that both staff and patient food was stored in the same refrigerator. The refrigerator had an odor and the shelves were not in clean condition. In the freezer, an unlabeled, half eaten ice cream sandwich was noted. MHA #1 stated that it was not possible to identify who had been eating it or how long it had been in there. On top of the refrigerator, an open box of sugar packets was found, with loose sugar noted on the bottom of the box. In a drawer across from the refrigerator, packets of condiments were stored. Some mustard packets had opened, soiling the sealed packets and the bottom of the drawer.

Based on observation, interview and record review, the facility failed to follow its policies for identifying, investigating and reporting episodes of patient physical abuse, resulting in increased risk of injury for three current patients on the 4 North Unit (#3, #8 and #9) and four discharged patients (#4, #5, #6 and #7.) {It was not possible to identify all patients that patient #2 attempted to injure since some progress notes stated only that patient (#2) attempted to hit or kick unidentified peers.} Findings include:

***Policy 9.02.14, states; "When an individual patient has been identified as a possible victim of abuse or neglect, it shall be referred to the hospital's Recipient Rights Advisor."
***Policy #42, states; "An incident is any unusual occurrence or accident involving a patient... "An incident report should be completed to report the event and/or injury and forwarded to the Risk Manager within 72 hours of the incident." ..... -"When a patient is involved in an incident that may result in an injury, the hospital employee that observed the incident will notify the Director of Nursing or Supervisor on the incidents."..... -"Any unusual matter which may require prompt action on the part of a hospital employee should be immediately reported to the Administration." -"The incident reporting procedure is designed to provide, in a concise form, the information necessary for proper attention to a particular event and a record for review and action."
***Facility Policy .05, Protocol for 1:1 Continuous Observation, states:
"The RN each shift is responsible for assessment/reassessment documentation of the patient's need for 1:1 staffing and obtaining new continuation orders. The RN should evaluate the need for continued 1:1 each shift and contact the physician if the patient no longer requires 1:1 staffing."
"Must be included on the Master Treatment Plan."
-(6.) "The assigned staff is to be free of all responsibilities with the exception of the patient requiring 1:1 observation."
-(7.) "Staff must be within "arm's length distance, eyes on the patient at all times."
***Facility Policy .02, "Interdisciplinary treatment Team Plan/Conference, states: -(9) "The Treatment Plan Review will be conducted on a weekly basis. During the review the team will address: Problems, Progress, and any changes of interventions from Master Treatment Plan, New problems... "
Per the CEO's statement, on 9/1/11 at approximately 1630 hrs., it is the hospitals expectation that all patient complaints and incidents are to be brought to the Recipient Rights Advisor's (RRA's) attention.
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During an interview conducted on 9/1/11 at approximately 0950 hrs. patient #3 stated to this surveyor that he had been bitten by patient #2 at breakfast (at approximately 0740 hrs.) in the 4 North dayroom doorway. Observation of patient #3's right anterior antecubital and forearm areas revealed teeth marks and discoloration, in an area approximately 6 cm long by 4 cm wide. At the top of the area, closest to the patient's head, four bright red tooth shaped marks were observed. A thin dark red line extended across the top two teeth marks. Patient #3 stated that the arm bled at the time of the bite.
Also, on 9/1/11 at approximately 1015 hrs., the Unit Social Worker (SW #1) was asked if she was aware of other patients being injured by patient #2. SW #1 stated that she knew of 3 patients who had been injured by patient #2, (patients #4, #5 and #6.) The Unit Clerk verified these findings. The date of the injury to patient #5 was identified as 8/29/11. The date of the injury to patient #4 was unclear at the time of this interview.
Record review on 9/1/11, from 1300-1600 hrs., of patient #2's clinical record revealed the following episodes patient #2 perpetrated physically abusing or attempting to abuse other patients:

a) 8/13/11, at 2000 hrs., "hitting at staff and peer."

b) 8/19/11, at 1900 hrs., "trying to kick peer and staff."

c) 8/20/11 at 1400 hrs., "Pt. became severely upset and out wildly into dayroom attacking female peer pushing her down."

d) 8/20/11 at 1600 hrs., "pt. running screaming through unit. Dashed at patient and shoved pt."

e) 8/21/11 at 0530 hrs., "(patient #2) ran out of room down hallway into room 408-1 and struck (patient #6) and scratched her forehead with his finger nails..."
8/21/11 at 1350, a Progress Note in patient #6's record states, "pt. was tearful throughout the shift about peers negative behaviors and... Pt. refused breakfast and majority of lunch."
f) 8/21/11, patient #4 was attacked and pinched 3 times according to an investigation conducted by the Recipient Rights Officer on 9/1/11 and reported to this surveyor on .
9/1/11 at approximately 1445 hrs.

g) 8/22/11 at 2000 hrs., "pt. kicking at peers"

h) 8/23/11 at 2000 hrs., "Pt...roaming in other pt. rooms. Pt is walking over peers. Pt. is very intrusive."

i) 8/23/11 at 2100 hrs., "Pt...trying to go in his peers rooms. Pt combative... "

j) 8/29/11 at 1530 hrs., "Pt ran down hallway and went into a female pt. room and scratched her in the face." On 9/1/11 at approximately 1445 hours the Recipient Rights Officer verified with staff that the injured patient #5 was the person injured.
On 9/1/11 at approximately 1400 hrs. the Chief Nursing Officer (CNO) was asked to provide Incident Reports for all episodes involving patient abuse by patient #2, the Chief Nursing Officer (CNO) stated that she was unaware of the allegations of abuse involving patients #4, #5 and #7 and should have been informed. At approximately 1500 hrs. the Recipient Rights Advisor was also asked for this documentation. Only 4 Incident Reports were produced: 1 for patient #7, on 8/17/11, 1 for patient #6, on 8/20/11 and 8/21/11 and 1 for patient # 3, on 9/1/11.
The facility failed to complete Incident Reports (per policy) for 2 of 5 injured patients (#4 and #5) and for 7 episodes of abuse noted in the list (above) 3, a-j. The CNO also verified that all incidents of patient #2 attempting to injure other patients should have been written up on Incident Report forms and forwarded per policy.

On 9/1/11 at approximately 1300 hrs. the Recipient Rights Advisor (RRA) stated that she was not aware of abuse allegations involving patients #4 and #5 but then at approximately 1445, the RRA stated that she had interviewed unit staff and determined that patient #4 was attacked by patient #2 on 8/21/11 and that patient #5 was injured by patient #2 on 8/29/11. At approximately 1500 hours, the Recipient Rights Advisor (RRA) provided an Incident Report documenting another patient injury. Per the report, patient #7 was injured by patient #2 on 8/17/11 at 1600 hrs. The report states that patient #2, "charged into dayroom attacked (patient #7,) scratching pt on right arm." The wound was described as an "abrasion" and it was treated with "laceration ointment" and a dressing."

The facility failed to provide nursing assessments of patient #2 each shift, per policy .05, to determine that level of supervision needed and inform the doctor. On 9/1/11 from approximately 1600-1730 hrs. patient #2's clinical record was reviewed for documentation of Nursing Assessments indicating the need for 1:1 staffing for patient #2. There was no documented evidence of such an assessment. At approximately 1730 hrs. the CNO verified that there was no nursing assessment of the need for supervision of patient #2 done on any shift on the following dates: 8/16/11-8/20/11, 8/23/11 and 8/28/11. The CNO also verified that these assessments should have been done per policy requirements.

Also; the facility failed to provide 1:1 staffing while awake as ordered and according to their policy (.05,) by assigning no 1:1 coverage to patient #2 or assigning staff tasks that might conflict with 1:1 duties, since the patient might be awake, in violation of facility policy. On 9/1/11 from 1200-1800, the CNO stated that a patient with orders for 1:1 staffing while awake is the same as a patient on 1:1 Continuous Observation status if the patient is awake and verified the above findings. Nursing assessments of patient #2's need for 1:1 supervision were not completed per policy.

Review of the "Daily Assignment Sheets" listed the following assignments:

-8/20/11, 2300-0730 hrs., the "Daily Assignment Sheet" states, "1:1 - no staff" for patient #2. (At 1400 hrs. and 1600 hrs. that day, patient #2 had injured 2 other patients.)
-8/17/11 2300-0730, MHA #3, assigned to patient #2's 1:1 while awake, was assigned to work on another floor (3N) that shift. (At 1600 on 8/17/11, per an Incident Report, patient # 2 "charged into the day room and scratched patient #7.")
-8/19/11, 2300-0730 hrs., MHA #4 was assigned to cover a lunch break for MHA #2 at 0330. (Break length was not specified.) A Progress Note 8/19/11, at 1900 hrs. stated that patient #2 was, "trying to kick peer and staff."
-8/23/11, 1500-2330 hrs., MHA #4 was also assigned to monitor visitation and deliver patient snacks for the unit.
-8/23/11, 2300-0730, MHA #3 was assigned to relieve MHA #2 for lunch break at 0400 hrs. (Break length was not specified. Progress note, 8/23/11 at 2000 hrs., stated, "Pt #2...roaming in other pt. rooms. Pt is walking over peers."")
-8/27/11, 2300-0730 hrs., staff #10, was assigned to supervise patient #2 and 2 other patients.
8/28/11, 1100-0730 hrs., MHA #5 was assigned 2 other unspecified.)
-8/29/11, 1100-0730, the MHA assigned to patient #2 was assigned 3 other patients. (At 1530 that day, patient #2's Progress Note stated," Pt ran down hallway and went into a female pt. room and scratched her in the face.")
The facility failed to provide 1:1 staffing while awake as ordered and according to their policy.

Also, the facility failed to document solutions or follow through on the "Corrective Action/Solution" section of the "Incident Report" forms that were completed (3 total).
-8/17/11 this portion of the form was left blank by the nurse who completed the form.
-8/20/11 Nurse #2 recommended, "Keep 1:1 at arm's length."
-9/1/11"he is able to harm other people despite 1:1.
The facility failed to formulate solutions for patient #2's behavior.

Also, on 9/1/11 at approximately 1630 hrs., review of patient #2's "Master Treatment Plan" (IPOS) revealed no documentation of his level of supervision (1:1 supervision while awake.), despite many episodes of abusive behavior to staff and peers, patient #2's IPOS related to behavioral issues had not been updated since 7/29/11.

Also, on 9/1/11 at 1030 hrs. review of patient #2's clinical record revealed that on 8/8/11, patient #2's level of staff supervision was decreased by the physician from 1:1 at all times to 1:1 while awake. (The latter level of supervision has remained in effect through 9/1/11.) There was no documentation in patient #2's clinical record to explain why staff supervision was decreased. On 8/5/11 at 1000 hours, the record states that patient #2, "bit nurse and drew blood." Episodes of physically aggressive behavior were documented in patient #2's Progress Notes on 8/7/11 at 1530 hrs "Two episodes of aggression during Visiting Hours...attempted to punch and bite staff" and at 1940 hrs. "Pt tried to push his way into exam room...started shoving staff." The facility failed to raise the acuity of the patient's 1:1 supervision based on the ineffectiveness of the current supervision level.

Also on 9/1/11 at approximately 1530 hrs, record review with the RRA revealed that patient #6, who was injured by patient #2 on two consecutive days, made a recommendation, received by the facility on 8/22/11, that the facility increase staff supervision of patient #2 to prevent additional patient injuries. --There was no evidence that the patient safety recommendations made by patient #6, who was injured by patient #2 on two consecutive days, had been considered by Administration.

Based on observation, interview and record review, the facility failed to obtain physician ' s orders for patient #2 when he was restrained (including physical management for involuntary medication administration) or secluded 7 times from 8/3/11-9/1/11. Findings include:
***Facility Policy " Restraint and Seclusion, #01, states:
1.(a) " There must be a physician ' s order prior to each use of restraint or seclusion. There are no PRN orders. "
2.(b) " In an emergency situation, when the need for a restraint or seclusion intervention occurs quickly and an order cannot be obtained prior to applying the restraint/seclusion, the order must be obtained during the emergency application or within a few minutes after the restraint or seclusion has been applied."
2.(d) " Written or verbal orders for restraint or seclusion are documented on the " Physician Order From " for the initial restraint or seclusion order. "
Observations, Interviews and Record Review re: patient #2:
1. On 9/1/11 at 1030 patient #2 was observed in the seclusion/quiet room in 4-point leather restraints resting quietly. A physician's order for 4-point restraints had expired at 1010 and a new order had not been obtained.
2. On 9/1/11 from 1030-1200 hrs., record review revealed that patient #2 had been restrained or secluded at the following times without documentation of a physician's orders:
a. 8/3/11, at 1530 hrs., patient #2's progress note states: " Requires repeated directions which is not following ...Attempting to bite, scratch, pinch. Runs down hall. Pulls staff. Aggression. Received Haldol 5 mg. IM (intermuscular injection,). Ativan 2 mg I M and Benadryl 100 mg. IM."
b. 8/7/11, at 940 hrs., IM patient #2' s progress note states: " Pt. started shoving staff. Pt given prn Ativan 2 mg., Benadryl 100 mg. and Thorazine 100 mg. IM."
c. 8/13/11 at 1100 hrs., patient #2's progress note states "increasing agitated and not following directives pt. escorted to the QR (Quiet Room) due to aggression, screaming, biting. Pt. received a PRN to decrease (unreadable word). Pt. remains in the QR until he can display some self control."
d. 8/21/11 at 0530 hrs., patient #2 ' s progress note states: "he (pt. #2) became increasing agitated and aggressive. (Patient #2) was placed in quiet room, he began screaming and kicking on door when (MHA #2) open door and approach ... "
e. 8/21/11 at 0530 hrs., above note continues, stating that after exiting the QR, patient #2 injured another patient and was taken back to the seclusion room: The Restraint/Seclusion form indicates that he was secluded from 0615-0815 hrs. after receiving 100 mg. Benadryl, 100 mg. Thorazine and 2 mg Ativan involuntarily at 0550 hrs..
f. 8/25/11 at 0001, patient #2 ' s progress note states: " Pt is totally psychotic and out of control at this time. PRN was given to decrease stimulization."
3. On 9/1/11 at approximately 1600 hrs., the Chief Nursing Officer verified that the above episodes constituted restraint or seclusion and that no physician orders could be found for any of them..