HospitalInspections.org

The facility failed to meet the conditions of participation for Patient's Rights when,

The facility staff failed to intervene when Patient #1 was sleeping in a compromising position. Patient #1 was sleeping in the prone (laying on the stomach) position, placing this and other patients in prone position at risk of airway obstruction resulting in hypoxia (low oxygen), anoxia (lack of oxygen to the brain) and death. (Patient #1 was found pulseless 4 hours later.)

- The nursing leadership failed to implement a neurological assessment policy and failed to train and ensure Physician ordered neurological assessments were completed for three (3) out of eight (8) patients with possible head injuries and Patient #1, following a head injury, was not assessed for neurological changes, placing these and any patient with a fall, at risk of worsening conditions including death from an undiagnosed, untreated, brain hemorrhage (bleed). (Patients #1, 5, 8, and 10)

Cross refer to A144

Based on interview, and record review, the facility failed to protect patient's rights to receive care in a safe setting, that ensures protection and interventions from harm when,

- The facility staff failed to intervene, based on facility policy, when a patient was left sleeping prone (laying on the stomach) while on one to one observation, placing this and other patients left in prone positions at risk of airway obstruction resulting in hypoxia (low oxygen), anoxia (lack of oxygen to the brain) and death. (Patient #1 was found pulseless 4 hours later.)

- The nursing leadership failed to implement a neurological assessment policy and failed to train and ensure Physician ordered neurological assessments were completed for three (3) out of eight (8) patients with possible head injuries and Patient #1, following a head injury, was not assessed for neurological changes, placing these and any patient with a fall, at risk of worsening conditions including death from an undiagnosed, untreated, brain hemorrhage (bleed). (Patients #1, 5, 8, and 10)

Findings include:

According to the National Institute of Health article titled "Trauma Neurological Exam" dated 11/4/22, found at: https://www.ncbi.nlm.nih.gov/books/NBK507915/, stated, "The neurological examination in the setting of trauma is a systematic evaluation of important clinical signs that provide evidence to help determine further management and investigation of the patient's condition...
Indications:
Individuals who sustain any type of significant trauma, especially concerning the cranium and spinal structures, should be evaluated to determine the nature and extent of the injury.
Technique:
...In the setting of trauma, a neurologic examination is focused on identifying and assessing the functions of vital portions of the central nervous system. The exam primarily focuses on testing the patient's mental status, cranial nerves (CN), sensory exam, motor exam, and reflexes."

Review of the facility provided Registered Nurse Department: Nursing Services job description (dated December 28, 2022) reflected,
"POSITION SUMMARY
The Registered Nurse (RN) is a registered professional nurse who coordinates and evaluates patient care through collaborative efforts with health team members in accordance with the nursing process and the standards of care according to Texas Board of Nursing.
Intervention
1. Employ principles of communication, interviewing techniques, problem solving, and crisis intervention when performing psychotherapeutic interventions.
2. Intervention is based on knowledge of psychiatric and medical nursing procedures, as well as the plan of care.
3. Accurately administer and document medication to patients.
4. Transcribe and carry out physician's/licensed practitioner's treatment orders accurately.
5. Utilize appropriate interventions in psychiatric and medical emergencies."

Review of Patient #1's El Paso Behavioral Health medical record reflected an 18-year-old-male admitted with a diagnosis of "Schizophrenic, unspecified." Patient #1 had been placed on an observation level of one-to-one (1:1, continuous observation where staff must be "at arm's length" from the patient at all times) due to multiple attempts to hurt himself in the facility. Patient #1's nursing notes reflected the following attempts to hurt himself:

1/15/23 at 3:35 pm, " ...attempted to throw self on floor, jumping off bed, to hurt self."
1/16/23 at 4:00 pm, " ...throws self on bed, floor, walls."
1/17/23 at 4:00 am, " ...throwing self back."
1/19/23 at 3:15 pm, " ...throwing self back"
1/19/23 at 10:00 pm, " ...Was in room on 1:1 observation when patient fell face forward (headfirst) and hit floor."

Review of Patient #1's, El Paso Behavioral' s mortality board review, dated and signed by the facility's Medical Physician staff on 1/24/23, reflected in part, Patient #1 was sent to the emergency room after a fall on 1/19/23. The patient acquired a chin laceration due to the fall. Patient #1 was stabilized, received derma bond (a clear, fast drying adhesive, used to close wounds not requiring stitches) to the laceration and returned to El Paso Behavioral on 1/20/23 at 12:43 am. Around 6 hours later, a Code Blue was called, and CPR was initiated; 911 was called and the patient was transported back to the emergency room. Patient#1's time of death was called at 7:07 am.

Review Patient #1's, Acute Care emergency room Physician's note dated 1/20/23 at 7:18 am reflected, "During intubation procedure, patient's jaw was very stiff and hard to open ...Upon further evaluation patient' s whole body is very stiff, likely onset of rigor mortis. Unable to move most joints, ED RN and respiratory therapist reported chest very stiff during CPR ..."

Review of facility provided Patient Observations \ Rounds Level of observation 1:1 Form, used by the mental health technicians (MHT) (undated) reflected in part,
"Ensure use of CPAP (continuous positive air pressure) if ordered
Monitor for coughing, wheezing, etc.
Monitor for sedation with medications
Monitor for change in skin coloring
Ensure not sleeping in prone position (laying flat with chest/stomach down)."

Review of the facility provided Special Precautions Guidelines and Patient Policy (revised 9/2017) reflected, "10.3.2 when a patient appears to be resting or asleep, staff should observe for the rise and fall of the patient's chest to assure he/she is breathing without difficulty, observing patient's for a minimum of 3 respirations and/or patient movement is advised for safety."

Review of Patient #1's Patient Observations \ Rounds Form Level of observation 1:1, dated 1/20/23, completed by an unknown staff member from 2:45 am to 3:45 am, then completed by Staff #5, MHT from 4:00 am to 6:30 am reflected Patient #1's sleeping position was documented every 15 minutes from 2:45 am to 6:30 am as sleeping in the prone position. A Registered Nurse (RN) had assessed him at 4:00 am and at 5:45 am, the patient was documented as remaining in the prone position. The document did not reflect the staff intervening or repositioning Patient #1 to his side or back or if the patient's face was unobstructed.

During a telephone interview, on the morning of 2/9/23, Staff #1, CEO stated, "We can't tell someone how to sleep." When informed the facility's 1:1 observation form stated, "Ensure not sleeping in prone position." Staff #1 stated, "Prone is the best position to prevent aspiration, with their head turned to the side." Staff #2, CNO stated, "The 'ensure not sleeping in prone position' is for the patients using a CPAP. The observation form was here before I got here. That is how we have been interpreting it." Staff #2, CNO was unable to provide instructions on using the observation form and how to interpret the form.

Review of Patient #1's Patient Observations\ Rounds Form dated 1/18/23 and 1/19/23 reflected Patient#1 had been recorded as sleeping on his back or side; he did not normally sleep prone.

During an interview, on the afternoon of 1/30/23, in the conference room, when asked if the nurses need to have a physician's order to do Neurological checks following a head injury, Staff #3, Medical Director stated, "No, a nurse can perform an assessment whenever they feel it is necessary." When asked if an order is written for Neurological checks, what was Staff #3, Medical Director's expectation of staff, Staff #3 stated, "I expect the orders will be followed."

Review of multiple patient's medical records revealed the facility's nursing staff had been using a form titled "Frequent Vital Sign and Neurological Assessment Form" (undated). The form had categories of "Witnessed Fall- No Head Injury" and "Unwitnessed Fall- Or Any Injury to Head Area;" one had instructions detailing how and when to complete the forms (Patient #2), some did not (Patients #5, 8, 12).

During an interview on the afternoon of 1/30/23, in the conference room, the different forms the staff had been using for neurological checks were discussed and when asked if the facility had a protocol for the implementation of Neurological checks, Staff #1, CEO, stated, "We don't have a policy for neuro checks."

During an interview on the afternoon of 1/30/23, in the conference room, Staff #2, CNO stated the facility previously had a form, but that they hadn't approved the use of that form. When informed the nurses were completing neurological exams on Seizure patients, Staff #2 reported the nursing staff had not been trained on the completion of Neurological checks and stated, "We'll do more training; they mainly deal with Psychiatric issues."

Review of Patient #5's Physicians orders, dated 9/8/22 at 2250 (10:50 pm), reflected, "TVO (telephone verbal order) Neuro checks x4 times, Notify Dr. of any changes."

Review of Patient #5's Nurses note, dated 9/8/22 at 11:50 pm, reflected, "At 2248 (10:48 pm), pt (patient) fell while in the bathroom. Patient reported feeling 'dizzy' and was helped to his bed ...After fall, pt was assessed for bruising, none was observed, no distress was noted." The note did not specify if the patient was a witnessed or unwitnessed fall or if there was any injury to his head.

Review of Patient #5's Frequent Vital Sign and Neurological Assessment Form dated 9/8/22, reflected the patient's blood pressure, pulse, respirations, oxygen saturation, temperature, pain, and mobility status were documented. Patient #5's LOC (level of consciousness) changes, Hand grasp equal, and PERRLA (pupil, equal, round, reactive to light and accommodation) had not been assessed.


Review of Patient #8's physician's orders, dated 10/18/22 at 11:15 am reflected, "Neuro checks q 15 minutes x 1 hour (every 15 minutes times one hour), then every hour x 4 hours. RE (regarding) status-post fall."

Review of Patient #8's nurse's notes dated 10/18/22 at 11:30 am reflected, "Pt at nurse's station jumping and hitting himself at 1111. Pt. slid down to floor in front of nurse's station hitting his head when hitting the floor. Assisted to a chair to be assessed. Alert and oriented x 4. Respirations noted even and unlabored. Denies any pain/discomfort. ROM (Range of Motion) performed in all 4 extremities without discomfort. Pupils equal, reactive to light and accommodation. Pt continues punching his face with his left hand ..."

Review of Patient #8's Frequent Vital Sign and Neurological Assessment Form dated 10/18/22, reflected, only the patient's blood pressure, pulse, respirations, oxygen saturation, temperature, pain, and mobility status were documented.

Patient #8's LOC (level of consciousness) changes, hand grasp equal, and PERRLA had not been assessed as ordered.


Review of Patient #12's nurse's note dated 11/8/22 at 5:26 pm reflected, "MHT reports patient was in art and attempted to do a handstand, lost his balance and landed on his head ...neuro checks intact, no complaints of pain to the injury."

Review of Patient #12's physician's orders dated 11/8/22 at 5:30 pm am reflected, "Neuro checks q 15 minutes x 1 hour. Notify Dr of abnormal finding or changes in condition"

Review of Patient #12's Frequent Vital Sign and Neurological Assessment Form dated 11/8/22, reflected, only the patient's blood pressure, pulse, respirations, oxygen saturation, temperature, pain, and mobility status were documented.

Patient #12's LOC (level of consciousness) changes, hand grasp equal, and PERRLA had not been assessed as ordered.

During a telephone interview, on the morning of 2/9/23, Staff #2 confirmed the facility's fall policy titled "Fall Prevention: Early Identification, Observation/Precautions, Interventions and Response & Notification" did not include the need for neurological assessments. Staff #2 stated, "We are going to add the neuro checks."