HospitalInspections.org

Based on document review, policy review, medical record review and interview, contract nursing staff did not ensure that comments made by a team member in reference to Patient #1 were reported to the supervisor in accordance with facility policy.

Findings include:

Review of policy #HR.19,Violence in the Workplace, last revised 08/29/16 revealed employees have a duty to warn their supervisor, security personnel, or human resources representatives if they are aware of or suspect any problematic workplace activity, situations, or incidents that involve other employees. This would include threatening or offensive acts or comments.

Review of the Department File review document dated 07/16/18 revealed a copy of policy #HR.19, Violence in the Workplace, last revised 08/29/16 was provided to Staff (Y), RN prior to the start of their contract.

Review of nursing note from Staff (Y) dated 12/12/18 at 06:53 AM revealed at around 02:00 AM Patient #1 became agitated and was attempting to get out of bed. At 03:28 AM the patient was medicated with Haldol 1mg. Staff (Y) indicated that Staff (AA), RN had stated "keep me out of that room because it wouldn't end well" around the time the time the patient was attempting to get out of bed. At approximately 04:15 AM Patient #1 was noted to be pleasant, but agitated and was again attempting to get out of bed. Around 04:17 am, while in Patient #1's room, Staff (Y) heard a big smack/boom noise and looked over and saw Staff (AA) holding Patient #1 down. At that point Staff (K), (RN), who was also in the room, told Staff (AA) to get out of the room. Staff (K) informed Staff (Y) that Staff (AA) had hit Patient #1 in the head.

Telephone interview on 01/08/19 at 02:32 PM with Staff (B), Physician revealed that Staff (Y) did not inform anyone of the comments made by Staff (AA) earlier that morning prior to the event involving Patient #1.

Based on policy review, medical record review and interview, nursing staff did not reassess vital signs for 5 of 20 patients (Patient #2, 12, 15, 16 and 20) prior to discharge in accordance with facility policy.

Findings include:

Review on 01/04/19 of policy "Monitoring Vital Signs-Adult" last revised 09/05/17 revealed all patients will have vital signs taken within one hour prior to discharge or transfer of a patient.

Review on 01/04/19 of policy "Assessment and Reassessment of Patients" last revised 05/21/18 revealed all patient's must have an assessment at time of transfer by all professionals who are responsible for their care and treatment.

Review of Patient #2 medical record dated 10/04/18 revealed the following vital signs were obtained at 11:00 AM: temperature 36 C, pulse 96, respirations 18, blood pressure 186/87 and Oxygen (O2) saturation 94% on nasal cannula. The patient was evaluated by the physician and noted to be stable. At 12:40 PM an order for discharge was written and at 04:45 PM the patient was discharged. The Patient Resident Transfer/Discharge Form documented the same vital sign results as those obtained at 11:00 AM.

Review of Patient #2 Emergency Department (ED) record dated 10/04/18 at 08:02 PM, revealed the patient returned to the ED and was admitted to the Intensive Care Unit for respiratory distress. It was noted that upon arrival to the subacute rehab facility, the patient was found to be gray, hypoxic and unresponsive with an O2 saturation of 83%.

Interview on 01/03/19 at 02:30 PM with Staff (E), Accreditation Coordinator verified that the 11:00 AM vital signs taken for Patient #2 on 10/04/18 were the same vital signs entered on the 04:45 PM Patient Resident Transfer/Discharge Form.

Review of Patient #12 medical record dated 12/26/18 revealed vital signs were last documented at 12:00 PM and the patient was discharged at 03:13 PM.

Review of Patient #15 medical record dated 12/21/18 revealed vital signs were last documented at 07:00 AM and the patient was discharged at 11:00 AM.

Review of Patient #16 medical record dated 12/19/18 revealed vital signs were last documented at 08:00 AM and the patient was discharged at 11:52 AM.

Review of Patient #20 medical record dated 12/19/18 revealed vital signs were last documented at 11:00 AM and the patient was discharged at 03:40 PM.

Interview on 01/03/19 at 10:00 AM with Staff (N), RN and on 01/04/19 at 10:15 AM with Staff (R), RN and at 11:00 AM with Staff (S), RN and at 11:15 AM with Staff (U), RN revealed that patients are to be assessed and vital signs taken within one hour prior to discharge.

Interview on 01/04/19 at 02:00 PM with Staff (A), RN verfied the above noted findings.