HospitalInspections.org

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation (CoP) for Patient's Rights as evidenced by:

1) failing to ensure that direct care staff were removed from the hospital schedule following the staff involvement in the alleged physical abuse of Patient #1. (See findings under A-144).

2) failing to ensure 2 (#1 and #3) of 5 (#1-#5) patients sampled were free from abuse by staff. Record review and interview revealed the hospital failed to ensure 2 (#1 and #2) of 5 (#1-#5) patients sampled were free from abuse/harassment from other patients. (See findings under A-145).

Based on record review and interview, the hospital failed to ensure the patient /patient representative's right to participate in the development and implementation of her plan of care was met. This deficient practice is evidenced by failure to ensure the patient/patient's representative was included in the development and implementation of the patient's plan of care for 1 (#3) of 5 (#1-#5) sampled patient records reviewed.
Findings:

Review of hospital policy titled "Informed Consent, Care Decisions and Conflicts Resolution; Patient Rights" revealed, in part: Care Decisions and Conflict Resolution. 1. The therapist or nurse, as applicable, will ensure the following occurs during the patient's stay: Obtaining patient signature and acknowledgement of master plan of informed treatment options. 4. Should a patient already have a legal representative, that representative will give informed consent for care, treatment, and services decisions. The responsible representative will be provided with treatment options, risks, and benefits through treatment plan review and asked to sign the treatment plan.

Review of Patient #3's medical record revealed an admit date of 03/05/2023 with an admission diagnosis of Bipolar disorder, current episode mixed. Further review revealed Patient #3 was discharged on 04/27/2023.

A review of Patient #3's Master Treatment plan dated 03/05/2023 failed to reveal a patient or patient representative signature verifying Patient #3 or Patient #3's representative participated in the development and implantation of her plan of care. Further review failed to reveal a reason why Patient #3 or Patient #3's representative did not sign the master treatment plan within the time span of 03/05/2023-04/27/2023.

In an interview on 05/09/2023 at 12:23 p.m., S12DON confirmed there was no signature on the master treatment plan where there should have been as required per hospital policy.

Based on record review and interview the hospital failed to ensure the patient/patient representative's right to be able to request or refuse treatment. This deficiency is evidenced by the administration of an antidepressant against the wishes of the patient/patient's representative to 1 (#5) of 5 (#1-#5) patients sampled.
Findings:

Review of hospital policy titled "Patient Rights; Informed Consent, Care Decisions, and Conflicts Resolution" revealed, in part: to outline the responsibility of the facility in establishing a mutual understanding between the patient/patient's family/representative and the facility about patient services received. To involve patients and significant others, when appropriate, in care decisions, conflict resolution and the informed consent process. Policy: The facility recognizes the benefit and the need to involve patients and significant others, when appropriate, in care, treatment and service decisions, conflict resolution, and to ensure that appropriate informed consent is obtained as outlined by the state Federal and other regulatory bodies. Care Decisions, in part: 1) The therapist or nurse, as applicable, will ensure the following occurs during the patient's stay, in part: Engaging patient/patient representative in discussing concerning proposed care, treatment, and services. Concurring with the patient/patient representative, when appropriate, on care/treatment needs, which will be incorporated into the master treatment plan. 2) The Physician will engage patient/patient representative in a discussion of the nature of the following, in part: Proposed care, treatment, services, medications, interventions. Reasonable alteration to the proposed care, treatment and service. Relevant risks, benefits and side effects related to alternatives, including the possible results of not receiving care, treatment and services.

A review of hospital document titled "Complaint and Grievance Log" revealed, in part: Patient/Family Name: Patient #5. Date of Complaint or Grievance: 02/08/2023. Nature of Complaint or Grievance: TX-did not want pt on medication, pt administered one dose of medication. Complaint Resolution: Psych NP had conference with parent. Discontinued mediations. Father had not answered when nursed called for consents.

A review of Patient #5's medical record revealed an admit date of 02/05/2023. Date of birth: 06/20/2008. Diagnosis: ODD, Major Depressive disorder, recurrent, severe with Anxiety, Suicidal Ideations, and Self-Harm with violent behavior and urinary tract infection.

A review of Patient #5's Psychiatric Evaluation revealed it was completed on 02/06/2023 at 7:38 p.m. by S11PMHNP. Further review revealed S11PMHNP ordered Escitalopram Oxalate 5 mg daily on 02/06/23 at 7:38 p.m.

A review of nurse notes dated 02/06/2023 and 02/07/2023 failed to reveal documentation that Patient #5's represetative was notified of the new order for Escitalopram Oxalate 5 mg daily.

A review of Patient #5's Medication Administration record revealed, in part: Escitalopram Oxalate 5 mg administered by mouth on 02/07/2023 at 9:00 a.m. Further review revealed Escitalopram Oxalate 5 mg administered on 02/08/2023 at 9:00 a.m.

A review of Hospital Pharmacy Orders revealed the Escitalopram Oxalate discontinued on 02/08/2023 at 6:14 p.m.

In an interview on 05/08/2023 at 1:50 p.m., S1DON confirmed there was no nursing documentation that Patient #5's representative was notified of the new antidepressant order. S1DON stated that the nurse did call for consent to start the Escitalopram Oxalate 5 mg and that the father responded that he did not want Patient #5 on an antidepressant due to a "Black Box Warning". S1DON reported that the nurse failed to document the conversation with Patient #5's father and continued by stating if the nurse had documented the discussion with Patient #5's father then the patient may not have been administered the medication.

Based on record review and interview the hospital failed to ensure each patient's right to care in a safe setting. This deficient practice is evidenced by:
1)The hospital failed to remove abusive staff from the hospital schedule following the physical abuse of 1 (#1) out of 5 (#1-#5) patients sampled.
2)The hospital failed to notify the Director of Nursing, the Administrator, and the patient representative following the physical abuse of 1 (#1) out of 5 (#1-#5) patients sampled.
Findings:

1)The hospital failed to remove abusive staff from the hospital schedule following the physical abuse of 1 (#1) out of 5 (#1-#5) patients sampled.

Review of hospital policy titled "Abuse and /or Neglect of Patients by Staff Members, Students, Interns" revealed, in part: Purpose: to prevent and rectify misconduct in a just and constructive manner to reduce likelihood of recurrence and to protect patients from abuse. Policy: Patients have the right to be free from neglect, exploitation, and verbal, mental, physical and sexual abuse. This facility supports and conforms to all state and federal guidelines for protection of patient's rights. Definition of "Abuse", in part, is the infliction of physical or mental injury. No employee will mistreat or neglect a patient. Examples of actions/inactions which could be considered mistreatment/abuse include, in part: Causing pain or suffering. Using inappropriate or excessive physical restraint techniques. Direct physical aggressive behavior toward a patient. Failing to intervene to protect a patient from abuse and/or mistreatment. Any staff or student suspected of any of the above infractions will be investigated under this policy. Employees are educated on the policy.

A review of Patient #1's medical record revealed S6LPN's nurse note dated 03/22/2023 at 11:00 a.m. stated she heard a commotion in the hallway, went to investigate and observed patient lying on his back in the hallway with S8MHT (MHT not identified by the nurse in her notes) on top of patient with hands around his neck. Instructed to stop and helped fellow staff members remove S8MHT from patient.

A further review of Patient #1's medical record revealed S14CN's nurse note dated 03/22/2023 at 11:00 a.m. stated commotion heard in hallway, walked out of nurse's station to investigate. When in hallway, observed patient on the floor, S8MHT (MHT not identified by the nurse in her notes) on top of patient with her hands around his neck. RN asked S8MHT to please remove her hands and remove herself from the situation. S8MHT was then removed from patient by staff. Patient and S8MHT separated from one another.

A review of document titled "Hospital/Licensed Provider Abuse/Neglect Initial Report" (self-report) dated 03/23/2023 at 8:00 a.m. submitted by S1ADON, involving S8MHT choking Patient #1 revealed that S2Admin reviewed the video footage of the incident in the hallway occurring the previous day (03/22/2023) and identified the perpertrator as S8MHT. The self-report indicated the incident on 03/22/2023 was substantiated as abuse.

Review of Staff Schedule dated Tuesday, 03/23/2023, revealed S8MHT was listed on the schedule for the 7:00 a.m.-7:00 p.m. shift.

In an interview on 05/09/2023 at 04:00 p.m., S2Admin stated that the S8MHT should have been removed from the schedule pending investigation in order to prevent further incidences of abuse.

2)The hospital failed to notify the Director of Nursing, the Administrator, and the patient representative following the physical abuse of 1 (#1) out of 5 (#1-#5) patients sampled.

Review of hospital policy titled "Assessment and Reporting of Abuse, Neglect" revealed, in part: Policy: The facilities shall promptly and properly respond to allegations of abuse, neglect or exploitation and shall comply with all reporting obligations. Procedure: Procedure to Respond to Alleged or Suspected Abuse, Neglect, Exploitation by Facility staff(employed or contracted) or by another patient. 1. Should a staff member identify, or be notified of, a suspected case or of abuse, neglect, and exploitation, he/she will notify his/her immediate supervisor and the Administrator/Administrator -on-Call and the Director of Nurses (DON) immediately. 2. The administrator/Administrator -on-Call shall take, or ensure that the following actions are taken, by appropriate staff members, in part: Immediately contacts family to inform family of allegations and actions taken and arranges a session.

A review of Patient #1's medical record revealed S6LPN's nurse note dated 03/22/2023 at 11:00 a.m. stated S10PMHNP and S1ADON notified (of incident) at this time.

In an interview on 05/09/2023 at 04:00 p.m., S2Admin stated that S1ADON did not notify S2Admin or S2DON of incident on 03/22/2023. S2Admin reported that the incident on 03/23/2023 would not have happened if he had been notified because S8MHT would have been removed from the schedule.

Based on record review and interview, the hospital failed to provide an environment free from abuse/neglect and failed to implement effective interventions to prevent future occurrences of abuse/neglect. This deficient practice was evidenced by the hospital failing to prevent abuse by staff and other patients to 3 (#1,#2, #3) of 5 (#1-#5) patients sampled.
Findings:

Review of hospital policy titled "Assessment and Reporting of Abuse, Neglect" revealed, in part: Policy: The facilities shall promptly and properly respond to allegations of abuse, neglect or exploitation and shall comply with all reporting obligations. Procedure: Procedure to Respond to Alleged or Suspected Abuse, Neglect, Exploitation by Facility staff(employed or contracted) or by another patient. 1. Should a staff member identify, or be notified of, a suspected case or of abuse, neglect, and exploitation, he/she will notify his/her immediate supervisor and the Administrator/Administrator -on-Call and the Director of Nurses (DON) immediately. 2. The administrator/Administrator -on-Call shall take, or ensure that the following actions are taken, by appropriate staff members, in part: Immediately contacts family to inform family of allegations and actions taken and arranges a session. 3. Patient-to-patient assaults, physical or secual, are to be reviewed to determine if the facility failed to take prudent action to prevent or respond to the alleged occurrence. These incidents should be examined as alleged neglect, i.e., the hospital's failure to act with due diligence.

Review of hospital policy titled "Patient Rights Louisiana" revealed, in part: 7. Patients have a right to an environment of care that preserves human dignity and contributes to a positive self-image. 8. Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect and/or exploitation.

Patient #1
A review of medical records revealed Patient #1's diagnoses included Major Depressive Disorder, Intellectual Disability mild, PTSD, ADHD, Genetic Disorder Chromosome Deletion Syndrome. Further review reveals date of admission 01/18/2023, discharge date 03/24/2023, and date of birth 06/18/2009.

A review of hospital document titled "Incident Report Log" dated 01/16/2023-03/24/2023 revealed, in part: Patient #1 was involved in an "altercation" on the following dates: 01/22/2023, 01/21/2023, 01/20/2023, 01/20/2023, 01/22/2023, 01/31/2023, 01/30/2023, 01/30/2023, 02/06/2023, 02/09/2023, 02/17/2023, 02/20/2023, 03/03/2023, 03/14/2023, 03/09/2023, 03/13/2023, 03/13/2023, 03/14/2023, 03/14/2023, 03/19/2023, 03/17/2023, 03/22/2023, 03/22/2023 (incident), 03/23/2023. Total of 24 incidents.

A review of hospital records revealed the alleged abuse of Patient #1 by S8MHT on 03/22/2023 at 11:00 a.m. was substantiated on video on 03/23/2023. Continued review of hospital records failed to reveal a "Hospital/Licensed Provider Abuse/Neglect Initial Report" (self-report) regarding the incident that occurred on 03/22/2023. Further review of hospital records failed to reveal the hospital reported S8MHT to the appropriate entities such as Law enforcement or the Direct Service Worker Registry. Further review of hospital records failed to reveal the hospital reported S1ADON to the appropriate licensing board for failing to notify administration of the abuse of Patient #1 by S8MHT on 03/22/2023.

A review of S14CN's nurse note dated 03/22/2023 at 11:07 a.m. (approximately 7 minutes following the abuse inflicted by S8MHT) stated a female peer slapped Patient #1. A review of the Incident Report Log, failed to reveal an entry for 03/22/2023 at 11:07 in reference to this incident. Review of medical record failed to reveal a provider assessment for Patient #1 following incident on 03/22/2023 at 11:00 am and 11:07 a.m.

A review of S14CN's nurse note dated 03/23/2023 at 8:00 a.m. described the second incident involving S8MHT's alleged abuse of Patient #1. The note stated S8MHT reports patient being physically aggressive with her and attempting to punch her. S8MHT also reports that she held patient by jacket to calm him and patient became more combative, attempting to bite and hit her. S8MHT verbalizes that she attempted to grab patient and patient moved causing S8MHT to scratch him on his neck. Scratches noted to left side of patient's neck. Nurse applied triple antibiotic cream to patient's neck. S1ADON and S10PMHNP notified at this time. Will continue to monitor behavior.

S14CN's nurse note on 03/23/2023 at 4:09 p.m. indicated patient transferred out to Hospital #2 Emergency room per DCFS policy and protocol for scratches to left side of neck from incident that occurred earlier in the day.

In a note documented by S16RN on 03/23/2023 at 11:00 p.m. revealed patient had bruising and lacerations on the left side of Patient #1's neck. Nurse applied triple antibiotic ointment to the area. DCFS requested hospital put patient on 1:1.

Nurses note on 03/24/2023 at 7:06 a.m. revealed neck with bruises and lacerations.

Provider note on 03/24/2023 at 1:29 p.m. revealed bruising and laceration to left side of neck and to left chest wall.

A review of document titled "Hospital/Licensed Provider Abuse/Neglect Initial Report" (self-report) for incident on 03/23/2023 revealed patient was transferred to Hospital #1 arranged by DCFS on 03/24/2023.

In an interview on 05/09/2023 at 3:00 p.m., S15ADON stated that Patient #1 had an intellectual disability and that he was a small boy (114.6 pounds) making him an easy target for the other patients. S15ADON reported he sometimes annoyed the other patients because of his unusual behavior and occasional aggressiveness.

In an interview on 05/09/2023 at 04:00 p.m., S2Admin stated that S1ADON did not notify S2Admin or S2DON of incident on 03/22/2023. S2Admin reported that the incident on 03/23/2023 would not have happened if he had been notified because S8MHT would have been removed from the schedule.

Patient #2
Observations of unit hallway on 05/08/2023 at 9:35 a.m. revealed Patient #2 on the phone with a family member. Patient #2 exhibited childlike, animated mannerisms with mildly delayed speech.

Review of Patient #2's medical record revealed date of birth, 05/02/06. Admitted on 04/06/2023 at 5:45 a.m. and readmitted on 04/28/2023 at 2:30 a.m. Diagnoses included Bipolar disorder; Developmental Delay second to Huntington's; CVA at birth; seizures; ADHD.

A review of hospital document titled "Incident Report Log" dated 04/03/2023-04/27/2023 revealed Patient #2 listed on 04/11/2023 for "Physical Assault" and sent to Hospital #3.

Review of Patient #2's medical record dated 04/11/2023 at 8:57 p.m. revealed patient was in a physical altercation with R1 at 8:13 p.m. where he sustained facial trauma. A photo in Patient #2's chart revealed swollen and bloody nose and facial trauma. Provider notified and patient sent to the emergency room where a CT scan of head and face were clear.

Review of doucment titled "Hospital/Licensed Provider Abuse/Neglect Initial Report" (self-report) stated that the aggressor was R1 who was sharing a room with Patient #2. Although the self-report stated that there was no prior aggression that should have alerted staff to be on a heightened alert for an incident between the patients, a review of R1's chart revealed he was admitted on 04/11/2023 at 10:38 a.m. with suicidal ideations and facing multiple assault charges.

A review of R1's psychiatric evaluation revealed R1 had anger issues and was agitated on admit. Following the incident R1 was placed on violence precautions and was placed in a separate room from Patient #2.

In an interview, S12DON stated that Patient #2 had a developmental delay that contributed to behaviors that annoyed some of the other patients since his first admission. S12DON reported that Patient #2 just wanted attention.

Patient #3
A review of Patient #3's medical record revealed date of birth was 08/29/07. Admitted on 03/05/2023 at 6:20 p.m. Diagnoses were ODD, PTSD, Bipolar disorder, Impulse Control disorder.

A review of document titled "Hospital/Licensed Provider Abuse/Neglect Initial Report" (self-report) dated 04/19/2023 at 8:30 a.m., revealed Patient #3 as the victim of alleged physical abuse. Patient #3 reported to S14CN that S7MHT grabbed her by the throat. Further review revealed that Patient #3 had told S7MHT that she was wanting to cut herself and then S7MHT grabbed her by the throat and told her to "quit saying things like that or next time she would make her pass out".
The report stated that S7MHT was removed from the unit, was asked to write a statement and then suspended. At the time she was informed of her pending suspension, the employee turned in her badge and stated that she was immediately resigning.
The physician had Patient #3's observation level increased to "line of sight of sight continuous observation" due to stating that she was having thoughts of self-harm.
Further review revealed that a note entered on the self-report on 04/25/2023 stated that the patient succeeded in self-inflicting superficial scratches to arm using a decorative plastic heart on her shoe, which was confiscated and removed.

A review of nurse's note dated 04/19/2023 at 8:30 a.m., revealed Patient #3 approached nurse and said the S7MHT choked her when she said she cut herself the day before (04/18/2023). Assessment revealed superficial scratches on her left forearm. No documentation regarding patient's neck. Documented "will monitor".

A review of the incident report dated 04/19/2023 completed by the nurse at the time of the incident revealed the psychiatric nurse practitioner was notified of incident and DCFS worker was notified of incident. The patient was placed on line of site status on 04/19/2023 per psychiatric nurse practitioner due to patient having cut herself on the left forearm with her fingernail.

In an interview on 05/08/2023 at 3:20 p.m., S1ADON stated she did not know how Patient #3 was able to cut herself using the decoration on her shoe while under continuous line of sight observation. S1ADON confirmed that S7MHT was listed on the self-report dated 03/23/2023 involving Patient #1. The cameras had shown that S7MHT was with S8MHT when entering into Patient #1's room. S1ADON confirmed that S7MHT resigned when told she would be suspended pending the results of the hospital investigation.

Based on record review and interview, the hospital failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program that measured, tracked and analyzed staff to patient abuse events on 2 (#1 and #3) of 5 (#1-#5) adverse reports reviewed.
Findings:

Patient #1
A review of document titled "Hospital/Licensed Provider Abuse/Neglect Initial Report" (self-report) dated 03/23/2023 at 8:00 a.m. submitted by S1ADON, revealed an alleged incident during which Patient #1 received scratches to his neck during an altercation with S8MHT. The self-report states that the altercation took place in Patient #1's room therefore no video footage was available. Further review of the self-report revealed that S8MHT and S7MHT stated they entered into Patient #1's room to calm him because Patient #1 was being loud and disruptive toward other patients. The report further states that S8MHT and S7MHT reported Patient #1 became increasingly combative and attempted to hit S8MHT. S8MHT put Patient #1 in a hold of which Patient #1 pulled away from and S8MHT scratched Patient #1 with her fingernails during the disengagement.

Continued review of the self-report states that Patient #1 reported that S8MHT pushed him onto his bed after he had acted out and that she grabbed him by the throat. He reports that this is when he was scratched. He reported that after she let him go he ran to the nurses station to report the incident to the nurse.

Additional review of the self-report revealed that a chart review discovered a prior incident that occured the previous day (03/22/2023). It was documented that S8MHT was monitoring the patient in the hallway and the patient made an effort to ram into S8MHT. It was at this point that S8MHT reports she put Patient #1 on to the ground and held him on the ground with her hand on Patient #1's upper right shoulder. At this time, four other staff members arrived and removed S8MHT from the scene. The report noted that Patient #1 did receive abrasion/bruising from the staff member, S8MHT, and that S8MHT's nails were not the appropriate length. After the S2Admin reviewed the video footage of the previous day (03/22/2023), it was determined that S8MHT would be terminated. The self-report indicated that Patient #1 was transferred to Brentwood Hospital which was arranged by DCFS on 03/24/2023. The self-report indicated the incident on 03/22/2023 was substantiated as abuse.

A review of the hospital Quality Assurance and Performance Improvement (QAPI) Safety/Risk Committee Meeting dated 04/24/2023 failed to reveal documentation related to the development, implementation, and maintenance of an effective and ongoing, quality assessment and performance improvement program pertaining to staff to patient abuse involving Patient #1. Further review failed to reveal evidence that the hospital measured, tracked, and analyzed the incident involving staff and Patients #1 in order to determine the cause and prevent future occurrences.

Patient #3
A review of self-report dated 04/19/2023 at 8:30 a.m. submitted by S2Admin, revealed an alleged incident during which Patient #3 reported that after telling S7MHT that she was wanting to cut herself that S7MHT grabbed her by the throat and told her to "quit saying things like that or next time she would make her pass out". The report further stated that S7MHT was removed from the unit, asked to write a statement and suspended. At the time she was informed of this the employee turned in her badge and stated that she was immediately resigning. Patient #3 had her observation level increased to line of sight due to stating she was having thoughts of self-harm.

A review of the hospital Quality Assurance and Performance Improvement (QAPI) Safety/Risk Committee Meeting dated 04/24/2023 failed to reveal documentation related to the development, implementation, and maintenance of an effective and ongoing, quality assessment and performance improvement program pertaining to staff to patient abuse involving Patient #3. Further review failed to reveal evidence that the hospital measured, tracked, and analyzed the incidents involving staff and Patients #3 to determine the cause and prevent future occurrences.

In an interview on 05/09/2023 at 4:55 p.m., S2Admin stated they have a process called "Culture of Safety" in which they report action plans to improve the hospital's culture of safety. S2Admin further confirmed that this document is not part of the QAPI and does not include the development, implementation, and maintenance of an effective and ongoing, quality assessment and performance improvement process pertaining to staff to patient abuse. S2Admin further reported that the corporate office realized that they need to incorporate the "Culture of Safety" process into the QAPI and include documentation that the hospital measured, tracked, and analyzed adverse patient allegations to determine their causes and prevent future occurrences.

Based on record review and interview the registered nursed failed to supervise and evaluate the nursing care of each patient. This deficiency is evidenced by the failure of nursing staff to accurately document assessment findings following an incidence of abuse.
Findings:

Review of hospital policy titled "Patient Rights Louisiana" revealed, in part: 9. Each patient has the right to medical care, pain assessment/reassessment and treatment in accordance with the highest standards accepted in medical practice.

Review of hospital policy titled "Documentation" revealed, in part: Purpose: to maintain a comprehensive and chronologically continuous account of treatment delivered to a patient by nursing staff. To provide specific information regarding medications, treatments, and observations which reflect the care and progress of the patient. To increase communication among the various disciplines providing care to the patient. To provide concise and comprehensive information as a part of a legal document. Policy: Inpatient nursing personnel document patient's progress every 12-hour shift, incorporating the elements of the nursing process and patient's treatment goals and progress within the patient's medical record. Procedure, in part: Inpatient: Daily: Routine: 4. Documents pertinent and factual information including assessment, interventions, education, and outcome.

A review of self-report dated 03/23/2023 at 8:00 a.m. submitted by S1ADON, revealed an alleged incident during which Patient #1 received scratches to his neck during an altercation with S8MHT.

A review of S14CN's Daily RN Assessment Note dated 03/23/2023 at 3:05 p.m. revealed a section titled, "Problem from Plan of Care". A review of this section failed to reveal an update to the Problem list pertaining to the incidences and injuries inflicted on Patient#1 that occurred on 03/22/2023 and 03/23/2023.
Further review fail to reveal an accurate skin assessment under the section titled skin assessment "Findings". The note read "No Issues/Skin Intact".

A review of S14CN's nurse note on 03/23/2023 at 4:09 p.m. indicated patient transferred out to Hospital #2 Emergency Room per DCFS policy and protocol for scratches to left side of neck from incident that occurred earlier in the day.

A review of nurse note documented by S16RN on 03/23/2023 at 11:00 p.m., revealed bruising and abrasions/superficial lacerations noted to left side of neck with pain to neck area 4/10. Triple Antibiotic Ointment applied to abrasions.

In an interview on 05/09/2023 at 04:00 p.m., S14ADON confirmed S14CN did not accurately document a physical assessment. S14ADON confirmed that the Plan of Care was not updated. S14ADON stated that on 03/23/2023 a DCFS worker assessed the patient and noticed bruising, welts and scratches and requested the patient to be seen at the emergency room.

Based on record review and interview, the hospital failed to demonstrate that the director of nursing monitored and evaluated the nursing care furnished thereby ensuring accordance with safe, acceptable standards of nursing practice. This deficient practice was evidenced by failure of the nursing staff to implement seizure precautions in 2 (#2 and #4) of 2 (#2 and #4) patients sampled with history of seizures.
Findings:

A review of hospital document titled "Job Description/Performance Review", "Director of Psychiatric Nursing", revealed, in part: Position Summary, in part: The Director of Nursing is responsible for upholding the standards of nursing care as established by the Nurse Practice Act, Psychiatric Standards of Nursing, and policy and procedures.

Review of hospital policy titled, "Seizure Precautions" revealed, in part: Purpose: to identify patients at risk for seizure activity, implement precautions to prevent injury, and provide immediate interventions for patients during seizure activity. Policy: Seizure precautions will be implemented for patients who have a history of recent seizure activity. Seizures will be treated as a medical emergency. Seizure precautions may include, in part: Include risk for seizures in shift report. Include risk of seizures in multi-disciplinary treatment plan. Prevent individual patient's known triggers once identified.

Patient #4
A review of Patient #4's medical record revealed patient was admitted on 04/28/2023 at 2:15 a.m. Date of Birth: 08/18/2007. Diagnoses included: Seizure Disorder, Psychotic Depression, Bipolar disorder.

A review of hospital document titled "Incident Report Log" revealed an entry on 04/28/2023 at 7:40 a.m. The entry had Patient #4's name listed under "Patient Info" and "Seizure" under "Occurrence Type". Further review revealed a section titled "Comments" with "bit lip" listed.

A review of Multidisciplinary Progress Note updated by S14CN On 4/28/2023 at 8:48 a.m. revealed an MHT came to front desk and announced Patient #4 was having a seizure. S14CN documented that when nurse presented to the bathroom patient was turned on left side and airway was protected. Upon assessment it was noted patient hit her head. Vitals were taken: Blood pressure was 125/63, heart rate was 96, Oxygen was 97, respirations were 16 and temperature was 98.0. Postictal patient began to sit up with assistance of staff, patient was asked if she remembered what had just occurred and she could not. Patient made aware of situation and what occurred. C14CN documented patient was AAOx4 at this time. Further review revealed nurse practitioner was notified and neuro-checks were ordered. ADON was notified. CN14 assessed Patient #4 and noted a wound to lip with no active bleeding. MHT reported patient hit her head on the wall before the seizure. Notified S13NP and orders received for neuro-checks. S13NP assessed patient on 04/28/2023 at 4:30 p.m. with no further orders.

A review of orders revealed the order for Keppra 750 mg twice a day by mouth entered into the system on 04/28/2023 at 2:24 a.m. per the night nurse.

A review of MAR revealed the patient received her first dose of Keppra 750 mg at the hospital on 04/28/2023 at 9:00 a.m. after her seizure.

A review of records revealed that the order for seizure precautions was entered on 04/29/2023 at 7:04 a.m.

In an interview on 05/08/2023 at 2:45 p.m., S1DON confirmed that no seizure precautions were implemented on admission. S1DON confirmed that seizure precautions were not entered into the system until 04/29/2023 at 7:04 a.m. S1DON stated the seizure precautions should have been implemented on admission as policy states as well as immediately after patient had an active seizure.

Patient #2
A review of History and Physical prepared by S13NP on 04/28/2023 at 4:40 p.m. revealed a section labeled "Assessment". Within the section the following was listed, in part: 3. Epilepsy. Continued review revealed a section labeled "Plan". Within the section, the following was listed, in part: 3., in part: Maintain seizure precautions.

A review of Patient #2's medical record failed to reveal that the order for seizure precautions was entered into the system by the admitting nurse. Further review failed to reveal documentation that seizure precautions were implemented as per hospital policy.

In an interview on 05/09/2023 at 12:45 p.m., S12DON confirmed there was no order for seizure precautions. S12DON further stated that the nurse should have put the order in for seizure precautions as per hospital policy.