HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 2 grievances (Pt. #9) reviewed, the hospital failed to ensure that the complaint/grievance was resolved.

Findings include:

1. On 6/14/2024, the hospital's policy titled, "Resolution of Patient Complaints and Grievances" (6/2023) was reviewed and required, "I... This policy establishes a mechanism and procedures to respond, review and resolve patient grievances... E... Grievance: A written or verbal complaint by a patient or a patient's representative regarding the patient's care... F... 3. Reviews the grievance and reviewer responses... 5. Maintains documentation of the steps taken to investigate the grievance process..."

2. On 6/14/2024, the hospital's complaints and grievance logs from January 2024 through June 14, 2024, were reviewed. On 5/10/2024, the log indicated that Pt. #9's caregiver/representative had a grievance regarding the care received from the hospital. Pt. #1 was admitted to the hospital on 5/4/2024 due to aggressive behavior. There was no documentation regarding resolution of the grievance.

3. On 6/14/2024 at approximately 2:00 PM, findings were discussed with E #13 (Senior Vice President Of Quality and Compliance. E #13 stated that there should be documentation regarding resolution of the complaint/grievance.

Based on document review and interview, it was determined that for 5 of 5 patients' (Pt. #1, Pt. #2, Pt. #3, Pt. #4, and Pt. #5) clinical records reviewed regarding informed consent, the hospital failed to ensure that the psychotropic drug consent was completed, as required.

Findings include:

1. On 6/14//2024, the hospital's policy titled, "Patient Rights" (June 2024) was reviewed and required, "... II... Privacy and Confidentiality. To be informed of the... treatment options, including potential risks, benefits..."

2. On 6/14/2024, the hospital's document titled, Psychotropic Medication Notice and Consent Form" (undated) was reviewed and included, "(Names of different psychotropic medication)... The Physician/designee and I discussed 1. The nature of my condition; 2. My physician's reasons for prescribing the medication... 4. Reasonable alternative treatments... 6. The common side effects...I have received the information about the psychotropic medication by means of: [Check those that apply]..."

3. On 6/14/2024, the clinical record for Pt. #1 was reviewed. Pt. #1 was admitted on 5/21/2024 due to schizoaffective disorder and aggressive behavior. The medication administration record (MAR), indicated that Pt. #1 received Lorazepam and Haldol (psychotropic medications) on 5/21/2024 and 5/22/2024. However, the psychotropic consent form was completed on 5/29/2024 (day of Pt. #1's discharge).

4. On 6/14/2024, the clinical record for Pt. #2 was reviewed. Pt. #2 was admitted on 6/12/2024 due to acute psychosis (deviation from reality). The MAR indicated that Pt. #2 was given Lexapro and Haldol (psychotropic medications) on 6/12/2023 and 6/13/2024. However, the psychotropic consent form was incomplete, i.e., Lexapro and Haldol were not checked.. The form also did not indicate that Pt. #2 gave consent for the administration of Lexapro and Haldol.

5. On 6/14/2024, the clinical record for Pt #3 was reviewed. Pt. #3 was admitted on 6/11/2024 due to bipolar disorder (type of mental illness). The MAR indicated that Pt. #3 was given Depakote (psychotropic medication) on 6/12/2024 and 6/14/2024. However, the psychotropic consent form was incomplete, i.e., Depakote was not checked. The form also did not indicate that Pt. #3 gave consent for the administration of Depakote.

6. On 6/14/2024, the clinical record for Pt #4 was reviewed. Pt. #4 was admitted on 6/12/2024 due to bipolar disorder. The MAR indicated that Pt. #4 was given Depakote and Lithium Carbonate (psychotropic medications) on 6/13/2024. However, the psychotropic consent form was incomplete, i.e., Depakote and Lithium were not checked. The form also did not indicate that Pt. #4 gave consent for the administration of Depakote and Lithium.

7. On 6/14/2024, the clinical record for Pt. #5 was reviewed. Pt. #5 was admitted on 6/12/2024 due to major depressive disorder. The MAR indicated that Pt. #5 was given Lexapro on 6/13/2024. However, the psychotropic consent form was incomplete, i.e., Lexapro was not checked.

8. On 6/14/2024 at approximately 10:30 AM, findings were discussed with E #5 (Director of Behavioral Medicine). E #5 stated that the psychotropic medication consent form for the above patients were incomplete. E #5 stated that the form should indicate the name(s) of the psychotropic medication and if the patient gave consent for the administration of the medication/s. E #5 added that the form should be completed prior to administration of the medication.

A. Based on document review and interview, it was determined that the hospital failed to ensure that video surveillance is maintained for at least 30 days for review to conduct a thorough investigation of any safety or security incident. This has the potential to affect current or future safety events that require an investigation.

Findings include:

1. The hospital's policy titled, "Camera use/Reviewing of Footage" (revised 2023) was reviewed and included, "Storage and Retention Requirements Video surveillance data must be maintained on a secure server dedicated to video surveillance and saved for at least 30 days before deletion ..."

2. On 06/13/2024, the hospital provided a "Public Safety Report" dated 05/21/24 at 10:15 AM, and included, "Type of incident: Code Gray (security assistance required) ... (Name of Pt. #1) ... Location 4-E (4-east adult male behavioral health unit) Patient (Pt. #1) above time and date, (Public Safety Officer, PSO/E/#1) was standing on 4E when (Pt. #1) walked past (E #1) swing hitting (E #1). Nursing called a code gray, (Pt. #1) was put in restraints, medicated by nursing staff."

3. On 06/13/2024, video footage of 4-East for 05/21/2024-05/22/2024, was requested. There was no video footage available for review.

4. An interview was conducted with the Director of Security (E #3) on 06/13/24 at 11:45 AM. E #3 stated that E #3, the Vice President of Nursing (E #4) reviewed video footage of an incident that occurred on 05/21/24, that involved (Pt. #1) punching a Public Safety Officer (PSO/E #1). E #3 stated that the video footage was not saved, their surveillance system does not have the capability to save footage unless E #3 saves the video if an incident is reported. E #3 stated that the video surveillance system saves footage for about 7 days, before it is overridden by new footage. E #3 stated that the footage was reviewed due to (E #1) being hit, and to ensure that all staff responded appropriately to the code gray. E #3 did not save the footage since there was no wrongdoing by staff.


B. Based on document review and interview, it was determined that for 1 of 5 records (Pt. #1) reviewed for safety rounding, the hospital failed to ensure that safety rounding was completed and documented in the clinical record.

Findings include:

1. The Hospital's policy titled, "Precautions" (revised 05/2022), was reviewed and required, "...Patient's on 1:1(one to one) ... are under constant visual surveillance at all times ... The RN (registered nurse) will ... ensure that the precautions are maintained as ordered ... b. Precaution sheets are completed in their entirety for all patients on precautions on the Behavioral Units."

2. On 06/13/2024, the clinical record of Pt.#1 was reviewed. Pt.#1 was admitted to the hospital's adult male behavioral health unit with a diagnosis of schizoaffective disorder on 05/21/2-24 at 12:45 AM and was discharged on 05/29/24 at 4:05 PM. The clinical record included the following:

-Physician's order dated 05/21/2024, "1:1 Observation Precaution"

-Precaution and Rounding Sheets from 05/20/2024 at 11:00 PM through 05/29/2024 at 6:45 AM, were reviewed. The clinical record lacked the Precaution and Rounding Sheets for 05/23/2024, 05/25/2024, and 05/29/2024 from 7:00 AM to 2:00 PM.

3. An interview was conducted with the Director of Behavior Health Unit (BHU/E #5) on 06/14/24 a 11:20 AM. E #5 stated that E #5 could not find the Precaution and Rounding sheets for (Pt. #1) for 5/23/24, 5/25/24 and 5/29/24. E #5 stated that E #5 checked the assignment schedules for these dates and staff was assigned for 1:1 observation, and thinks that the flow sheets were misplaced before they were scanned into the clinical record.

Based on document review and interview, it was determined that for 2 of 3 patients' (Pt. #6 and Pt. #7) clinical records reviewed regarding use of violent and/or self-destructive restraints or seclusion, the hospital failed to ensure that the care plan was modified to reflect use of restraint or seclusion as an intervention.

Findings include:

1. On 6/14/2024, the clinical record of Pt. #6 was reviewed. Pt. #6 was admitted on 5/03/2024 due to disorganized thoughts and delusion (deviation from reality). On 5/4/2024 from 6:45 PM through 8:45 PM, Pt. #6 was placed in seclusion due to aggression and combative behavior. The clinical record lacked documentation that the care plan was modified to reflect the use of seclusion as an intervention.

2. On 6/14/2024, the clinical record of Pt. #7 was reviewed. Pt. #7 was admitted on 5/23/2024 due to agitation. On 5/26/2024 from 2:45 PM trough 4:45 PM, Pt. #7 was placed in violent restraints (four point) due to aggressive behavior. The clinical record lacked documentation that the care plan was modified to reflect the use of restraint as an intervention.

3. On 6/14/2024, the hospital's policy titled, "Restraint/Seclusion Policy" (5/2024) was reviewed and included, "I... To provide guidelines for the safe and effective use of restraints and/or seclusion in situations where appropriate to prevent or minimize harm to self or others..." The policy did not include modification of care plan regarding use of restraint or seclusion.

4. On 6/14/2024 at approximately 1:00 PM, findings were discussed with E #5 (Director of Behavioral Medicine). E #5 confirmed that the care plan was not modified. E #5 stated that the care plan should reflect use of restraint and seclusion as intervention.

Based on document review and interview, it was determined that for 1 of 3 clinical records reviewed (Pt.# 1) regarding use of violent and/or self-destructive restraint, the hospital failed to ensure the physicians' orders for restraints were complete.

Findings include:

1. The hospital's policy titled, "Restraint/Seclusion" (revised 05/2024) was reviewed and required, "4. Use of restraint or seclusion must be in accordance with the order of a physician ... 5. In an emergency, a nurse ... may initiate the use of restraint prior to obtaining an MD order ..."

2. On 06/13/2024, the clinical record of Pt.#1 was reviewed. Pt.#1 was admitted to the hospital's adult male behavioral health unit on 5/21/24 at 12:45 AM with a diagnosis of schizoaffective disorder (mental condition with hallucinations, delusions, anxiety). The clinical record included a physician's phone order dated 05/21/2024 at 10:30 AM, "Restraint/Seclusion ... Aggressive behavior threatens safety of others, Attacking sitter and security guard." The order lacked the physician's signature.

3. An interview was conducted with a Registered Nurse (RN-E #8) on 06/14/24 at 10:25 AM. E #8 stated that on 05/21/24, (Pt. #1) had to be restrained due to (Pt. #1) attacked staff (Public Safety Officer/E #1 and Constant Observer/E #2). E #8 stated that a physician order is obtained by the RN for any type of restraint or seclusion, the physician will then sign off on the order. E #8 confirmed that for (Pt. #1) the physician order was not signed.

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt. #6) clinical records reviewed regarding use of restraints or seclusion, the hospital failed to ensure that a face-to face evaluation within 1-hour after initiation of seclusion was completed.

Findings include:

1. On 6/14/2024, the hospital's policy titled, "Restraint/Seclusion Policy" (5/2024) was reviewed and required, "... III... Seclusion: The involuntary confinement of a patient alone in a room or are from which the patient is physically prevented from leaving... IV... 7. Within one (1) hour of restraint/seclusion application for the management of violent or self-destructive behavior, the trained practitioner... must conduct a face-to-face evaluation..."

2. On 6/14/2024, the clinical record of Pt. #6 was reviewed. Pt. #6 was admitted on 5/03/2024 due to disorganized thoughts and delusion (deviation from reality). On 5/4/2024 from 6:45 PM through 8:45 PM, Pt. #6 was placed in seclusion due to aggressive and combative behavior. The clinical record lacked documentation that a face-to-face evaluation was completed.

3. On 6/14/2024 at approximately 1:00 PM, findings were discussed with E #5 (Director of Behavioral Medicine). E #5 confirmed that the clinical record did not include a face-to-face evaluation within one hour after initiation of seclusion. E #5 stated that one hour face to face evaluation is only completed for patients placed in violent restraints.