HospitalInspections.org

Based on document review and staff interviews, the psychiatric hospital failed to follow their policy and register a grievance for 1 of 3 patients reviewed (Patient #2) after their ex-husband contacted the hospital multiple times with questions and complaints. Failure to register a grievance resulted in Patient #2's ex-husband not having their concerns investigated and formally addressed. The psychiatric hospital's administrative staff identified a census of 51 on entrance.

Findings include:

1. Review of the policy, "Managing Patient Grievances", last approved 06/2023, revealed in part: "...A 'patient grievance' is a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff person(s) present)...The staff person responding to the grievance should speak with the patient or patient's representative (or will designate a staff member to speak with the patient/patient representative), within 24 hours of the receipt of the complaint to clarify the issues and inform the patient of the time frame for investigation and written response."

2. Review of Patient #2's medical record revealed they were transferred from an ED and admitted on 8/18/23. Patient #2 had an admitting diagnosis of disorganized schizophrenia (disorganized speech, thinking and behavior).

3. During an interview on 10/24/23 at 1:15 PM, Psychiatric Mental Health Nurse Practitioner (PMHNP) H recalled that Patient #2's ex-husband had sent them a long email outlining multiple concerns and then PMHNP H had had quite a long conversation with him. Described him as "relentless", kept saying that he should get all of Patient #2's information, stated he was trying to get guardianship.

4. During an interview on 10/24/23 at 2:20 PM, the Chief Medical Officer (CMO) revealed that they knew the Director of Business Development had had interactions with Patient #2's ex-husband when he came to the area outside of the psychiatric hospital, he had signs and seemed to be protesting at the psychiatric hospital. The CMO did not interact with Patient #2's ex-husband.

5. During an interview on 10/24/23 at 2:55 PM, Director of Business Development recalled visiting with Patient #2's ex-husband three times: once in the hospital lobby when Patient #2's ex-husband inquired about getting medical records, and then twice when he came to the area outside the hospital carrying signs that said "fraud" and "false imprisonment". Director of Business Development listened to his concerns and took that information back to the leadership team to discuss.

6. Review of patient grievances 7/1/23 to present revealed there was no grievance associated with Patient #2's stay at the psychiatric hospital.

7. During an interview on 10/25/23 at 9:00 AM, Patient Advocate I could not recall receiving a grievance related to Patient #2's stay. Confirmed that if the concerns were not quickly resolved it should have come to them for follow-up. As far as Patient Advocate I knew there had been no investigation and written follow-up related to Patient #2's ex-husband's concerns.

Based on document review and staff interviews, the psychiatric hospital's administrative staff failed to ensure 1 of 3 patients reviewed (Patient #1) received timely and appropriate evaluation and treatment after sustaining a hand injury after punching a wall. Failure to ensure timely and appropriate evaluation and treatment after sustaining a hand injury resulted in Patient #1 being evaluated and treated for the hand injury at another facility after being discharged from the psychiatric hospital. The psychiatric hospital administrative staff identified a census of 51 patients on entrance.

Finding include:

1. Review of policy, "Daily Nursing Assessment and Progress Note", effective 5/2023, revealed in part: "Nursing staff members are responsible for documenting clinical observations and care that he/she deliveries/provides to each patient". Nurses should document "...All injuries, illnesses and unusual health situations, new behaviors etc."

2. Review of Patient #1's psychiatric hospital medical record revealed in part:
a. On 7/16/23 at 11:17 PM, Patient #1 was admitted to the psychiatric hospital after eloping from Residential Care Program A (supervised independent living). Patient #1 complained of self-harming behavior, and suicidal thoughts with a plan to cut themselves.
b. On 7/23/23 at 9:20 PM, RN A documented that Patient #1's right wrist and hand were red and swollen after they were punching walls. Patient #1 refused ice. RN A put in a med consult (request for a medial provider evaluation).
c. On 7/23/23, RN B noted that at about 5:35 PM Patient #1 started punching the walls in the unit and put a very large hole in the wall. RN B did not document any type of assessment for injuries.
d. On 7/24/23 at 11:10 AM, RN C noted that patient complained of hand pain due to punching walls. No other medical concerns. RN C did not document any type of assessment for injury.
e. On 7/24/23 at 1:15 PM, RN D noted that Patient #1 started kicking and punching walls. RN D did not document any type of assessment for injury.
f. On 7/24/23 at 3:30 PM, RN D noted that Patient #1 started punching walls again, and had pulled the hand sanitizer out of the wall. Patient #1 was assessed, redness noted on knuckles, no swelling, denied pain. Med consult again placed for right hand.
g. On 7/25/23 at 11:45 PM, RN G documented that Patient #1 punched the wall multiple times and broke it. RN G did not document any type of assessment for injury.
h. On 7/26/23 at approximately 3:30 PM, Patient #1 was discharged back to Residential Care Program A.
i. Chief Medical Officer's (CMO) Discharge Summary noted that Patient #1 had required as needed medications due to property destruction and self-injurious behaviors. CMO did note note any type of hand injury or medical evaluation.

3. Review of Patient #1's Urgent Care B medical record revealed in part:
a. On 7/26/23 at approximately 3:00 PM, Patient #1 was seen at Urgent Care B for complaints of right hand pain that they had had for approximately two days. Patient #1 stated they had been punching walls at the psychiatric hospital and Residential Care Program A Youth Care Worker E had brought Patient #1 to Urgent Care B after Patient #1 was discharged from the psychiatric hospital. Patient #1's hand was swollen, and Patient #1 had pain with movement of their 5th finger. On further exam, Advanced Registered Nurse Practitioner F noted mild flexion limitation in Patient #1's right hand fingers, mild tenderness in the right hand, dorsal (back of hand) swelling in right hand, and mild swelling in certain joints of the right hand.
b. Patient #1's x-ray was negative for acute fracture or dislocation. Ace wrap was applied and they were advised to rest, ice, and elevate their hand.

4. During an interview on 10/19/23 at 1:45 PM, RN B explained that they were the House Supervisor and were often called to assist and then document what they observed. Confirmed that they likely would not have done an assessment for injuries, that would have been the responsibility of the assigned RN.

5. During an interview on 10/24/23 at 9:35 AM, RN D did not recall Patient #1 but explained that it is the responsibility of the next shifts to ensure that the med consult had been done. Explained that the med consult is put into the computer and it will prompt you until it is completed.

6. During an interview on 10/24/23 at 9:00 AM, RN G recalled that Patient #1 was agitated after they hit the wall with their hand, and RN G did not want to further agitate Patient #1 so RN G did not do any type of assessment for injuries. RN G was aware of Patient #1's history of hitting walls and thought that in the past Patient #1 had been sent to the ED for evaluation.

7. During an interview on 10/19/23 at 2:15 PM, CMO explained that psychiatric hospital had contracted providers who managed the medical needs of patients as needed. CMO confirmed that the physician who was contracted to do the medical consult for Patient #1's hand missed the order so a medical evaluation was not completed.

8. During an interview on 10/16/23 at 2:40 PM, Youth Care Worker E stated they came to transport Patient #1 back to Residential Care Program A after they had been discharged from the psychiatric hospital. Patient #1 had asked for medical attention from a psychiatric hospital staff member in front of Youth Care Worker E before they left the psychiatric hospital but the staff member did not do any type of evaluation or treatment. Youth Care Worker E recalled Patient #1's hand looked "awful", so Youth Care Worker E took Patient #1 to Urgent Care B.

I. Based on document review and staff interviews, the psychiatric hospital's administrative staff failed to ensure a nursing care plan was developed for 2 of 3 patients reviewed (Patient #2 and Patient #3). Failure to ensure a nursing care plan was developed could potentially result in nursing care that was not individualized and focused on each patient's specific medical and psychiatric problems which could result in substandard nursing care. The psychiatric hospital's administrative staff reported a census of 51 patients on entrance.

Findings include:

1. Review of policy "Nursing Standards of Practice", last approved 02/2023, revealed in part, "On admission, the nurse initiates the collection of data concerning the health status and emotional state of the person...Problem lists are derived from admission data and are formulated in the nursing care plan...Nursing actions are consistent with the care plans..."

2. Review of Patient #2's medical record revealed they were transferred from an ED and admitted on 8/18/23. Patient #2 had an admitting diagnosis of Disorganized Schizophrenia (disorganized speech, thinking and behavior). Patient #2 was discharged on 8/23/23. Medical record lacked a nursing care plan.

3. Review of Patient #3's medical record revealed that they were admitted on 9/14/23. Patient #3 had an admitting diagnosis of Major Depressive Disorder. Patient #3 was discharged on 8/18/23. Medical record lacked a nursing care plan.

4. During an interview on 10/25/23 at 9:30 AM, Nurse Manager J confirmed that both Patient #2 and Patient #3's medical records lacked a nursing care plan.

II. Based on document review and staff interviews, the acute care hospital's administrative staff failed to ensure a nursing care plan was kept up to date for 1 of 3 patients reviewed (Patient #1). Failure to ensure a nursing care plan was updated contributed to Patient #1 requiring medical attention at another facility after discharge from the psychiatric hospital. The psychiatric hospital's administrative staff reported a census of 51 patients on entrance.

Findings include:

1. Review of the policy "Nursing Standards of Practice", last approved 02/2023, revealed in part, "The individuals progress or lack of progress toward goal achievement directs reassessment, reordering of priorities, new goal setting, and revision of the nursing care plan and the treatment plan... The plan includes documentation of all resolved problems and dates of resolution."

2. Review of Patient #1's medical record revealed:
a. On 7/16/23 Patient #1 was admitted to the psychiatric hospital.
b. On 7/23/23 at 9:20 PM, RN A documented that Patient #1's right wrist and hand were red and swollen after they were punching walls. Patient #1 refused ice. RN A put in a med consult (request for a medial provider evaluation).
c. On 7/23/23, RN B noted that at about 5:35 PM Patient #1 started punching the walls in the unit after returning from the cafeteria, and Patient #1 put a very large hole in the wall at the end of a hall. RN B did not document any type of physical assessment for injuries.
d. On 7/24/23 at 11:10 AM, RN C noted that Patient #1 complained of hand pain due to punching walls. RN C did not document any type of assessment for injury.
e. On 7/24/23 at 1:15 PM, RN D noted that Patient #1 started kicking and punching walls. RN D did not document any type of assessment for injury.
f. On 7/24/23 at 3:30 PM, RN D noted that Patient #1 started punching walls again, and had pulled the hand sanitizer out of the wall. Patient #1 was assessed, redness noted on knuckles, no swelling, denied pain. Med consult again placed for right hand.
g. On 7/25/23 at 11:45 PM, RN G documented that Patient #1 punched the wall multiple times and broke it. RN G did not document any type of assessment for injury.
h. On 7/26/23 at approximately 3:30 PM, Patient #1 was discharged.
i. CMO Discharge Summary noted that while hospitalized Patient #1 required as needed medications due to property destruction and self-injurious behaviors. CMO did note note any type of injury or medical evaluation to Patient #1's hand.
j. Nursing Care Plan lacked any reference to Patient #1's hand injury, and lacked dates for any other problem resolution.

3. During an interview on 10/24/23 at 9:35 AM, RN D could not recall if the careplan had been updated but stated chances were good that it had been if this had been happening the whole time. RN D acknowledged that after an incident like this they should check to make sure the care plan was updated.

4. During an interview on 10/24/23 at 9:00 AM, RN G could not remember whether or not the care plan had been updated but acknowledged that should be part of the process after this type of incident.

5. During an interview on 10/25/23 at 9:30 AM, Nurse Manager J confirmed that Patient #1's care plan had not been updated to include a hand injury, also shared that they would expect to see dates when other problems were resolved.