HospitalInspections.org

Based on interview and record review it was determined the facility registered nurses failed to supervise and monitor the nursing care of 1 of 10 sampled patents (Patient #3), resulting in delayed treatment for Patient #3 and the potential for less than optimal outcomes. Findings include:

Review of Patient #3's medical record revealed she was a 41-year-old female who was involuntarily admitted to the facility on 08/05/2021 with a diagnosis of paranoid schizophrenia. Review of her Petition for Mental Health Treatment order dated 10/08/2021 revealed Patient #3 continued to have paranoid behaviors with breakdowns every morning, believes she has spiritual injections, is being spiritually raped and abused, is responding to internal stimuli and is easily agitated. Nurse note dated 10/31/2021 at 1118 indicated internal medicine contacted regarding order for Patient requesting consult for possible vaginal inspection. Internal medicine recommended follow up with provider after discharge. Patient informed of decision, and stated she needed something for "these sores down there ever since I smelled sperm on me and hair down there, I've had sores". Internal medicine orders dated 10/31/2021 to send Patient #3 to emergency department for evaluation. Nurse Practitioner note dated 10/31/2021 at 1230 indicated Patient #3 complained of vaginal pain, with vaginal discharge "smelled like sperm", bruises, swelling on the inside. She denied any sexual partners in the last two years. The note indicated due to no resources for internal pelvic exam at the facility, Patient #3 to be sent to ER (emergency room) for exam. Patient #3 agreed to this. Nurse note dated 10/31/2021 at 1910 indicated Patient #3 was returning from emergency department with no exam completed due to guardian unable to be contacted. The note indicated internal medicine contacted for possible laboratory testing or medication. Review of the medical record did not reveal any orders for testing or medication to treat patient #3's concerns. Review of facility Reassessment Post Emergency Room Form for Patient #3 dated 10/31/2021 untimed, revealed the skin assessment section to be blank. Review of medical record for Patient #3 from 10/31/2021 until the time of the survey did not reveal an assessment of her vaginal area.

In an interview on 11/18/2021 at 1210 in her room, Patient #3 had difficulty remaining on one subject for longer than a few seconds during the conversation. She discussed her past living situations, her past jobs, her plans, and did not stay on topic during the conversation. When queried about her time at the facility Patient #3 stated she had been on fire with no treatment for three months in her vaginal area. She did tell the surveyor she liked her room, did not want to go to the place the social worker was trying to send her, and did not feel like she had been sexually assaulted. She stated she did find animal hair inside of her.

In an interview on 11/22/2021 at 1500 with Staff O, the Director of Nursing, the surveyor asked her if she was able to review the medical record of Patient #3. Staff O stated she was. Staff O stated Patient #3 did complain of blisters on her vaginal area and nursing did not complete an exam, there was no skin assessment completed on Patient #3. Staff O stated that the skin assessment upon return from the emergency department on 10/31/2021 should have been completed and it was not done. Staff O further commented "per our policy this should have been completed. It is to be completed every time a patient leaves the facility and returns, and a skin assessment is done upon admission and as needed."

Review of facility "Wanding the Patient - Inpatient" nursing procedure, (dated January 2021) on 11/22/2021 at 1600, revealed section 4.3.2: Document any skin abnormalities (i.e., cuts, scratches, bruises, sutures, etc.) on body map. 4.3.4: Any concerns related to skin abnormalities should be communicated to the physician.

In an interview on 11/22/2021 at 1550, Staff Q (Physician) stated he would now order lab testing for Patient #3.