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Based on observation, interview and policy review, the hospital failed to ensure all patients received care in a safe setting as evidence by 1) failing to ensure a prohibited item was secure and 2) failing to ensure the unit was free from items that may cause asphyxiation.
Findings:

1) Failing to ensure a prohibited item was secured.

Review of the hospital's current policy titled, "Behavioral Health Contraband" revealed, in part, a section titled, "Prohibited Items" including vi. Sharp objects.

A tour of Unit "a" on 03/07/2022 at 9:19 a.m. revealed a small wooden pencil with a sharpened tip on the countertop of Room "b" which was an occupied room.

In interview on 03/07/2022 at 9:20 a.m., S5DBH verified the pencil was found in the room and it was a prohibited item.

2) Failing to ensure the unit was free from items that may cause asphyxiation.

Review of the hospital's policy titled, "Behavioral Health Contraband" revealed, in part, a section titled, "Prohibited Items" included items that may be used for asphyxiation such as plastic bags.

A tour of Unit "a" on 03/07/2022 at 9:20 a.m. revealed a trash container located in the dayroom "c" near the kitchenette doors with a plastic bag inside the paper bag of the trash can.

In interview on 03/07/2022 at 9:20 a.m., S5DBH verified the plastic bag was found in the trash and it was a prohibited item.

In interview on 03/07/2022 at 9:21 a.m., S6RN indicated patient's snacks arrived daily in the plastic bags and the bags were routinely discarded in the trash can.


44495

Based on record review and interview the facility failed to recognize factors related to safety and quality improvement on risk management review. This deficiency is evidenced by failure of S11RM to identify neglect in review of an incident self-reported to state office.

Findings:
Review of the Hospital / Licensed Provider Abuse/ Neglect Initial Report dated 02/02/2022 revealed an incident report of patient to patient sexual assault which occurred on 02/02/2022 at 8:05 a.m. Patient #1, identified as the aggressor, was on one to one observation precaution status with strict visual contact. S9BHT was assigned to Patient #1 and left Patient #1 unattended in his room while S9BHT went to the nurse's station for supplies. While unattended, Patient #1 left his room and assaulted Patient #8. In the investigation report, S11RM stated the allegation of neglect was not substantiated.

In interview on 03/08/2022 at 11:34 a.m., S2CPHQ verified S9BHT did not follow the physician's order of care and his decision to leave Patient #1 alone was neglect and resulted in the sexual assault of Patient #8.

Based on observation and interview the registered nursed failed to supervise and evaluate the nursing care of each patient. This deficiency is evidenced by the failure of S8BHT to perform 15 minute observations 1) on 03/08/2022 at 8:15 a.m. for 3(R1, R2, R3) of 8 (R1, R2, R3, R4, R5, R6, R7, R8) assigned patients; and 2)on 03/08/2022 at 8:30 a.m. for 8 (R1, R2, R3, R4, R5, R6, R7, R8) of 8 (R1, R2, R3, R4, R5, R6, R7, R8) assigned patients.
Findings:

Direct observation during tour of BH2 on 03/08/2022 at 8:40 a.m. revealed S8BHT had not completed the Behavioral Health Observation 15 minute checks record at 8:15 a.m. for 3(R1, R2, R3) of 8 (R1, R2, R3, R4, R5, R6, R7, R8) assigned patients

Further review of the Behavioral Health Observation 15 minute checks record revealed he had not completed the 8:30 a.m. 15 minute checks on 8 (R1, R2, R3, R4, R5, R6, R7, R8) of 8 (R1, R2, R3, R4, R5, R6, R7, R8) patients.

On 03/08/2022 at 8:40 a.m. S4CNO verified the above finding.

Based on record review and interview the hospital failed to ensure the nursing staff performed a timely initial nursing assessment. This deficiency is evidenced by the failure of the nursing staff to perform a nursing assessment on one (Pt.#8) of nine (Pt.#1, Pt.#2, Pt.#3, Pt.#4, Pt.#5, Pt.#6, Pt.#7, Pt.#8, Pt.#9) records reviewed.
Findings:

Review of the hospital policy, "RN Assessment and Reassessment," revealed in part, "Nursing assessment data will be used to formulate an appropriate nursing diagnosis and plan of care...Whenever, the assessment cannot be completed within eight (8) hours due to the patient's condition, the reason will be reported and documented in the progress note section of Epic...The inability to complete the assessment will be reported and documented in the progress note section in Epic each shift until completed."

Review of the electronic medical record for Patient #8, navigated by S12RN, revealed she was admitted 02/24/2022 on the 7 p.m. to 7 a.m. shift. Review of the Nursing Flow Sheet in Epic revealed the initial nursing assessment was not performed until 02/25/2022 during the 7 p.m. to 7 a.m. shift.

Review of the nursing progress notes section for 02/24/2022 and 02/25/2022 failed to reveal documentation that the initial nursing assessment was not done.

In interview on 03/08/2022 at 11:00 a.m. S12RN, S2CPHQ, and S4DBH verified there was no documentation in the nursing progress notes that the assessment was not done. S3CMO stated the Epic system provides reminders if the nursing assessment is not complete.

Based on record review and interview the nursing staff failed to administer prn medications in accordance with accepted standards of practice. This deficiency is evidenced by failure of the nursing staff to monitor the therapeutic effect of prn medications in 4 ( Pt.#4, Pt.#5, Pt.# 8, Pt.#9) of 6 (Pt.#4, Pt.#5, Pt.#6, Pt.#7, Pt.#8, Pt.#9) patients reviewed for therapeutic assessment after medication administration.
Findings:

Patient #4
Review of the electronic medical record for Patient #4, navigated by S7RN, revealed an order placed 02/25/2022 at 10:32 a.m. for hydroxyzine capsule 50 mg, oral, three times daily prn anxiety and an order placed 02/26/2022 at 4:50 p.m. for ibuprofen 600 mg, oral, every 6 hours prn pain.

Review of the MAR revealed hydroxyzine 50 mg was given on 03/02/ 2022 at 7:00 p.m.

Review of nurse progress notes for 03/02/2022 at 7:00 p.m. revealed hydroxyzine 50 mg was orally administered for anxiety. Further review reveals no documentation of the therapeutic effect of the medication.

Review of the MAR for Patient #4 revealed ibuprofen 600 mg was orally administered 03/02/2022 at 12:23 p.m. for cramping with a pain score of 7/10.

Review of the pain assessment flow sheet for Patient #4 revealed a pain assessment on 03/02/2022 at 12:23 p.m. and no reassessment after the medication was administered.

Review of the nurse progress notes on 03/02/2022 after 12:23 p.m. revealed no reassessment for therapeutic effect.

In interview on 03/07/2022 at 2:40 p.m. S7RN, S2CPHQ, and S5DBH verified the therapeutic effect of the medications was not documented.

Patient #5
Review of the electronic medical record for Patient #5, navigated by S12RN, revealed an order placed 09/22/2021 at 7:11 a.m. for acetaminophen 650 mg, oral, every 6 hours prn temperature > 100.4 or pain.

Review of the MAR for Patient #5 revealed acetaminophen 650 mg was orally administered on 09/25/2021 at 11:25 p.m.

Review of the pain assessment flow sheet for Patient #5 revealed 5/10 pain noted on 09/25/2021 at 11:25 p.m. There was no reassessment for therapeutic effect.

Review of the nurse progress notes for 09/25/2021 after 11:25 p.m. and the early morning of 09/26/2021 revealed no documentation of reassessment for therapeutic effect.

Review of the MAR for Patient #5 revealed acetaminophen 650 mg was orally administered on 09/27/2021 at 22:45.

Review of the pain assessment flow sheet for 09/27/2021 at 10:45 p.m. revealed no pain assessment at the time the medication was given and no reassessment for therapeutic effect.

Review of the nurses progress notes for 09/27/2021 from 10:45 p.m. until midnight revealed no documentation pain, the administration of medication for pain, or reassessment of therapeutic effect.

In interview on 03/08/2022 at 9:45 a.m. S12RN, S2CPHQ, and S4DBH verified the therapeutic effect of the medication was not documented.

Patient #8
Review of the electronic medical record for Patient #6, navigated by S12RN, revealed an order on 01/26/2022 at 11:27 for haloperidol 5 mg, IM injection, prn breakthrough psychosis/ mania.

Review of the MAR for Patient #8 revealed haloperidol 5 mg was intramuscularly administered on 01/27/2022 at 8:24 a.m.

Review of the nurse progress notes for 01/27/2022 at 8:28 a.m. revealed the patient was "highly agitated". Further review of the nurse notes revealed no documentation of therapeutic effect.

In interview on 03/08/2022 at 10:50 S12RN, S2CPHQ, and S4DBH verified the therapeutic effect of the medication was not documented.

Patient #9
Review of the electronic medical record for Patient #9 revealed an order for quetiapine 25 mg, oral, every 8 hours prn anxiety or non-redirectable agitation.

Review of the MAR for Patient #9 revealed quetiapine 25 mg was orally administered 02/23/2022 at 6:27 a.m.

Review of the nurse progress notes for 02/23/2022 revealed a note at 7:51 a.m. that stated "around 0615 patient was at nurse window waiting to receive morning medication. When she yelled "He grabbed my vagina" patient was grabbed by a male peer on the unit. MD, Supervisor, Hospital Police were notified."

In interview on 03/08/2022 at 11:15 a.m. S12RN, S2CPHQ, S4DBH verified the note did not document medication was given as a result of the incident and there was no documentation of therapeutic effect.