HospitalInspections.org

Based on observations and interview, the hospital failed to ensure services were provided in a setting that was safe for patients 20 (patients #1-20) of 20 patients reviewed and for all patients currently receiving care and services.

Findings:

On 08/13/24 at 10:25 AM an observational tour was made of the MHU, ED and Medical surgical units that showed the following:

1. Observations of the MHU observation room #1. The bed frame in the room showed a crack to the top rail on the top right side of frame with what appeared to be a screw in the crack. A metal plate in the room at lower wall level that did not fully cover an open area in the wall. An exposed screw in the wall by the door and
2. the cover over the camera was no longer in place.

On 08/13/24 at 1:25 PM another observational tour was made of the MHU and Medical/Surgical Units that showed:

1. The women's shower room on the MHU showed an area of trim that was made of a rigid plastic that was damaged (broken and splintered with sharp edges).

2.Seclusion room #1 showed multiple exposed screws in the sheet rock and an exposed wall outlet due to improperly fitted strike plate.

3. Observation of an unoccupied room on the Medical/Surgical Unit showed areas to the lower walls on either side of the shower that were cracked and crumbling.

4. Med/Surg room 80 showed drywall was cracked and crumbling at the base of the shower.


During an interview on 8/13/24 at 1:30 PM, Staff A stated:
1, "I don't know how long the bed frame in the seclusion room has been damaged, it was dangerous and has been reparied."
2. "Damaged furniture should be reported immediately. An exposed screw could be an issue. Drywall should be inspected periodically and reported. An availablility of parts should result in repairs being initiated within 24-48 hours."
3. " Damage should be reported when it is noted.
4. "This is not new and organisms can grow in nooks and crannies (re: damaged drywall)."
5. "I don't know when or why the outlet cover was removed.

During an interview with hospital staff Bon 8/13/24 at 1:24 PM, Staff B stated, "The damaged trim in the women's shower room was a safety issue."

Based on record review and interview the RN failed to evaluate pain at least twice daily utilizing a pain intensity scale for two (Patient # 15H and 18E) of 20 medical records reviewed.

Findings:

Patient 15H
A review of the clinical record showed patient was admitted to MHU 2/23/24 and transferred to another hospital 2/26/24. Discharge Summary documented "patient complained of abdominal pain. X-ray of the abdomen showed a foreign body in rectum. Patient was seen in the emergency room and he developed a perforation and was trasferred...." Abdomnial x-ray 2/26/24 impression: There is a radio-opaque foreign body in the rectum and rectosigmoid. It measures 18 cm in length.

Clinical documentation showed no nursing assessment from 2/23/24 - 2/26/24 that documened assessing a pain level and no VS record for this patient reflects a pain level from 2/23/24 - 2/26/24.

Patient 18E
A review of the clinical record showed patient was admitted to MHU 12/29/23 and discharged 1/2/24. The Nursing Assessment dated 8/27/23 at 8:00 AM was the only assessment that documented "no pain." ANursing Assessment dated 8/27/23 at 3:06 PM documented pain but no pain rating on a scale of 1-10. The patient was in-patient for four days and showed one documented pain assesment in the nursing assessments and none in the VS record.

On 08/14/24 at 2:50 PM, Staff A stated:
1. "A patient's pain level should be assessed at every shift and if pain medicaton was administered and
2. "ain level should be assessd again within 30 minutes to an hour after medication administration."

Based on record review and interview, the hospital failed to ensure physicians and licensed independent practitioners completed a history and physical (H&P) within twenty-four (24) hours of admission for two (Patient # 14I and 19D) of 20 patient medical records reviewed .

Findings:

A review of Patient #14I and 19D showed the H&Ps were not completed and documented in the patient's EMR within 24 hours of admission.

On 08/14/24 at 10:30 AM, Staff F stated, H&Ps were completed by medical staff within 48 hours for patient 19D and 72 hours for patient 14I instead of within 24 hours of the patients' admission.