HospitalInspections.org

Based on hospital policy review and staff interview, it has been determined that the hospital failed to follow its grievance policy and procedure relative to Grievances Committee membership.

Findings are as follows:

Review of the Patient/Visitor Complaint Procedure document, revised in 1/2020, states, in part,
"IV. Procedure ...D.) Receipt, Investigation and Resolution ...2.) Investigation: ...e.) All Grievances will be referred to the appropriate Committee for review. Committee membership will include a physician leader, the Chief Nursing Officer (or designee), the Vice President of Quality, the Patient Experience Officer, Risk Manager, Privacy Officer..., and others as assigned by the committee ...."

During surveyor interview with the Systems Director of Risk Management on 10/8/2020 at 12:20 PM, she stated that committee membership consisted of the Patient Experience Officer and Risk Management. Furthermore, she acknowledged that the facility is aware that the committee membership lacks the disciplines identified in the policy.

Based on record review and staff interview, it has been determined that the hospital failed to provide care in a safe setting for patient ID #14 related to patient observation and safety checks.

Findings are as follows:

Review of the hospital policy for Patient Observation, revised in 10/2017 reveals:
" ...III. Definitions ...

Five-Minute Observation: A staff member will be assigned to monitor and observe the patient every five minutes. Staff will document on the Q5-minute check observation form.

Fifteen-Minute Observation: A staff member will be assigned to monitor and observe the patient every fifteen minutes. Staff will document on the Q15-minute check observation forms. All patients on the Dual Diagnosis unit will have a minimum of Q15-minute observation ...."

Review of the medical record for Patient ID #14 revealed that in 10/2020 s/he was admitted to the Dual Diagnosis unit (W4 unit) from the Emergency Department with "pressured speech" and complaints of auditory verbal hallucinations (AVH, seeing and hearing something that may/may not be there). On 10/2/2020 at 10:33 AM the provider ordered fifteen-minute observation per the hospital policy for the dual diagnosis unit.
Further review of the medical record revealed that on 10/4/2020 at 6:30 AM a Code Grey (requests emergency assistance) was called for this patient, who was "lying on the floor, having epistaxis (bleeding from the nose) and complaining of hip pain." The patient stated that s/he and another patient, Patient ID #13, also on 15 minute checks, admitted with a dual diagnoses and aggressive behaviors, had an altercation which resulted in her/him being "pushed to the floor." Patient ID #14's injuries resulted in a nondisplaced fracture of the right nasal bone and a left femoral neck fracture (for which s/he underwent surgical repair).

Review of the Patient Observations and fifteen (15) minute safety checks for Patient ID #14 revealed on the morning of the incident (10/4/2020), at 6:30 AM, 6:45 AM and 7:00 AM, s/he is documented by nursing as being in her/his room and sleeping.

During an interview with the Risk Management Coordinator on 10/8/2020 at approximately 1:30 PM, she stated that the altercation between Patient ID's #13 and #14 occurred in the TV room area, which is located near the entrance to the unit.

During email correspondence with the Systems Risk Manager on 10/13/2020 at 3:16 PM, she confirmed that the Code Grey was initiated at 6:35 AM, despite the Patient Observation and fifteen (15) minute safety checks document stating Patient ID #13 was in his/her room sleeping.

During an interview with Staff A, who completed the Patient Observations and fifteen (15) minute safety checks for Patient ID #14, she stated she had to defer to her documentation as to the patient's location, even when notified of the time of the Code Grey.

Based on medical record review and review of the Medical Staff Bylaws and Rules and Regulations (last revised 12/19) it has been determined that the hospital's medical staff failed to enforce the rules pertaining to the Bylaws for 7 of 7 patients. (ID #'s 1,2,4,7,9,10 and 13) admitted to the Dual Diagnosis Behavioral Health unit (W4).

Findings are as follows:

1. The Rules and Regulations of the Medical Staff state, in part, "4.5 History and Physical Assessment
4.5.1 A complete medical history and physical assessment shall be recorded within 24 hours of admission by the attending physician or his/her designee ...
15.2.1 Standards for admission history and physical assessment:
15.2.1.1 ...A minimum history shall include documentation in the record of a pertinent statement of all conditions present upon admission and the reason for the procedure or admission and a relevant past medical history including medications, habits and allergies. A minimum physical shall include documentation in the record of vital signs and an exam appropriate to the present illness, and a heart and lung exam. An indication of mental status shall be recorded ...
15.7 All clinical entries in the patient's medical record shall be accurately dated and authenticated."

1. Review of the medical records for Patient ID #'s 1,2,4 and 7 revealed the patients were admitted to W4 unit in September 2020. Further review of the medical records revealed there was no evidence of history and physicals (H&P's) completed by the medical attending physician. Also, the psychiatrist's "History and Physical" documents lacked evidence of an evaluation date, vital signs and physical examination of the heart and lungs.

During surveyor interview on 10/7/2020 at approximately 2:00 PM, the hospital's Risk Management Coordinator acknowledged that the above H&P's lacked documentation required by the Bylaws.

During an interview with the Systems Risk Manager on 10/8/2020 at 1:30 PM, she stated that the "medical attending physician", not the psychiatrist, is responsible for completing the admission history and physical assessment. She also acknowledged that there had recently been weekends without medical attending coverage for the unit.

2. Review of the medical records for Patient ID #' 9, 10, and 13 revealed s/he was admitted to unit W4 in September and/or October 2020. Further review of the medical record revealed the H&P was not completed within 24 hours of admission.

During surveyor interview on 10/7/2020 at approximately 2:00 PM, the hospital's Risk Management Coordinator, she acknowledged that the above H&P's lacked Bylaws required completion within 24 hours of admission.