HospitalInspections.org

Based on review of facility policy, medical record review, and interviews, the facility failed to implement preventive actions to ensure the safety of a vulnerable patient with dementia for 1 patient (#4) of 5 patients reviewed.

The findings included:

Review of facility policy, "Alleged Assualt or Abuse of Patients Receiving Services at [named facility]" last revised 6/2022, showed "...always ensure the immediate safety of the patient where there is an allegation or threat of abuse..."

Medical record review showed Patient #4 was admitted on 11/4/2022 with diagnoses including Dementia, Atrial Fibrillation (irregular heart rate), Aortic Stenosis (narrowing of the aortic valve), Metabolic Encephalopathy (delirium and confusion), Chronic Kidney Disease, and Cerebrovascular Disease. She had previous history of dementia and presented with an increased altered mental status (AMS). She was continued on her Seroquel (antipsychotic medication).

Review of a Psychiatric Consult dated 11/7/2022 at 12:01 PM showed Patient #4 was admitted with a history of dementia with increased AMS. Her assessment showed diagnoses including dementia with some degree of vascular changes, and she lacked the capacity to make decisions for herself.

Medical record review showed Patient #5 was admitted on 11/23/2022 with Symptomatic Anemia (low blood levels), Chest Pain, IV drug abuse, Alcohol Abuse and Hypertension (high blood pressure). The patient's mental status "waxed and waned" and he was suffering alcohol withdrawals.

Review of a Security Report dated 11/25/2022 at 9:40 PM showed security was called by the House Supervisor related to a male patient (Patient #5) had possibly stolen property from another patient (Patient #4). Security had been notified "...an incident occurred between the two patients and Patient #5 had stolen valuable property assigned to Patient #4...possible performed sexual acts with him. We went to the 5th floor and made contact with [Patient #5] after he had been moved to another room to separate the patients. I asked [Patient #5] about the situation and he admitted that [Patient #4] had given him a ring...he emptied his pockets and observed a bag of meth [illicit drug methamphetamine]..." The officers spoke with the patient about the alleged incident and Patient #5 admitted to "...having played along with [Patient #4] delusions of him being her deceased husband...he stated he knew it was not right, but he did not argue or attempt to persuade [Patient #4] otherwise...we were able to recover the ring..."

Medical record review of a Hospitalist Follow-up Progress Note for Patient #4 dated 11/26/2022 at 6:24 AM showed "...notified patient had multiple interactions with a younger male patient and she had been found in his hospital room. Nursing notified house supervisor who reports Risk Management was made aware. Due to unusual interactions and patient having dementia, SANE [sexual assault nurse examiner] nurse was contacted for further examination. Male patient was transferred to another floor..."

Medical record review of a Hospitalist Progress Note for Patient #4 dated 11/26/2022 at 10:30 AM showed "...events noted overnight including patient being found in another patient's room with concerns for sexual exploitation...patient herself this morning is resting comfortably no complaints...dementia with variable behavioral issues currently under control on Seroquel..."

Medical record review of an admission H&P for Patient #4 dated 11/27/2022 at 8:39 AM showed "...on the night of 11/25/2022, patient [#4] had an interaction with another patient [#5] in his room and this patient [#5] was moved to another floor and the patient [#4] moved closer to the desk..."

During an interview on 11/30/2022 at 12:02 PM, the Chief Nursing Officer, stated she was notified by the Nursing Director of the alleged incident which had occurred on 11/25/2022 between the two patients. Patient #4 had dementia and thought Patient #5 was her deceased husband. She had been in and out of Patient #5's room. Patient #4 had a history of wandering and staff had tried to redirect the patient on several occasions. The CNA (Certified Nurse Assistant) observed Patient #4 in Patient #5's room with her pants pulled down and escorted Patient #4 back into her room.

During an interview on 11/30/2022 at 12:10 PM, the Nursing Director stated Patient #4 was confused and had been going in and out of Patient #5's room throughout the day on 11/25/2022. The staff had to redirect her back to her room on several occasions. There had been a bed request to transfer Patient #5 to another unit on 11/25/2022 at 8:48 AM, related to the behaviors, and the patient had not been moved. When the nightshift Registered Nurse (RN) received report, she had called the House Supervisor and asked about the transfer for Patient #5 related to the behaviors. During the CNA's rounds, she had observed Patient #4 in the room with Patient #5 and took her back into her room. Around 8:30 PM, the CNA observed Patient #4 in Patient #5's room with her pants down to her knees and the CNA immediately took the patient back to her room. Patient #4 had a bed alarm on, which was implemented on 11/16/2022, and the alarm had sounded numerous times during the dayshift and evening shift. The bed alarm tracking system was checked and found the staff were in the room within 30-40 seconds after the alarms had sounded to silence the alarms. She confirmed there was no sitter with the patient and no additional interventions had been put into place to ensure Patient #4's safety.

During an interview on 12/1/2022 at 7:05 AM, CNA #1 stated on 11/25/2022 she had received in report Patient #4 had been going in and out of Patient #5's room and she was told she needed to watch both patients closely. Around 8:00 PM, she noticed Patient #4 in Patient #5's room with her pants down to her knees and she had separated the patients. The patient had a bed alarm in place which had alarmed several times. There was no sitter was with the patient and no other interventions were in place.

During a telephone interview on 12/1/2022, RN #1 stated the patient had dementia and needed frequent redirection by the staff. When she came on shift on 11/25/2022 at 7:00 PM, she received report Patient #4 had been going into Patient #5's room during the dayshift and there was no sitter with the patient. She had called the House Supervisor to check on a room status for Patient #5 since the request had been placed earlier in the morning.