HospitalInspections.org

Based on record review, staff interview, and review of the facility's policy and procedures, it was determined the facility failed to ensure a registered nurse supervised and evaluated the nursing care of the patients for compliance with hospital policy for
one (#2) of three patients sampled.

Findings include:

The medical record for patient #2 was reviewed. Review of the intake screening revealed the patient arrived to the facility on 10/19/10 and the intake screening was completed at 5:11 a.m. by a registered nurse. The patient was determined to be medically stable following the assessment. The patient was noted to be exhibiting signs and symptoms of delusions, confusion, and difficulty determining reality as well as "paranoid, persecutory delusions." (Intake Screening, 10/19/2010). Review of the physician's history and physical (10/20/2010) revealed the patient was medically stable. Review of the medical record for the patient revealed that, on 10/19/10, during the intake process, the patient revealed he was illegally arrested and placed in jail. The patient reported while in jail he woke up with bodily fluids on his person, bruising, and " sores " on the back. The patient demanded a cat scan, x-rays, and blood test to ensure that he was not " cloned and raped " while in jail. The patient reported while he was in jail that he was in seclusion and could not remember being raped, only waking up sometime between September 29th and October 5th with bruises. On 10/22/10 during a group meeting, the therapist documented the patient focused on the need for x-rays and a cat scan, the bruising on his thighs, and he wanted to file a " grievance. " Documentation revealed the patient was given a piece of paper and pencil to write his/her complaint. Review of the medical record revealed a piece of paper with a hand written complaint, dated 10/22/10 at 11:00 a.m. Review of the patient ' s complaint revealed while in jail the patient woke with bodily fluids on his person, bruising to both thighs, and sores on his back. The patient requested help. Documentation revealed staff presented the patient ' s hand written complaint to the physician. Review of the physician ' s progress notes on 10/22/10 stated the patient is very paranoid, rapid speech, and delusional. The patient believes he was raped 22 days ago because of bruising to his thighs. Review of the physician ' s orders on 10/22/10 at 11:00 a.m. revealed an order for a collateral report from the patient ' s mother about the bruises on the patient ' s legs. Review of the medical record revealed no documentation the patient ' s mother was contacted for information regarding the bruising on the patient ' s legs. Review of the physician ' s progress note on 10/24/10 at 11:00 a.m. revealed the patient requested the abuse hotline telephone number. Documentation revealed the patient was provided the number for the abuse hotline and the state agency. Documentation revealed the patient called the abuse hotline and reported the abuse. The physician documented the patient remained psychotic, rapid speech, irritable, and delusional. Review of the facility's policy, "Criteria for Reporting Abuse (3/2009)," stated every mandated hospital team member has an affirmative duty to report any actual or suspected case of abuse or neglect. The nursing staff failed to follow the facility's policy for reporting a suspected case of abuse when the patient made statements upon admission and the same allegations were hand written by the patient several days later. Interview with the risk manager on 10/27/10 at 4:15 p.m. confirmed the nursing staff failed to follow the facility's policy for reporting suspected abuse.