HospitalInspections.org

Based on document review and interview the facility failed to provide care in a safe setting in 3 of 3 patients.

On 10/25/2011 at 1:45 PM patient (Pt) #1 medical record (MR) was reviewed and revealed 7/26/2011 9:57 medical screening: diagnosis of Dementia, Osteoporosis, Anemia, Cerebral Vascular Accident, Hypertension, Chronic Obstructive Pulmonary Disease, Hyperlipidemia and Depression. Emergency Department course: Pt has Urinary tract infection, most likely causing her agitation will admit for intravenous feeding and intravenous antibiotics.

The MR revealed Pt #1 was admitted on 7/27/2011 at 16:30 to the senior care unit. The record reflects an "83 year old escorted by ambulance staff via stretcher. Pt is unable to sit in the admissions area for admission due to physical status. Pt is total care and non-verbal with staff. Pt yells "momma" frequently and screams out loudly. Pt has slight contracture of upper extremities, is disoriented, incoherent at times and incontinent. She was placed in bed and positioned by staff on to her left side for comfort."

Further review reveals 7/29/2011 13:33 Therapist/social services note: "Therapist attempted to meet individually with patient to obtain history, provide therapy, and to help develop treatment and aftercare plans. Pt unable to participate in interview. Pt appears disoriented, agitated, and uncooperative. Pt shows no insight and cannot acknowledge a need for inpatient or outpatient treatment. Pt has difficulty communicating. Pt has difficulty interacting appropriately with staff or peers."

Further review of MR revealed on 8/3/2011 at 15:16 nursing documentation reflects "Pt continues to be disruptive in groups due to audio visual hallucinations. Pt yells out "Mary" or "Momma" constantly. Pt is labile and easily distraught if not redirected." At 15:57 patient #1 was placed in a chair in the day room. Nursing documentation reflects "Pt sitting in day room, loud, disruptive, verbally aggressive with staff."

Further review of MR reveals at 17:47 Pt #1 who is 100 % dependent on staff is sitting in the day room. Nurses notes reflect the following:"...when he (patient #2) entered the dayroom he saw this peer (patient #1) sitting on a chair to his left of the door and grabbed her under the arms and threw her across the room 5-6 feet. This caused her injury to left of her forehead (hematoma the of 2 inches round) and left shoulder. The techs immediately went to her assistance. Once out of the room vital signs and neuro checks were done." This documentation indicates that Pt #1, who was thrown from her chair was not assessed for physical injury or head trauma prior to being removed from the day room for vital signs and neuro checks. No vital signs or neuro checks were found to be recorded for patient #1 record.

Pt #2 who was subdued by staff as reflected in patient #1 chart "At the same time two RN's "assessed" him to the floor.... and code white was immediately called. ...patient was further subdued while Staff #4 (presently on unit) gave orders for emergency dose of medication." Pt #2 MR reveals on 8/3/2011 at 17:25 he was given Zyprexa 10 mg and Ativan 2 mg intramuscularly (IM) left buttock. 17:30 order was received to transfer to acute services. 8/3/2011 at 17 35 patient #2 MR reveals "pt continues to fight staff, is uncooperative, agitated, Dr remains on unit, orders given for medication, patient given Ativan 2 mg IM to the right buttock. 8/3/2011 17:38 report called to nurse on acute care unit. 8/3/2011 17:40 pt voluntarily walked with staff from senior care, drowsy from medication administration, left senior care without incident pt escorted to acute care by the house supervisor and techs" There was no nursing documentation of assessment for this Pt after he was subdued by staff before he was transferred to acute care.

On 10/25/2011 at 2:30 PM Pt #3 MR record was reviewed and revealed the following. Pt #3 was admitted with a diagnosis of Paranoid schizophrenia, Human immunodeficiency virus, and past history of killing multiple wives. Further review revealed on 8/3/2011 at 17:23 "Pt was in the dayroom, was hit in the left eye by a peer (Pt #2) that was out of control. The peer (Pt #2) was throwing a chair, knocked over the vital signs machine, threw a peer (Pt #1) from her chair. This peer (Pt #3) was not specifically targeted,. This RN did not see this peer get hit. The peer reported it after the incident." There is no documented assessment of this Pt in the electronic medical record for injury. 8/3/2011 at 18:00 "reported to staff that he was hit in the left eye by a peer (Pt #2). assessed the pt, the pt has minimal swelling to the left eye with minor discoloration/bruising started. continue to monitor Dr present on the unit, had Dr. assess the pt, house supervisor notified." There was no nursing intervention documented in the electronic medical record. (No ice applied to the eye, no pain scale noted or pain medication offered)

On 10/25/2011 at 1:30 PM in the conference room staff #2 was interviewed and revealed on 8/3/2011 patient #1 was placed in the day room in a chair with other ambulatory patients. Staff #2 was questioned as to why an 83 year old depended geriatric patient who was agitated and yelling out was placed in the day room to be further stimulated and over stimulate other ambulatory psychiatric patient she answered "that's where patients sit. She was visible from the nurses station." When asked if she was comfortable placing a non ambulatory dependent patient in a day room with ambulatory patients she stated "I guess we could have placed her in her room"

Staff #2 was further questioned regarding the lack of nursing assessment for Pt #2 there was no comment. Staff #2 was also questioned about the lack of nursing intervention for Pt #3. Staff #2 indicated she had seen Pt #3 the next day and he had not said anything about needing pain medication.

The facility failed to provide care in a safe setting for Pt's #1, #2 and #3. Pt #1 was not protected from uncontrolled physical aggression directed toward her and was not safely assessed before being moved form the day room. Pt #2 aggressive outburst was not controlled safely within the environment. Neither Pt #2 or #3 were immediately assessed for injury.

Based on record review and interview the facility failed to monitor the effectiveness and safety if service and quality of care based on 3 of 3 patients.

On 10/25/2011 at 4:00 PM in the conference room the incident reports were reviewed for Patients #1, #2 and #3 which were involved in the same incident on 8/3/2011. Pt #3 file ID 12887 was submitted 8/3/2011 and a "Brief factual description" is as follows: "pt attempting to go to the dayroom with only his underwear on, the pt redirected to go to this room if he did not want to get dressed, pt voluntarily walked to the end of the hallway, the pt then stopped and yelled "I'm not doing this", the pt ran to the dayroom pushed through the door, threw a peer on the floor, threw a chair, knocked over the vital sign machine breaking it, punched a peer in the left eye, the peer that he threw was sent to Baptist ER for treatment, the peer that he punched has a bruise to the left eye and mild swelling"
It is noted on the incident form "Suggestions for avoiding similar event: unknown, this event occurred quickly and spontaneously." The follow up is noted as "staff responded swiftly and appropriately. This patient has not history of aggressive behavior or reason to have behaved in such a manner. Resolution "closed"

Pt #2 ID 12888 was submitted on 8/3/2011 a 'Brief factual description" is as follows. "pt was in the dayroom, a peer became agitated, hit the pt in the left eye causing a mild amt of swelling and bruising beginning." It is noted on the incident form "suggestions for avoiding similar event: unknown, the incident occurred quickly, staff attempting to get peers out of the dayroom." The follow up is noted as "patient attempting to block aggressive patient from entering further into the dayroom. He was struck by all account in the left eye. slight discoloration. NO swelling or pain reported." Resolution closed.

Pt #1 ID 12907 was submitted on 8/5/2011 a 'Brief factual description" is as follows. " Patient H.S. picked up victim and threw 5-6 feet. Victim landed on floor. Techs secured victim while nurses restrained H.S. Patient complained of dizziness and knee and shoulder pain. 911 was called, patient was transported to ER for further evaluation" Suggestions for avoiding similar events: Incident occurred rapidly with provocation. No history of past aggressive behavior." Follow up: waiting for all staff accounts. (1/5 staff statements were provided for review). Resolution: closed

On 10/26/2011 at 11:00 AM an interview with staff #2 revealed the family had notified the police. The police had given the facility a copy of the official report. The family had inquired if the facility had notified the police, they had not. Further interview with staff #3 revealed the facility had not conducted any Quality review for this event. Further interview with staff #2 revealed she felt the staff (nurses and techs) had functioned in an acceptable manner. No documentation was brought forward reviewing the appropriate placement for either the victim Pt #1 or the aggressor Pt #2. No problem was identified therefor no suggestions to avoid future patient injuries secondary to aggressive patient was formulated.