HospitalInspections.org

Based on interview and record review, the facility failed to meet the Conditions for Participation for Patient Rights by failure to 1). Notify responsible party of peer to peer altercation involving a minor patient (#2); failure to 2). Perform timely one hour face to face evaulations for patient in restraints (#1); and 3). Failure to ensure staff provided 1:1 staff to patient ratio constant observation precautions as prescribed for 2 patient's (#'s 1 and 2), resulting in the loss of patient rights for patient #'s 1 and 2 and the potential for loss of patient rights by all patients served by the facility.
Findings include:

(See A- 131): Failure to notify the responsible party of peer to peer altercation involving a minor patient (#2);
(See A-144): Failure to perform timely one hour face to face evaulations for patient (#1) in violent restraints.
(See A-179): Failure to ensure staff provided 1:1 staff to patient ratio constant observation precautions as prescribed for 2 patient's (#'s 1 and 2),

Based on interview and record review, the facility failed to notify the patient's responsible party of a peer to peer altercation involving minor patient for 1 of 11 (#2) patients reviewed for patient rights, resulting in the potential for less than optimal outcomes for patient #2.
Findings include:

Review of an incident and accident report on 9/14/2021 at 1130 revealed patient #2 was hit in the right eye by another patient (#1) on 8/7/2021 at 0830. Comments documented on the incident report included:
Nurse Practitioner (NP) was called to the patient's room to evaluate the patient.
Caregiver in the room at the time of the injury.

A review of the medical record for patient #2 was conducted with the Emergency Department (ED) Nurse Manager Staff F at 1400 on 9/14/2021 and revealed the following:
Patient #2 was a 8-year-old-male who presented to the facility on 8/4/2021 at 2021 for a "psych evaluation" due to aggression.
However, further review of the medical record revealed there was no evidence that documented the patient was seen by the medical staff (NP) following the altercation. Nor was there evidence that documented the patient's responsible party was notified of the peer to peer altercation.

During an interview on 9/14/2021 at 1500 with ED Staff Nurse H she explained she recalled the patient. She said she was assigned to the patient and was told by staff that the patient #2 was standing in his doorway when patient #1 passed by and hit the patient (#2) in the eye. Staff H said the patient appeared shocked and did not respond aggressively. Staff H said she informed the NP. Staff H said she recalled the NP being present and evaluating the patient.
However, there was no evidence that documented the NP assessed the patient following the altercation in the medical record at that time.

When asked to explain if she (Staff H) had notified the patient (#2's) responsible party she said "the foster caregiver" was there. When asked if the "foster caregiver" was the patient's foster care mom she said she was not sure.

An interview was conducted with the Director of Quality and Patient Safety (Staff D) on 9/15/2021 at 1400. She provided "an Addendum" provider note dated 9/14/2021 at 1556 that documented the provider had assessed the patient following the altercation on 8/7/2021 at 1554. Staff D confirmed the "Addendum" was not documented until 9/14/2021 and when further queried regarding the date of the addendum she replied "yes, I know".

Additionally, at that time when asked to explain the facility's policy for notifying the responsible party of a change in a patient's condition she replied, we do not have a policy for that. She said we would have expected the foster care agency staff to notify the foster care parent of the altercation.

Review of the facility's "Assessing and Reporting Suspected Victims of Abuse/Neglect/Elderly/Vulnerable Person" policy no. 1CLN 018 Effective Date: November 11, 2013, documented:
Objective: To assure that all patients who are suspected victums of abuse, neglect, exploitation, or endangerment are identifed, treated, and referred to appropriate professionals and/or resources.
Policy: All patients are assessed as potential victims of violence...
Definitions:
"...8. Physical Abuse is usually recurrent and escalates in both frequency and severity. It may include the following: pushing, shoving, slapping, punching, kicking, choking...".
Documentation: "...9. Appropriate consents from patient, parent or legal guardian as required."
However, that was not done.

Based on interview and record review, the facility failed to ensure staff consistenly performed one to one (1:1) staff to patient ratio close observational precautions according to their policy and procedure for two (#'s 1 and 2) of six patients reviewed for 1:1 monitoring resulting in patient (#2) being purposely hit in the eye by patient #1.
Findings include:

Review of the medical record for patient #1 on 9/14/2021 at 1130 revealed the following:

Patient #1 was a 13-year old male who presented to the Emergency Department on 8/6/2021 at 1714. The patient had been previously discharged to an outpatient partial hospitalization on the morning of 8/6/2021. According to the triage note dated 8/6/2021 at 1714 the patient got into an argument with his grandfather, kicked his grandfather and was suicidal and wanted to die.

Review of physician orders for patient #1 documented the following:
On 8/6/2021 at 1900, "One to one observation".
On 8/7/2021 at 0105, "One to one observation".
On 8/8/2021 at 0234, "One to one observation".

Review of nursing notes for patient #1 on 8/7/2021 (no time documented), "per constant observer and security report, patient became upset after a phone call with his grandma and came out of his room upset and punched another patient (#2) in the eye while being escorted to room by security and constant observer, patient restrained...".

Review of Constant observer flow sheets for patient #1 dated 8/7/2021 between 0700-0900 documented the following:
At 0700, Activity: patient sleeping; Behavior: talking to staff: Location: patient room.
At 0715, Activity: patient lying still or sitting: Behavior: talking to staff and quiet; Location: patient room.
At 0730, Activity: patient lying still or sitting, Behavior: singing, interferring with medical care; Location: patient room and bathroom.
At 0745, Activity: patient walking, lying still or sitting; Behavior (illegible); Location: patient room and bathroom.
At 0800, Activity: patient lying still or sitting, watching TV; Behavior quiet; Location: patient room.
At 0815, Activity: patient lying still or sitting, watching TV; Behavior: quiet; Location: patient room.
At 0830, Activity: patient lying still or sitting, watching TV; Behavior: quiet; Location: patient room and bathroom.
At 0845, Activity: Out of bed without notifying staff, lying still or sitting; Behavior: fluids taken, watching TV, Agitation; Location: patient room and bathroom.
At 0900, Activity: lying still or sitting; Behavior: Quiet and restrained; Location: patient room.
At 0915, Activity: lying still or sitting; Behavior: Quiet and restrained; Location: patient room.

An interview with the Director of Quality and Patient Safety (Staff D) and the Administrative Director (Staff E) was conducted on 9/15/2021 at 1345 regarding how the patient #1 was noted to have gotten out of bed, went to the bathroom in a hallway, and assaulted patient #2 while being on 1:1 constant observer precautions on 8/7/2021 at 0845. At that time Staff E replied our policy is 1:1 within the line of sight near the patient. No further explanation was offered to explain how patient #1 was able to leave his room without staff intervening for the safety of all patients.

Review of the medical record for patient #2 on 9/14/2021 at 1400 revealed the following:
1400 on 9/14/2021 and revealed the following:
Patient #2 was a 8-year-old-male who presented to the facility on 8/4/2021 at 2021 for a "psych evaluation" due to aggression.
Review of physician orders for patient #2 documented the following:
On 8/7/2021 at 0106, "One to one observation".

Review of nursing note dated 8/7/2021 at 0731 documented:
Patient constant observer and security report patient was standing in doorway when another patient (#1) walked past and hit patient in the eye, patient (#2) appeared shocked by did not respond aggressively, Nurse Practitioner (NP) notified and she examined patient eye. Registered Nurse (RN) informed NP that patient appeared drowsy following.

Review of an incident and accident report on 9/14/2021 at 1130 revealed patient #2 was hit in the right eye by another patient (#1) on 8/7/2021 at 0830. Comments documented on the incident report included:
Nurse Practitioner (NP) was called to the patient's room to evaluate the patient.
Caregiver in the room at the time of the injury.

A review of the facility's "Constant Observer (CO) for Patients Under Harm Precautions" policy no. PC-CO.2.033 Effective Date August 1, 2020 documented:
Levels of Observation:
"One-to-one Observation: one CO to one patient within line of sight, in close proximity with no physical barriers in the same room/area unless there exists a risk to the constant observer. Close proximity is determined by the phyisican, LIP, RN or QMHP"
However, this was not done.

Based on interview and record review, the facility failed to complete timely face-face evaluations within 1 hour after the initiation of restraints according to their policy and procedure for one patient (#1) of four patient reviewed for restraints, from a total sample of 11 patients, resulting in the potential for unnecessary restraints for patient # 1.
Findings include:

On 9/14/2021 at 1110 review of Patient #1's restraint record was completed with Registered Nurse Staff F. The review revealed the following information:

1. On 8/12/2021 at 2145 the patient was placed in 4 point restraints for agitation and an altercation with his guardian. However, there was no face-face evaluation documented in the medical record.

2. On 8/19/2021 at 1615 the patient was placed into 4 point keyed soft limb restraints for hostile and aggressive behavior. However, there was no face-face evaluation documented in the medical record.

At that time (On 9/14/2021 at 1110), when queried Staff F confirmed those evaluations should have been performed and documented in the medical record within one hour of the application of restraints.

On 9/15/2021 at 1000 during an interview with the Director of Quality and Patient Safety (Staff D), she provided "two (2) Addendum" provider notes dated 9/14/2021 at 1453 and at 1701 that documented the provider had assessed the patient #1 while restrained on the aforementioned dates.

At that time, Staff D confirmed the "Addendum" notes were not documented until 9/14/2021 and when further queried regarding the date of the addendum for a provider note dated 8/13/2021 at 0700 and 8/19/2021 at 1615 respectively, she replied yes I know.

Review of facility policy titled, "Restraint in the Non-Psychiatric Healthcare Setting", with an Effective date of 2/20/2020 documented:
V. Procedure And/Or Provisions:
E. When restraint/seclusion is used for the management of violent or self-destructive behavior that jeopardizes the patient's immediate physical safety a face-to-face evaluation must occur within one (1) hour of the initiation of the intervention...".
A physician/MLP designee face-to-face comprehensive, clinical assessment must be performed.
However, this was not done.