HospitalInspections.org

Based on clinical record review, review of investigative notes, written statements, policy and procedure reviews and interviews, it was determined that:


1. The facility failed to protect the personal privacy of 1 (Patient #12) of 15 (#1-15) patients in that a visitor was able to view the patient in a state of undress and while experiencing bodily functions. See A-143 for details.


2. The facility failed to ensure one (Patient #12) of fifteen (#1-15) ED patients received care in a safe setting in that Registered Nurse (RN) #3's hand made deliberate contact with Patient #12's buttock while Patient #12 was on his hands and knees on an ED stretcher, the above mentioned contact was not recognized or reported as possible abuse, was left alone in an ED exam room on a ED stretcher while on hands and knees, was visible while unclothed and experiencing bodily functions to patient/visitors, was restrained without assessment of behavior necessitating restraint, without physician's order for restraint and without monitoring for toileting, nutrition and hydration and circulation. See A-144 for details.


3. The facility failed to protect the rights of Patient #12 in that the policy and procedure titled "Abuse and Neglect, Suspected", numbered ONO15PCS, was not followed. The facility failed to follow the Abuse and Neglect, Suspected policy in that ED staff did not recognize and report possible abuse, an incident report was not initiated, and chain of command was not involved. See A-145 for details.


4. Based on clinical record review, restraint log review and interview it could not be determined one of one (Patient #12) patient was placed in restraints in the Emergency Department (ED) without an assessment, without an order ormonitoring of the patient while in restraints on 06/23/16 and 06/24/16 to ensure the immediate physical safety of Patient #12, other patients, and staff. See A-154 for details.



Failure to protect patient rights did not allow Patient #12 to receive care in an environment which protected his right to privacy, dignity, respect and care in a safe setting. The failed practice affected Patient #12 and had the potential to affect any patient in the ED.

Based on clinical record review, interview, and policy and procedure review, it was determined there was no evidence the facility obtained consent for care from 4 (#9, #11, #12 and #14) of 15 (#1-15) patients. Failure to obtain consent for care did not allow the patient or their representative to make a clear, informed and knowledgeable decision regarding their care. The failed practice affected Patients #9, #11, #12 and #15.


Findings:


A. Review of Patient #9's clinical record revealed no evidence of signed consent for care. The above findings were confirmed by Clinical Informatics Analyst #3 during an interview at 1500 on 07/07/16.


B. Review of Patient #11's clinical record revealed no evidence of signed consent for care. The above findings were confirmed by Clinical Informatics Analyst #3 during an interview at 1511 on 07/07/16.


C. Review of Patient #12's clinical record revealed no evidence of signed consent for care. The above findings were confirmed by Clinical Informatics Analyst #3 during an interview at 1055 on 07/07/16.


D. Review of Patient #14's clinical record revealed no evidence of signed consent for care. The above findings were confirmed by Clinical Informatics Analyst during an interview at 1515 on 07/07/16.


E. Review of the policy and procedure titled "Surrogate Decision Maker" received from the Compliance Officer at 1120 on 07/07/16 revealed the following under IX. When Should Consent be obtained: A. Informed consent should be discussed sufficiently prior to the proposed treatment or procedure to provide the patient with adequate time to deliberate.

Based on interview and review of investigation notes, it was determined the facility failed to protect the personal privacy of 1 (#12) of 15 (#1-15) patients in that a visitor was able to view Patient #12 in a state of undress and while experiencing bodily functions. Failure to protect the personal privacy of Patient #12 did not afford him the basic right of privacy and dignity. The failed practice affected Patient #12.


Findings:


A. During an interview with the Emergency Department (ED) Nurse Manager at 1515 on 07/06/16, she stated she was "called by an anonymous person stating someone might have been struck on the bare behind." The ED Nurse Manager stated she did not have a patient name. The ED Nurse Manager stated she immediately called HR (Human Resources). The ED Nurse Manager stated she then interviewed the two nurses (Registered Nurse #2 and #3) independently of each other. The ED Nurse Manager stated the nurses told her the inner core door was left open so they could observe the patient. The ED Nurse Manager stated the nurses told her the patient was up on all fours on the stretcher with his head down and was defecating while in that position. The ED Nurse Manager stated RN #2 and #3 told her they hung sheets on the side rail of the ED stretcher to try and protect Patient #12's privacy.


B. Review of the ED Nurse Manager's investigative note received from the Chief Nursing Officer at 1430 on 07/07/16 revealed the ED Nurse Manager "spoke with a Ms. (NAMED) at 1250 on 06/27/16. NAMED stated she saw a nurse strike a patient on the buttocks that was on all 4s and the nurse said to "stop it." The patient was seen having a bowel movement on the bed. She described the nurse that did this as mid-height, blonde hair, heavy-set and believed her name was (first name of RN #3). Caller stated she was here with her mother and didn't want to give other information. I thanked her and assured I would investigate.


C. Review of RN #3's statement received from the Chief Nursing Officer at 1430 on 07/07/16 revealed the following: "...was walking past room 208... and noted pt (patient) to be up on hands and knees rocking back and forth with his head tucked down on stretcher. (NAMED-RN #2) who was the patient's primary nurse was standing there and I looked at her and told her "your patient has the farts or is crapping the bed." "I placed my blankets on the counter and went into the patient room to check on patient and noted the patient to be having a bowel movement in the bed. I placed my hand on his buttock to let him know I was behind him and to alert him to my presence because the patient had been violent on previous shift and had an altered mental status. ... I then stated "stop pooping you are not on a toilet." He stated I'm sorry and laid down in the bed on top of the stool and rolled over onto his back..."


D. Review of RN #2's statement received from the Chief Nursing Officer at 1430 on 07/07/16 revealed the following: "Friday morning I rec'd (received) report on a pt suspected to have overdosed on an unknown substance who had been placed in restraints d/t (due to) inappropriate actions and violence on the previous shift. He remained minimally responsive and mostly incoherent and refused to wear a gown or even be covered with a sheet without becoming sexually inappropriate. Restraints were released by myself as soon as I came on shift and he required the blinds to be opened as well as the door in order to monitor him as closely as needed and a soiled linen container was placed in the doorway to obstruct the view from room 203 (pt was in 208) when that door was opened. Later that morning, (NAMED-RN #3) was walking past the room and noticed the patient up on his hands and knees as well as the smell of stool, as she entered the room I stood up from my desk to see if I needed to assist (my desk was in the direct line of sight to the room) and watcher her touch the pt on the buttock as he was defecating in the bed, and tell him to "Stop, you're not on the toilet!" The pt then stopped, laid back down, and was cleaned up by (NAMED-RN #3), (NAMED) and myself while the pt laughed with us all and required constant reminders to not further cover himself in stool."


E. The findings in A, B, C and D were confirmed by the CNO during an interview at 1500 on 07/07/16.

Based on staff interview, review of investigative notes and review of written statements provided by two (#2 and #3) registered nurses, it was determined the facility failed to ensure 1 (#12) of 15 (#1-15) ED (Emeregency Department) patients did not receive care in a safe setting as follows:


1. Registered Nurse (RN) #3's hand made deliberate contact with Patient #12's buttock while Patient #12 was on his hands and knees on an ED stretcher. The above mentioned contact was not recognized or reported as possible abuse. The failure to recognize as potential abuse did not protect the patient from the alleged perpetrator during his ED stay.


2. Patient #12 was left alone in an ED exam room on a ED stretcher while on hands and knees which did not protect his physical safety.


3. Patient #12 was unclothed and experiencing bodily functions to patient/visitors which did not protect his right to respect and dignity.


4. Patient #12 was restrained without assessment of behavior necessitating restraint, without physician's order for restraint and without monitoring for toileting, nutrition and hydration and circulation.


The failed practice affected Patient #12 and had the potential to affect any patient who presented to the ED. Findings:


A. During an interview with the ED Nurse Manage at 1515 on 07/06/16 she stated Patient #12 was "up on all fours" on the ED stretcher and that if staff tried to staff in the exam room with him, his behavior worsened - "masturbated."


B. Review of the investigative note dated 06/27(16) handwritten by the ED Nurse Manager, received from the CNO at 1430 on 07/07/16 revealed the following; "spoke with Ms. (NAMED) @ (at) 1250 - she stated that she saw a nurse strike a patient on the buttocks that was on all 4s and the nurse said to "stop it." The pt (patient) was seen having a bowel movement on the bed ..."


C. Review of the clinical record of Patient #12 revealed no evidence of the above behaviors in A and B., an assessment of behavior necessitating restraints, physician's order for restraints, and restraint monitoring for toileting, nutrition and hydration as well as circulation.


D. During an interview with the Chief Nursing Officer at 1500 on 07/07/16 she confirmed the findings in B and C.

Based on interviews, investigative note review, employee statement review, and policy and procedure review, it was determined the facility failed to protect the rights of Patient #12 in that the policy and procedure titled "Abuse and Neglect, Suspected," numbered ONO15PCS, was not followed. The facility failed to follow the Abuse and Neglect, Suspected policy in that ED staff did not recognize and report possible abuse, an incident report was not initiated, and chain of command was not involved. Failure to follow the above policy and procedure did not allow for a thorough investigative process per the policy, did not ensure upper management staff was aware and involved, and did not allow for identification of staff knowledge deficits, staff re-education and quality assurance monitoring. The failed practice affected Patient #12 and had the potential to affect any patient with suspected abuse or neglect.


Findings:


A. During an interview with the Emergency Department (ED) Nurse Manager at 1515 on 07/06/16 she stated when she received the complaint she immediately called Human Resources (HR). She then talked to Registered Nurse (RN) #2 and #3 separately. The ED Nurse Manager requested written statements from RN #2 and #3. Upon receiving the written statements, the ED Nurse Manager concluded there was no allegation of abuse.


B. Review of the ED Nurse Manager's handwritten note, received at 1430 on 07/07/16 from the Chief Nursing Officer (CNO) revealed the following: "spoke with a Ms. (NAMED) at 1250 on 06/27/16. NAMED stated she saw a nurse strike a patient on the buttocks that was on all 4s and the nurse said to "stop it." The patient was seen having a bowel movement on the bed. She described the nurse that did this as mid-height, blonde hair, heavy-set and believed her name was (first name of RN #3). Caller stated she was here with her mother and didn't want to give other information. I thanked her and assured I would investigate. 1315 contacted (NAMED) in HR to see how to move forward/schedule investigation. (NAMED and NAMED - RN #2 and #3) were both on duty - fitting description. 1345 - spoke with (NAMED/RN #2) and (NAMED/RN #3) immediately after à (left facing arrow) provided me with typed statements on 6/28."


C. Review of the incident/accident/occurrence log and the complaint log received from the Facility Compliance Officer at 1400 on 07/06/16 did not reveal any reports involving Patient #12.


D. Review of the policy and procedure titled "Abuse and Neglect, Suspected," numbered ONO15PCS, received from the Facility Compliance Officer at 1000 on 07/06/16 revealed the following:


"Definitions:


Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes deprivation by an individual of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being ...


POLICY:


IV. All hospital co-workers (as mandated reporters) must report suspected abuse or neglect or face possible disciplinary action from the state (per responsibilities as outline below.) In addition to state reporting requirements, there are regional and local laws that require all health related professionals to notify other agencies, such as police.


V. Staff Responsibilities:

A. Patient Care Staff 's responsibility:

i. Remove the patient from imminent physical danger (as needed) and ensure the patient is protected at all times while the investigation is in progress.

ii. Initiate the chain of command: notify the supervisor (Department Manager or House Supervisor) immediately.

iii. Complete an incident report (should be completed by the staff person identifying the potential abuse.) (refer to "Incident Reporting Information System" policy.)


B. Department Manager of House Supervisor responsibilities:

1. Continue the chain of command. Notify the Executive Director of Nursing of the service line and CNO.

2. Notify social worker for interview and further follow-up.

3. Notify the Risk Manager.


C. Risk Manager Responsibilities:

i. Oversee and facility the investigation of occurrence.

ii. Ensure report is made to the appropriate state agency within 24 hours of identification of suspected abuse/neglect/misappropriation/other inappropriate actions/injuries of unknown origin.

iii. Take necessary corrective action depending on the results of the investigation(s).

iv. Analyze occurrences to determine needed change to prevent future occurrences ....


IX. ADULT ABUSE/NEGLECT:


A. Adult Abuse


i. Adult abuse is the willful infliction of bodily harm to a person aged 18 or older by a spouse, child, family member, legal guardian, or a primary caregiver.

1. This definition would cover physically abusive acts such as slapping, hitting, punching, sexual abuse, weapon injuries, burns and other physical injuries. "

E. The findings in C and D were confirmed by the CNO during an interview at 1500 on 07/07/16.

Based on clinical record review, restraint log review, written statements provided by Registered Nurse #2 and #3, and interview, it was determined one of one (#12) patient was placed in restraints in the Emergency Department (ED) without an assessment, physician's order for restraint, and monitoring of the patient while in restraints. The failed practice affected Patient #12 and had the likelihood to affect any patients placed in restraints in the ED.


Findings:


A. During an interview with the ED Nurse Manager at 1515 on 07/06/16, she stated Patient #12 was restrained in the ED due to bowel movement on the ED stretcher, patient defecating on himself and performing other inappropriate sexual behavior.


B. During an interview with the CNO at 1500 on 07/07/16, she confirmed the use of restraints on Patient #12.


C. Review of Patient #12's clinical record revealed the following:

1. No documentation of behavior necessitating restraints.

2. No documentation or evidence of an assessment to determine the need for restraints.

3. No documentation or evidence of the type of restraint used.

4. No documentation or evidence of alternative measures attempted before the use of restraints.

5. No documentation or evidence of a physician ' s order for restraint to include justification for use, type of restraint used, precautions or other consideration, providers name and timed signature.

6. No assessment, reassessment, monitoring or care of Patient #12 to include minimally every two hour assessment for circulation, mental status, behavior, skin condition, level of distress and agitation, toileting, nutrition or hydration.


The above findings were confirmed by Clinical Informatics Analyst #3 1055 on 07/07/16.

Based on clinical record review, interview and policy and procedure review, it was determined there was no evidence 4 of 4 (#8, #10, #11 and #12) Emergency Department patients were reassessed every four hours by a registered nurse per policy and procedure. Failure to reassess the patient every four hours did not allow the nursing staff to be aware of any changes in the patient's condition and initiate treatment accordingly. The failed practice affected Patients #8, #10, #12 and #14.


Findings:


A. Review of the clinical record of Patient #8 revealed the initial nursing assessment was performed at 0105. There was no evidence of another nursing assessment before the patient was discharged at 0758. The above findings were confirmed by Clinical Informatics Analyst #3 during an interview at 1500 on 07/07/16.


B. Review of the clinical record of Patient #10 revealed the initial nursing assessment was performed at 1042. There was no evidence of another nursing assessment before the patient was discharged at 1914. The above findings were confirmed by Clinical Informatics Analyst #3 during an interview at 1505 on 07/07/16.


C. Review of the clinical record of Patient #12 revealed the initial nursing assessment was performed at 2015 on 06/23/15, and a second nursing assessment was performed by Registered Nurse (RN) #1 at 0338 on 06/24/16. There was no evidence of any other assessments including restraint monitoring until 1600 on 6/24/16 by RN #4. There was no evidence of insertion of the foley catheter. The above findings were confirmed by Clinical Informatics Analyst #3 during an interview at 1055 on 07/07/16.


D. Review of the clinical record of Patient #14 revealed the initial nursing assessment was performed at 0005 on 06/26/16. There was no evidence of another nursing assessment before the patient was discharged at 0606 on 06/26/16. The above findings were confirmed by Clinical Informatics Analyst #3 during an interview at 1515 on 07/07/16.


E. Review of the policy and procedure titled "Documentation: Patient Assessment and Coordination of Care received from the Compliance Officer at 1120 on 07/07/16 revealed the following under II. Assessment (shift)/Reassessment, A. Assessment/Reassessment is completed by the shift primary RN. iii. Emergency Department: Completed every 4 hours or more frequently as indicated by the patient ' s plan of care or changes in patient condition. ..."


The above findings were confirmed by Clinical Informatics Analyst #3 during an interview at 1055 on 07/07/16.