HospitalInspections.org

Based on record review and staff interview it has been determined that the hospital failed to ensure that patients receive care in a safe setting, for 1 of 1 patient who sustained a fracture, Patient ID #1.

Findings are as follows:

Record review for Patient ID #1 revealed s/he was admitted to the Psychiatric Unit in December of 2023. The patient was transferred from a long-term care facility with multiple diagnoses including, but not limited to, dementia, schizophrenia, major neurocognitive disorder, and a history of aggressive behaviors. The patient has remained at the hospital while awaiting long-term placement. The patient requires the assistance of 2 staff to transfer from a chair to the bed.

Review of a hospital incident report revealed that on 7/24/2024 between 5:00-6:00 AM, the Nurse, Staff F, asked the MHW (Mental Health Worker) Staff D, to take the patient to the bathroom. Staff D asked MHW, Staff E, to assist her. Both Staff D and Staff E were attempting to transfer the patient to a scoot chair (a chair with wheels) to take him/her into the bathroom. The patient was resisting, trying to hit and spit at staff.

The hospital incident report states that the Social Worker, Staff I, was called into the patient's room by the patient on 7/24/2024 at approximately 8:00 AM. Patient ID #1 informed the Social Worker that Staff D had held his/her hand tight during care.

A review of the follow up report documented by the hospital Risk Manager states, " ... [she/he] was trying to strike and spit on them while they were attempting to get [him/her] to the bathroom as requested. Staff D held [his/her] wrist to avoid being hit."

During an interview on 7/30/2024 at approximately 10:20 AM with the Social Worker, she stated that when the patient called her in to tell her about the incident, she observed the patient's right hand thumb to be bruised and swollen. The Social Worker reported this to the nurse and filed an incident report.

The patient was assessed by the Nurse and Nurse Practitioner and an x-ray was ordered. The x-ray report dated 7/24/2024 revealed a fracture involving the medial base of the first proximal phalanx (base of the thumb) with intra-articular extension (extending into the joint). Soft tissue swelling was present.

A review of the orthopedic consult dated 7/24/2024 states in part, "avoid weightbearing to the right upper extremity until pain improves, continue immobilizer with volar wrist splint for 3 to 4 weeks, ice elevation ..."

During an interview on 7/30/2024 at approximately 9:25 AM, with Nursing Staff F, and Staff H who were on duty at the time of the incident, both denied witnessing the event.

During an interview with MHW Staff E at 8:15 AM on 7/30/2024, she stated that Staff D asked her to assist with getting the patient to the bathroom. She stated that the patient was spitting and trying to hit them and she was standing behind the patient and did not hold his/her arms. She reported that Staff D was standing in front of the patient.

During an interview with Staff D on 7/30/2024 at 8:45 AM, she stated that she asked Staff E to assist her with the transfer. She reports the patient was not speaking in English, was "flapping [his/her] arms and saying No, No." She said the patient said she/he wanted to go to church, not the bathroom and was spitting at her. Staff D reported she was trying to bring the patient's arms down by putting her arms over the patient. She said the patient did not complain of pain when she/he was returned to his/her room from the bathroom. Staff D was asked if she held the patients wrist as was stated in the incident report, but she denied holding or grabbing the patient's wrist.

During surveyor interview with the Risk Manager on 7/30/204 at approximately 1:15 PM, she acknowledged that when the Unit Manager investigated the incident, Staff D initially stated that she held the patient's wrist to prevent him/her from hitting them.

The hospital was unable to produce evidence that the patient received care in a safe setting and failed to provide the patient with the necessary care needed relative to transfers without sustaining an injury.



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Based on record review, staff interview and hospital policy the hospital failed to follow their policy relative to restraints for 1 of 1 record reviewed for the use of non-violent restraints, Patient ID #2.

Findings are as follows:

Review of the policy titled "Violent and Non-Violent Restraint" dated 9/2004, revised on 2/17/2024, states in part:

"Definitions

1. Restraint: any manual method, physician or mechanical device, material or any equipment or medication that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely...

6. Non-violent restraint: the use of restraint to manage non-violent, non-delf destructive behavior that interferes with treatment or devices necessary to support medical healing.

7. Qualified [Registered Nurse] RN: an RN who has completed specific training to perform evaluation and assessment of patients who may need restraint or seclusion..."

"Initiation of Restraint or Seclusion

Non-Violent Restraint:

The authorized provider or staff member determines the less restrictive interventions to prevent interference with treatment or devices necessary to support medical healing.

The authorized provider chooses the type of restraint.

The ordering provider either enters the order into the electronic medical record or issues an order to the RN.

Order limits - Every 24 hours.

Orders may never be "as needed" PRN.

The ordering provider performs an in-person assessment of the patient within 24 hours of the initiation of the restraint, and if continued once every 24 hours.

Documents the assessment, which includes:

The patient's immediate situation, reaction to the intervention, medical and behavioral condition, and the need to continue or terminate the restraint."

Record review for Patient ID #2, reveals he/she was admitted to the emergency department on 4/15/2024, and transferred to the critical care unit (CCU) on 4/16/2024.

On 4/16/2024, the patient had the following orders for non-violent 2-point restraints for preventing him/her from removing the endotracheal tube:

The initial order is documented on 4/16/2024 at 11:05
The next order is documented on 4/17/2024 at 17:06 (6 hours over the required 24 hours)
The next order is documented on 4/18/2024 at 22:26 (5 and a 1/2 hours over the required 24 hours)
The next order is documented on 4/19/2024 at 12:46
The next order is documented on 4/24/2024 at 11:54 (5 days later)
The next order is documented on 4/26/2024 at 11:46 (48 hours over the required 24 hours)
The last order is documented on 4/27/2024 at 11:39

Further review of the patient's record revealed the following: Only 4 of the 10 days the patient was in restraints was an in-person assessment completed per the hospital's policy. The providers face to face encounters were only documented on the 4 dates listed below:

4/16/2024 at 10:30 AM
4/17/2024 at 14:05 (4 hours over the 24 hours)
4/18/2024 at 15:42, (1 ½ hours over the 24 hours)
4/19/2024 at 12:39

During an interview with the Risk Manager on 7/30/2024 at approximately 12:00 PM, she was unable to produce evidence that the restraint orders were renewed every 24 hours as required. Additionally, she was unable to provide evidence of documentation of the restraints from 4/19/2024 through 4/24/2024, or the ordering provider performing an in-person assessment of the patient within 24 hours of the initiation of the restraint, and if continued once every 24 hours. The Risk Manager acknowledged that the hospital failed to follow their policy relative to restraint orders, face to face assessment and documentation requirements.





30526

Based on record review and staff interview, it has been determined the hospital failed to ensure that all nursing performance evaluations are completed at least once a year, for 4 of 4 nursing staff whose personnel files were reviewed, Staff D, E, F and H.

Findings are as follows:

1. Review of the files for Staff D, a mental health worker (MHW), revealed she was hired in 2021 and her most recent performance evaluation was completed on 4/1/2022.

2. Review of the files for Staff E, a MHW, revealed she was hired in 2018 and her most recent performance evaluation was completed on 4/11/2022.

3. Review of the files for Staff F, a registered nurse (RN), revealed she was hired in 2018 and her most recent performance evaluation was completed on 4/5/2022.

4. Review of the files for Staff H, an RN who was hired in 2021, revealed her most recent performance evaluation was completed on 6/21/2022.

During surveyor interview with the risk manager on 7/30/2024 at approximately 11:50 AM, when questioned about the lack of annual performance evaluations, she informed the surveyor that the hospital only completes performance evaluations once every three years. Additionally, she provided the surveyor with a copy of the hospital's policy titled, "Employee Performance Review Process' which is dated 6/1/2017 and revised on 6/30/2023, which states in part: "Performance evaluations are completed on the calendar year but not to exceed three years for all eligible employees..."

The hospital failed to provide annual nursing evaluations as required by federal regulation.





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