HospitalInspections.org

Based on video review, observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. This was evidence by:

1) Failing to ensure staff rounded every 15 minutes on 19 (#1-#19) psychiatric patients of 19 (#1-#19) psychiatric patients with 15 minute observations ordered. (See findings under Tag A0144);
2) Failing to ensure staff identified and reported allegations of abuse for 1 (#1) of 1 (#1) patient reviewed for reporting abuse. (see findings under Tag A0145);
3) Failing to ensure the use of seclusion was performed according to hospital policy. This deficient practice is evidenced by failure to notify the family of 1 (#1) of 1 (#1) patients who was placed in seclusion. (See findings under Tag A0167);
4) Failing to ensure the use of restraint was in accordance with the order of a physician or other licensed independent practitioner who was responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. (See findings under Tag A0168);
5) Failing to ensure staff provided continuous monitoring for a patient in seclusion. (See findings under Tag A0175);
6) Failing to ensure a one hour face to face evaluation was performed by a physician, other licensed practitioner, or a trained registered nurse for a patient who was placed and released from seclusion. (See findings under Tag A0178).

Based on video review and interviews, the hospital failed to ensure staff rounded every 15 minutes on 19 (#1-#19) psychiatric patients of 19 (#1-#19) psychiatric patients with 15 minute observations ordered.

Findings:

A review of hospital policy titled Level of Observations last revised 03/01/2023 revealed in part:
Observation Levels:
Every 15 minutes- the staff member will visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities. Physically walks to find each patient on q 15 minute observations. Documents patient's location and reports identified risk to RN when indicated. Documents the location on the close observation form and documents the activity when indicated, e.g., water offered, and etc. Initials the form every 15 minutes.


On 03/21/2024 a review of video footage from 3/20/2024 revealed the following:
8:32 p.m. revealed Patient #1 in hallway.
8:33 p.m. Patient #1walks into Patient #2's room "a" and closed the door. S6MHT was seen in the hallway, she was assigned Patient #1 and Patient #2.
8:42 p.m. Patient R1 is seen coming out his room "b" and going into Patient #2's room "a" and immediately back out.
9:08 p.m. No one is seen going back into Patient #2's room until 9:08 pm Patient #1 exits the room "a". Patient #1 then walks down the hallway to the bathroom.
9:09:05 p.m. Patient #1 enters the bathroom. Staff are noted in the hallway. Patient #1 does not speak with staff.
9:09:59 p.m. Patient #1 exits the bathroom.
9:10 p.m. Patient #1 goes into Patient #2's room "a" and exits at 9:12: 39 with his beddings in his arms.
9:12 p.m. Patient #1 is in the hallway talking with staff.
9:13 p.m. Patient #1 speaks with S4RN.
9:14 pm Patient #1 is seen fighting with Patient R2
9:15:54 p.m. Patient #1 placed in the seclusion room by S5LPN and S6MHT.
9:21 p.m. S4RN checks on Patient #1.
9:29 p.m. S7MHT checks on Patient #1.
9:39 p.m. S4RN let Patient #1out of seclusion.

In an interview on 03/21/2024 at 4:10 p.m. S1RAdm and S2Adm verified the above information and all 19 admitted patients were on q 15 minute observations.

Further review of video footage revealed staff failed to check on Patient #2 from 8:33 p.m. till 9:10 p.m.

In an interview on 03/21/2024 at 4::20 p.m. S1RAdm verified staff failed to conduct observation rounds on Patient #2 as noted above.

In an interview on 03/22/2024 at 1:20 p.m. S1RAdm verified staff did not round from 8:33 p.m. on 03/20/2024 until S7MHT rounded on the 11 female patients at 9:21 p.m. and no one rounded on the 6 male patients till the fight at 9:14 p.m. S6MHT and S7MHT were in the hallway with backs to the hall and S5LPN was in the nutrition room. During this time frame approximately 6-7 residents were in and out their rooms; therefore staff did not do observations for the other 10 patients.

A review of video footage from 03/21/2024 between 2:00 a.m. to 5:10 a.m. S4RN is seen making rounds at 2:55 a.m. and 5:10 a.m.; however, the Mental Health Technicians failed to make rounds on all 19 patients.

In an interview on 03/21/2024 at 4:30 p.m. S1RAdm verified the MHTs failed to round every 15 minutes between 2:00 a.m. and 5:10 a.m. on 03/21/2024.

Based on interviews, the hospital failed to ensure staff identified and reported allegations of abuse for 1 (#1) of 1 (#1) patient reviewed for reporting abuse.

Findings:

A review of hospital policy title Assessment and Reporting of Abuse and Neglect last revised 01/01/2023 revealed in part: 1. Should a staff member identify, or be notified of a suspected case of abuse, neglect, and exploitation, he/ she will notify his/ her immediate supervisor and the Administrator- on - Call and the Director of Nursing (DON) immediately.

On 03/22/2024 at 12:39 p.m. S6MHT stated she was assigned Patient #1 and Patient #2. S6MHT said that Patient #1 told her that Patient #2 threw him on the bed and sucked his privates.

On 03/22/2024 at 12:50 p.m. in an interview S4RN stated she was sitting in the nurse's station and Patient #1 was talking to S6MHT and Patient #1 said he wanted to go home. S4RN also said that Patient #1 said Patient #2 sucked his penis.

In an interview on 03/22/2024 at 10:16 a.m. S2Adm stated S6MHT and S7MHT stated Patient #1 reported the incident to them but they did not believe it because they only saw him go in the room briefly.

In an interview on 03/22/2024 at 10:25 a.m. S3DON verified the staff failed to report abuse per policy.

Based on record review and interview, the hospital failed to ensure the use of seclusion was performed according to hospital policy. This deficient practice is evidenced by failure to notify the family of 1 (#1) of 1 (#1) patients who was placed in seclusion.

Findings:

A review of hospital policy titles Seclusion and Restraints LA/MS last revised 06/01/2024 revealed in part: 5. Notify the family as applicable of seclusion/ restraint.

Family Notification:
1. The legally authorized representative (LAP) shall be notified as soon as feasible but not greater than 24 hours of each episode of seclusion/ restraint initiated in response to a behavioral emergency.
2. The date and time of notification and the name of the staff member providing the notification must be documented in the patient's medical record.
3. Documentation will include an unsuccessful attempts, telephone numbers called, and name of the person spoken with.

A review of Patient #1's medical record failed to reveal documentation his family was notified that he was placed in seclusion.

In an interview on 03/22/2024 at 10:25 a.m. S3DON verified the staff failed to notify Patient #1's family of being placed in seclusion.

In an interview on 03/22/2024 at 12:50 p.m. S4RN stated she did not recall telling Patient #1's mother that Patient #1 was in seclusion with the door closed and locked.

In an interview on 03/22/2024 at 1:08 p.m. S5LPN stated she and S7MHT placed Patient #1 in the seclusion room with the door closed and locked.

Based on policy review, record review and interview, the hospital failed to ensure the use of restraint was in accordance with the order of a physician or other licensed independent practitioner who was responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This deficient practice is evidenced by 1 (#1) of 1 (#1) patients sampled being placed in soft restraints with no physician's order.

Findings:

A review of hospital policy titled Seclusion and Restraints LA/ MS last reviewed 06/01/2023 revealed in part: Additionally, only the trained Registered Nurse may initiate the emergency application of restraint or seclusion prior to obtaining an order from the physician or NPP. The physician/ NPP will be notified as soon as possible after the initiation of seclusion and/ or restraint. The RN will document physician/ NPP contact and physician order on Physician Order for Seclusion and Restraint Form. For facilities with electronic medical record (EMR), the physician or NPP will directly enter the physician's order in the ENR. The physician/ NPP order must include the specific behaviors which constituted the behavioral emergency, specify the reason for restraint or seclusion, the type of restraint, and duration of seclusion or restraint.

In an interview on 03/22/2024 at 10:25 a.m. S3DON verified the staff failed to document any details about placing Patient #1 in seclusion to include and order for the seclusion.

On 03/22/2024 at 12:50 p.m. in an interview S4RN admits the door was closed to the seclusion room and it locks automatically. S4RN denies documenting any of the incident, sexual allegations, fight, or seclusion order.

Based on policy review, video surveillance review and interview the hospital failed to ensure staff provided continuous monitoring of 1 (#1) of 1 (#1) patients observed in seclusion per hospital policy.

Findings:

A review of hospital policy Seclusion and Restraints LA/MS last reviewed 06/01/2023 revealed in part: 3. Utilization of Seclusion: Assign a trained/ competent staff member to provide one- to- one observation of the patient for continuous monitoring while in seclusion.

On 03/21/2024 a review of video surveillance from 03/20/2024 revealed in part:
9:14 p.m. Patient #1 is seen fighting with Patient R2.
9:15:54 Patient #1 placed in the seclusion room by S5LPN and S6MHT.
9:21 p.m. S4RN checks on Patient #1.
9:29 p.m. S7MHT checks on Patient #1.
9:39 p.m. S4RN let Patient #1out of seclusion.

In an interview on 03/21/2024 at 4:10 p.m. S1RAdm and S2Adm verified the above information.

In an interview on 03/21/2024 at 4:12 p.m. S3DON verified staff failed to ensure Patient #1 was continuously monitored while in seclusion.

Based on policy review, record review and interview the hospital failed to ensure a one hour face to face evaluation was performed by a physician, other licensed practitioner, or a trained registered nurse. This deficiency is evidenced by the failure to document a one hour face to face evaluation in 1 (#1) of 1(#1) reviewed patient placed in seclusion.



Finding:

A review of hospital policy title Seclusion and Restraints- LA/MS last reviewed 06/01/2023 revealed in part: 4. Face to face evaluation: A one- hour face to face evaluation must be conducted in person by a physician or other NPP, or trained RN in the absence of the physician or NPP. A telephone call or telemedicine methodology is not permitted.
A review of Patient #1's medical record failed to reveal a documented face to face evaluation after being placed in seclusion. Conduct one hour face to face, if trained to do so, even if the patient is no longer in restrain/ seclusion and physician is not present.
Document on the Face to Face Evaluation Form: date/ time, patient's immediate situation, patient's reaction to the intervention, patient's medical and behavioral condition, need to continue or terminate the restraint or seclusion, behaviors, alternative interventions to prevent restraint/ seclusion, medical review of patient's status post- intervention.

In an interview on 03/22/2024 at 10:25 a.m. S3DON verified the staff failed to document any details about placing Patient #1 in seclusion to include a face to face evaluation after being placed in seclusion.