HospitalInspections.org

The Condition of Patient Rights was not met as evidenced by:

The Hospital failed to protect and promote each patient's rights and/or failed to ensure that patients received care in a safe setting as evidenced by:

1. Staff failed to immediately implement their abuse policy to protect the patient when a family member alleged that a staff member was verbally abusive to a patient.

2. The hospital failed to ensure that an allegation of abuse was investigated with appropriate corrective action, remedial or disciplinary action occurred timely due to the hospital's administrative protocols;

3 The hospital failed to conduct a comprehensive investigation after a patient reported to the family member that a staff member was verbally abusive.

4. Staff violated their work rules and/or neglected their duties when they failed to maintain continuous observation and patient's environment continued to be unsafe.

5. The hospital failed to ensure that staff were attentive and that patient's remained in the line of sight when conducting continuous observations.

6. The hospital failed to follow their own policies regarding allegations of abuse.

Please reference A122, A144, A145

Based on clinical record reviews, review of hospital policies and procedures and interviews with facility personnel for one of three sampled patients (Patient #1), the facility failed to ensure that a grievance was investigated and a response was completed in accordance with hospital policy. The findings include:

Patient #1 was admitted to the hospital on 8/8/17 for behaviors of agitation and delusions. Review of the 2018 grievances for Patient #1 identified on 9/14/18 and 9/17/18, the patient met with the patient advocate regarding comments made to the patient by RN #1. Further review identified that RN #1 told Patient #1 that "you are crazier" after returning from visits with your family. On 9/17/18, the patient advocate reported the incident to the Division Director. Further review failed to identify that an investigation was conducted from 9/17/18-9/24/18
(7 days) regarding RN #1's behavior toward Patient #1.

Interview with the Division Director on 10/4/18 identified that the incident was not discussed with RN #1 since the nurse went on vacation from 9/25/-10/4/18. Subsequently, on 10/5/18, the facility conducted an investigation, reviewed the incident with RN #1 and the patient was moved to another unit.

Review of hospital policy identified that the Client's Rights Offcier (CRO) will provide the grievant and their representative with a written Greivance Acknowledgement Form within three business days of the receipt of the grievance. The Client's Rights Officer will initate an investigation and interview any person(s) who may have information that will assist in the prompt resolution of the grievance. The investigation may include a review of medical records, policies and procedures, state and federal statutes and other related documents.

1. Based on medical record review, review of facility documentation, review of facility policies and interviews for two of three patients ( Patient #8, Patient #10), who were on CO (constant observation) status and/or had a history of PICA (eating substances that have no nutritional value), the facility failed to ensure that the ordered observation level was maintained and/or that small items were not provided as per the plan of care to ensure patient safety.
The finding includes:

a. Patient #8 had a history of self-injurious behavior and PICA (eating substances that have no nutritional value). The treatment plan dated 4/30/18 identified that the MHA (mental health aide) will monitor for increasing signs of agitation that may result in in self- injurious behavior. Review of physician orders dated 5/5/18 and 5/6/18 directed CO and the patient could have one marker at a time with top off. Review of physician orders dated 5/7/18 directed every 15 minute checks for risk of self- injurious behavior and did not direct marker use. Review of nursing notes dated 5/7/18 indicated that at 7:20 PM, Patient #8 reported swallowing three marker caps, complained of throat pain, was sent to the Emergency Department (ED). Review of the hospital documentation dated 5/7/18 identified that the patient had swallowed marker caps and the plan would be to allow the caps to pass naturally as they were not sharp. Review of special observation monitoring sheets dated 5/7/18 identified that Patient #8 was monitored from 12:00 AM to 7:00 AM. Further review lacked documentation for CO monitoring from 7:15 AM to 10:00 AM and every 15 minute monitoring from 10:15 AM to 7:00 PM. In addition, during that period of time, the patient could have ingested the marker caps.

Interview with MD #16 on 10/9/18 at 12:46 PM identified that, although he did not write the order, the patient could usually have three markers at a time on every 15 minute checks but, should never be given the marker caps. The facility policy for special observation identified that this included every 15 minute observations and CO. The policy further identified that the nursing staff assigned to the Special Observation is responsible and accountable for ensuring patient safety. The policy directed that the patient's hands, face, and neck must be in clear view at all times unless otherwise specified in the MD order.

b. Patient #8 had a history of self-injurious behavior and PICA. The treatment plan dated 4/30/18 identified that the MHA (mental health aide) would monitor for increasing signs of agitation that may result in in self- injurious behavior. Review of physician orders dated 6/12/18 at 9:30 AM directed CO for risk of self- injurious behavior. Physician orders dated 6/1/218 at12:00 PM noted may have glasses while on CO at RN discretion. Review of nursing narratives dated 6/12/18 indicated that at approximately 7:30 PM, Patient #8 reported swallowing a plastic lens from the eye glasses and the right eye glass was missing. Special observation sheets dated 6/12/18 identified that
P #8 was on CO after the "may have glasses" order was written at 12:00 PM and up to 7:30 PM when Patient #8 reported the incident. The facility investigation dated 6/12/18 noted that Patient #8 refused to say when he/she swallowed the lens and staff interviews did not indicate that staff had observed the incident. Patient #8 was sent to the ED on 6/12/18 and a lens was removed endoscopically.

Interview with the Division Director of General Psychiatry on 10/9/18 indicated that when a patient was on CO, nothing should be between the staff member observing and the patient being observed. Further interview identified that the purpose of CO with a patient that ingests objects is to allow for staff intervention. The facility policy for special observation identified that this included every 15 minute observations and CO. The policy further identified that the nursing staff assigned to the Special Observation is responsible and accountable for ensuring patient safety. The policy directed that the patient's hands, face, and neck must be in clear view at all times unless otherwise specified in the MD order. The facility client and family handbook identified a patient right to receive individulaized treatment.

c. Patient #10 was admitted to the B3S unit on 1/10/18. Patient #10's diagnoses included major depressive, personality disorder. Patient #10 had a history of ingestion of foreign objects to include hairpins and had a tracheostomy tube. Review of physician orders dated 8/15/18 at 8:50 AM directed CO for medical and behavioral monitoring. Review of CO documentation identified that MHA #11 (mental health aide) turned over CO of the patient to MHA #12 at 8:30 PM. The CO documentation further noted that at 8:30 PM, Patient #10 was in the shower and at 8:45 PM, Patient #10 swallowed some hair pins. Review of nursing narratives dated 8/15/18 indicated that Patient #10 had ingested hair pins, pulled out the tracheostomy tube and was sent to the hospital on a medical emergency for evaluation. Review of the hospital x-ray dated 8/15/18 identified what appeared to be metal objects in the left upper quadrant of the abdomen. Patient #10 underwent an unsuccessful endoscopic retrieval of the hairpins and was discharged back to the facility.

Interview with MHA #11 on 10/4/18 at 10:13 AM identified that when she began to constantly observe Patient #10 and the patient was going into the shower. Patient #10's hair was not in hair pins. MHA #11 further indicated that MHA #12 reported that patient had hair pins and the patient subsequently admitted to swallowing the pins. Interview with MHA #12 on 10/4/18 at 10:24 AM identified that Patient #10's hair was braided and placed two hair pins on the bedroom dresser, went into the hall near his/her room and was in the hall when MHA #12 relieved her. Further review failed to indicate that Patient #10 was constantly observed/supervised during the change in staff assignments.

Review of the event with the B3S Director of Nursing on 8/4/18 at 10:40 AM indicated that the accounts of
MHA #11 and MHA #12 differed and, although Patient #10 was on CO, neither MHA saw the patient swallow the hair pins.

The facility policy for CO identified that this was an observation in which the patient required ongoing monitoring to ensure his/her safety and/or the safety of others. The policy further noted that nursing staff assigned provided this by having a clear view of and unimpeded access to the patient at all times. The facility client and family handbook identified a patient right to receive individulaized treatment.



2. Based on medical record review, review of facility documentation, review of facility policies and interviews for one of two patients (P#8), who had a history of PICA (eating substances that have no nutritional value), the facility failed to ensure that the patient was timely assessed to ensure patient safety following a self injuries act.
The finding includes:

Patient #8 had a history of self-injurious behavior and PICA. Review of the treatment plan dated 4/30/18 identified that the MHA (mental health aide) will monitor for increasing signs of agitation that may result in in self- injurious behavior. Review of physician orders dated 5/24/18 directed every 15 minute checks from 11:15 PM to 2:15 PM for impulsive, risky behavior. Review of nursing narratives and/or the incident report dated 5/24/18 identified that Patient #8 reported swallowing a broken, sharp small piece of a plastic comb, complained of difficulty breathing and found relief following the administration of two respiratory treatments/medications, Zyprexa, Benadryl and Tylenol. Further review identified that the on-call MD was notified (MD #14) at 11:50 PM on 5/24/18 and did not assess Patient #8 until 8:35 AM on 5/25/18(7 1/2 hours later). MD #14 documented that assessment on the incident report however, an assessment by MD #14 was not documented and orders were not given by MD #14 to send Patient #8 to the ED for evaluation. Although MD #14 indicated on the incident report that Patient #8 was in no acute distress at 8:35 AM, the note by the RN identified that Patient #8 began to complain of abdominal pain at 8:00AM. Review of the progress note by MD #12 (medical MD) dated 5/25/18 at 1:40 PM indicated that
Patient #8 complained of chest/abdominal pain since the ingestion, the pain fluctuated and the patient was subsequently sent to the ED for evaluation. Review of hospital documentation dated 5/25/18 at 5:45 PM noted that a foreign body was removed endoscopically.

Interview with MD #14 on 10/5/18 at 1:40 PM identified that he did not immediately examine the patient and/or send the patient to the ED because the RN was a very knowledgeable nurse and reported that the patient was not in any acute distress.

The facility policy for patient safety event and incident management identified the following: 1. Ingestion of foreign bodies was considered an aggressive act to self. 2. A patient safety event was an event, incident or condition that could have resulted or did result in harm to a patient. 3. An exam is required for all patient injuries. 4. The incident report form is an administrative form only and does not substitute for the necessary clinical documentation in the medical record. The facility client and family handbook identified a patient right to have complaints of pain appropriately assessed and interventions made in a timely manner.

Based on clinical record reviews, review of hospital policies and procedures and interviews with facility personnel for one of three sampled patients (Patient #1), the facility failed to protect the patient from any form of abuse by staff in accordance with hospital policy. The findings include:

Patient #1 was admitted to the hospital on 8/8/17 for behaviors of agitation and delusions. Review of the 2018 grievances for Patient #1 identified on 9/14/18 and 9/17/18, the patient met with the patient advocate regarding comments made to the patient by RN #1. Further review identified that RN #1's verbal comments told to Patient #1 that "you are crazier" after returning from visits with your family. On 9/17/18, the patient advocate reported the incident to the Division Director. Further review failed to identify that an investigation was conducted from 9/17/18-9/24/18 (7 days) regarding RN #1's behavior toward Patient #1.

Interview with the Division Director on 10/4/18 identified that the incident was not discussed with RN #1 since the nurse went on vacation from 9/25-10/4/18. Subsequently to surveyor inquiry on 10/5/18 (18 days after incident was reported), the facility conducted an investigation, reviewed the incident with RN #1 and the patient was moved to another unit per the patient/family request. The facility failed to remove the RN from patient care pending an investigation of verbal abuse.

Review of the patient rights policy identified that all patients have the right to personal dignity, privacy, and confidentiality. Review of hospital's abuse policy identified that when an allegation of abuse is reported to a supervisor or manager on duty, the patient should be moved to a physically safe location and an assessment is conducted. In addition, for all allegations of verbal abuse, neglect, or exploratation, the alleged perpetrator may be removed from patient care pending the outcome of the preliminary investigation.