HospitalInspections.org

Based on record review and interview, the facility failed to ensure an investigation was performed for injuries sustained by 1 of 1 patients (Patient #3) due to physical altercation with staff.

Findings included:

Record review at time of survey of Patient #3's medical records showed the following:

16-year-old male, admitted involuntarily to facility on 1/21/22 under the care of Dr. Staff #C and discharged facility 2/4/22. Reason for admit was due to hearing command hallucinations telling him he's gay, aggressive fighting with peers and threatening to kill peers. Diagnoses were Disruptive Mood Dysregulation disorder, Major Depressive disorder, Oppositional Defiant disorder. The patient needed a Spanish interpreter.

Nursing progress notes dated 2/4/22 3:00 pm (day of discharge) showed that patient got into physical fight with Mental Health Technician (MHT) in patient's room when MHT entered to gather linens.

There was a Restraint/Seclusion document present in chart with physician order dated 2/4/22 at 3:05 pm to physically restrain patient and give the medication Zyrexa Zydis 10 mg by mouth now. In addition, the form showed that nursing assessment documentation revealed patient had a mild linear scratch to forehead, inner upper lip, and mild bruises.

Facility occurrence report dated 2/4/22, 3:00 pm, showed there was an injury to patient caused by staff. It also showed that Supervisor Staff #M was notified.

In Patient #3's discharge summary, performed by PMHNP Staff #D, there was nothing noted about patient's injuries or any information about the incident.

In an interview on 8/25/22 at 3:30 pm, Staff # B stated that incident reports are discussed in the following morning's huddle meeting. Injuries to patients are discussed and it was then when it was determined if an investigation would take place. In addition, Staff #B stated that Supervisor Staff #M never reported this incident the staff huddle meeting.