HospitalInspections.org

Based on document review and interview, the facility failed to ensure care in a safe setting; ineffective 1:1 observation of a patient; failed to follow P&P (policy/procedure) related to patient observation for 1 of 10 MRs (Medical Record) reviewed. (Patient # 7).

Findings include:

1. Review of hospital policy titled: "Patient Rights and Responsibilities", Policy Stat ID 10359862, indicated on page 3, under PROCEDURE, have right to; 18. "Receive care in a safe setting, free from... physical abuse", Last revised 9/2021.

2. Review of hospital policy titled: "Patient Observation", Policy Stat ID 12931622, indicated on page 2, under PROCEDURE, 3. Level III - 1:1 Observation, 1. "The patient is to be under constant visual observation by an assigned staff member, regardless of other unit activities"; 2. "Staff member must remain in close proximity to the patient". Last revised 1/2023.

3. Review of Patient # 7's MR (Medical Record) indicated the following:
(a). Patient # 7 admitted on 8/30/23, on 100 unit (room 110); diagnosis of Bi-polar disorder; history of Unspecified Dementia. Patient discharged on 9/11/2023.
(b). Provider orders by NP # 51 (Nurse Practitioner - Psychiatric), on 8/30/2023 at 11:45 am, indicated 1:1 Observation - wandering into other room/bathrooms.
(c). Nurse note on 9/2/2023 for 7 am - 7 pm - reflected patient confused, roamed in rooms, milieu and other patients rooms. Patient continued 1:1; often redirected. Found patient in patient room; a room that wasn't hers/his. BHA (Behavioral Health Associate) observed patient being punched in chest; redirected patient into her/his room. Large bruise saw on her/his chest, 15 minutes after being directed to her/his room.

4. Review of incident report; for patient # 7; dated 9/2/2023 at 2:40 pm, reflected the following:
A. Patient lying in another patient's bed; was punched in chest, upper left.
B. Other patient followed her/him into his/her room and with closed hand hit her/him in chest.
C. Purple discoloration noted to patient's chest.

5. In interview on 10/3/2023 at approximately 12:52 pm with N # 5 (Registered Nurse - Staff), confirmed the following:
A. Recalled that patient # 7 wandered into another patient's room (Patient # 3) and had gotten hit by patient # 3.
B. Patient # 7 was a wanderer; intrusive. Patient was on a 1:1.
C. Patient # 7 was probably not being watched as closely as she/he should have been; not watched good enough.

6. In interview on 10/3/2023 at approximately 2:40 pm, with S # 21 (BHA - staff), confirmed the following:
A. Patient into another patient's room; was fast; got hit by another patient; witnessed by another BHA.
Patient # 3 will lash out.
B. Patient # 7 was intrusive; constantly moving; on 1:1 observations.

7. In phone interview on 10/4/2023 at approximately 12:50 pm, with S # 20 (BHA - staff), the following was confirmed:
A. Don't recall if patient # 7 on a 1:1, but should have been. Was not assigned to any 1:1 that day.
B. Patient wandered to other patient rooms. Not entirely sure how she/he was able to get into room so quick and get punched. Walked into room, after seeing patient (Patient # 7) go into other patient's room (Patient # 3), to redirect patient. Patient # 3 was in room already. Patient # 7 got hit before could get all the way into room.

Based on document review and interview, the Registered Nurse failed to follow the P&P (Policy & Procedure) related to Assessment/Reassessment, for documentation completed in a patient's MR (Medical Record), for 1 of 10 MRs reviewed. (Patient # 7).

Findings include:

1. Review of hospital policy titled: "Assessment/Reassessment", Policy Stat ID 12386392, indicated on page 1, under POLICY, 3. "scope and intensity of further assessment performed is dependent upon the patient's ..... response to any previous care"; 5. "Assessment is on-going as appropriate throughout the hospital stay", 7. "Nursing will re-assess each patient every shift ... and document findings". Last revised 9/2022.

2. Review of Patient # 7's MR (Medical Record) indicated the following:
(a). Patient # 3 admitted on 8/30/23, on 100 unit; diagnosis of Bi-polar disorder; history of Unspecified Dementia.
Patient discharged on 9/11/2023.
(b). MAR (Medication administration record) reflected on 9/3/2023 that patient was administered Tylenol 650 mg (milligram) po (per mouth) for pain. Documentation on MAR lacked a time when administered.
(c). Daily Nursing Assessment on 9/3/2023, reflected pain score of "0" for day shift and lacked an entry for pain assessment & pain score for night shift.
(d). Nurse notes on 9/3/2023 at 7:00 pm & 10:00 pm, reflected no entry(ies) for any patient complaints of pain, nor Tylenol that was administered, nor any re-assessment(s) after Tylenol.
(e). Daily Nursing Assessments for pain score and assessments also lacked entries for the following: 8/30/2023 for day shift & night shift, and 9/1/2023 for day shift.

3. In interview on 10/3/2023 at approximately 12:52 pm with N # 5 (Registered Nurse - Staff), the following was confirmed:
A. MR documentation lacked entries for pain assessment; time Tylenol given, for re-assessment, and effectiveness of pain medication given.
B. Should have been documented; completed. Policy not followed.