HospitalInspections.org

Based on document review, interview and observation, the facility failed to ensure staff were aware of which patients were on assault precautions on 2 of 2 units (Units 200 and 300), failed to ensure patients were free from abuse on 1 unit (Unit 300), and failed to show evidence that 1:1 precautions were provided for 1 of 10 patients (patient 7) medical records reviewed (see tag A0144).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure that Patient's Rights were promoted.

Based on document review, interview and observation, the facility failed to ensure staff were aware of which patients were on assault precautions on 2 of 2 units (Units 200 and 300), failed to ensure patients were free from abuse on 1 unit (Unit 300), and failed to show evidence that 1:1 precautions were provided for 1 of 10 patients (patient 7) medical records reviewed.

Findings include:

1. Review of facility policy, PATIENT ABUSE AND NEGLECT, Policy No I-A.20.: Revised: 7/2020, indicated the following: All hospital employees have an obligation to protect patients, prevent abuse or neglect from occurring, and to report any and all information concerning occurrences where abuse or neglect may have occurred.

2. Review of patient 5's MR indicated the following: Daily Nursing Narrative dated 6/24/20, 7p (pm) to 7a (am)...patient 5 touched another patient and that other patient hit patient 5, a staff member witnessed the incident, no injury. On 6/25/20, patient 5 noted to have a bruise on his/her left side of head, new order received to send patient to ER (emergency room) for head scan. CT (computed tomography) scan completed 6/25/2020 at 7:28 pm, indicated no acute intracranial hemorrhage. Patient back from ER at 8:50 pm. Patient 5 walked out of his/her room and another patient pushed patient 5, making patient 5 fall. Patient 5 complained of pain in his/her arm and was sent back to ER to be evaluated. Provider order form indicated patient 5 was injured by another patient and sent out for x-ray of arm. Discharge Instructions 06/26/2020, indicated XR (X-ray) Humerus Right Portable 06/26/2020 09:11 EDT (Eastern Daylight Time) Fracture of humeral shaft, right, closed. Follow up appointment on 7/9/2020. Patient Safety Observation Rounds indicated on 6/26/2020, patient readmitted to facility.

3. Review of patient 10's MR indicated patient admitted on 6/18/20 and discharged on 7/8/20. Daily Nursing Narrative indicated on 06/24/2020, 7p (pm) 7 (am) patient found hitting another patient, staff tried to separate them and patient spit on another nurse. Nurse directed patient to room and advised patient not to hit others, patient in room reading. On 6/25/2020 around 9 pm, patient 10 hit 3 patients on his/her way to room. One patient had to be sent out to ER to rule out fracture of the arm. Patient continues to show aggressive behaviors towards others, not easy to redirect.

4. When asked what patients were on assault precautions, staff member N4 (Medical Assistant on 300 unit) indicated in interview on 07-09-2020 at approximately 6:09 pm that patients on assault precautions were patients assigned to rooms 1021-2 and 1024-1.

5. Observation on 7/9/2020, on the 300 unit with N3 (Interim Chief Executive Officer), at approximately 6:15 pm, the white board at nurses station which indicated pertinent information for each patient indicated patients on assault precautions included but not limited to patients in rooms 1017-1, 1017-2, 1021-1, 1022-2, 1025-1 and 1026-2.

6. Review of MR's indicated patients in rooms 1017-1, 1017-2, 1021-1, 1022-2, 1025-1 and 1026-2, were on assault precautions.

7. When asked what patients were on assault precautions, staff member N5 (Medical Assistant on 200 unit) indicated in interview on 07-09-2020 at approximately 6:23 pm that patients on assault precautions were patients assigned to rooms 1011-1, 1011-2 and 1015-2.

8. Observation on 7/9/2020, on the 200 unit with N3, at approximately 6:28 pm, the white board at the nurses station which indicated pertinent information for each patient indicated patients on assault precautions included, but not limited to, rooms 1012-2, 1015-1, and 1016-1.

9. Review of MR's indicated patients 1011-1, 1012-1 (room # per Vital Signs Flowsheet), 1012-2 (room # per Vital Signs Flowsheet), 1015-1, 1015-2, 1016-1, were on assault precautions.

10. Interview on 07-09-2020, on the 300 unit at approximately 6:15 pm, and on the 200 unit at approximately 6:28 pm, with N3 confirmed N4 and N5 were not aware of all patients that were on assault precautions.

11. Policy titled "PRECAUTIONS", last reviewed/revised 5/2019, indicated 1:1 observation is the most restrictive and involves continuous monitoring and physical proximity to the patient at all times. The policy states "Nursing staff must maintain a continuous log which indicates the patient's location every 15 minutes and documents the patient's thoughts and behaviors."

12. Review of patient 7's MR indicated per Nurses Notes dated 5/20/20 at 11:00 pm, that the patient went to another patient's room "attacks and scratches" him/her on the face. An order was written at 11:00 pm on 5/20/20 for 1:1 sitter. The record lacked documentation that the patient had a 1:1 sitter after the order on the following dates: 5/22/20 (the 1:1 observation section on the "PATIENT SAFETY OBSERVATION ROUNDS" form was blank); on 5/23/20 (the 1:1 observation section on the "PATIENT SAFETY OBSERVATION ROUNDS" form was blank); and additionally, the Nurses Notes dated 5/23/20 at 7 a-7p, state "Pt (patient) is on every 15 minute safety checks ..."); and on 5/27/20 (the 1:1 observation section on the "PATIENT SAFETY OBSERVATION ROUNDS" form was blank).

13. Interview of N2 (Director of Nursing) at approximately 4:00 pm on 7/9/2020, verified the medical review information for patient 7. He/she verified at approximately 6:50 pm on 7/9/20, that patient 10 was the aggressor toward patient 5.