HospitalInspections.org

Based on medical record review, policy review, staff interview and review of incident reports, the facility failed to ensure the patient or his or her representative has the right to make informed decisions regarding his or her care (A131). The facility failed to ensure care was received in a safe setting (A144).

Based on medical record review and staff interview, the facility failed to ensure the patient or his or her representative has the right to make informed decisions regarding his or her care.for one of ten medical records reviewed (Patient #1). The active census was 48 patients.

Findings include:

Review of the medical record for Patient #1 revealed an involuntary admission to the inpatient psychiatric facility on 02/19/22 due to active psychosis with decompensation. The patient's past mental health history included schizoaffective disorder bipolar type and post-traumatic stress disorder. The medical record noted in bold red lettering the patient had a legal guardian. Further review of the record revealed the facility updated the listed legal guardian throughout the hospitalization with regards to the treatment plan and obtaining consent for psychotropic medications. The patient was transferred to the emergency department on 03/02/22. The medical record lacked evidence the legal guardian documentation was obtained and/or maintained in the medical record.

This finding was confirmed with Staff E on 03/21/22 at 10:45 AM.

Based on medical record and policy review, staff interview, and review of incident reports, the facility failed to ensure care was received in a safe setting for one of ten medical records reviewed (Patient #1). The active census was 48.

Findings include:

Review of the medical record for Patient #1 revealed the patient was involuntarily admitted to the psychiatric hospital on 02/19/22 after presenting to the emergency department due decompensating mental illness. The patient was noted to be exhibiting bizarre behaviors, persecutory type delusions, and auditory and visual hallucinations. The mental health diagnoses included schizoaffective disorder bipolar type and post-traumatic stress disorder. The patient was admitted to the Recover Unit to room 1062B. She was placed on fifteen-minute checks and was prescribed antipsychotic medications for stabilization.

Review of incident reports revealed Patient #1 and another patient were caught engaging in sexually inappropriate behaviors/sexual intercourse on 03/01/22 at 9:40 PM during safety rounds. Patient #1 was immediately moved to another unit, and the practitioner was notified with orders to send the patient to the emergency department for further evaluation. The other patient refused twice to be sent for further evaluation reporting the sexual intercourse was consensual.

An interview was conducted with Staff C on 03/07/22 at 10:53 AM who reported based on the internal investigation findings Patient #1 was found in the other patient's room and engaged in sexually inappropriate behavior. On 03/02/22 at 8:45 AM the internal investigation ensued with the other patient reporting the act was consensual. Patient #1 was unavailable for interview due to being transferred to the emergency room and did not return. Staff C reported Patient #1 would not give any information regarding the incident and refused the Sexual Assault Nurse Exam (SANE) in the emergency department. The medical record noted the facility nurse assessed Patient #1 on 03/01/22 at 9:58 PM noting no injury. Patient #1 remained at the psychiatric facility until approximately 5:45 AM on 03/02/22 awaiting transportation to the emergency room. The medical record lacked evidence the patient was interviewed any further, in the nearly eight hours she remained at the facility, to determine mental capacity and/or if the act was consensual/non-consensual. Additionally, there was no evidence the police were notified.

Review of the policy titled, Allegation of Sexual Assault, reviewed 02/21, revealed staff will document the conversation with the patient, and report to the police and appropriate agencies.

Interview with Staff C on 03/21/22 at 9:24 AM revealed the police were not notified as Patient #1 never alleged rape/assault. The patient was sent to the emergency room for examination by the SANE nurse who would notify local law enforcement. The facility followed its Sexually Acting Out policy (last revised 12/21) and the patients were separated, level of observation was increased, and the treatment plan was updated.

This deficiency substantial Substantial Allegation OH00130701.

Based on medical record review and staff interview, the facility failed to ensure the medical record contained a practitioner order for transfer to the emergency department for one of ten medical records reviewed (Patient #1). The active census was 48 patients.

Findings include:


Review of the medical record for the Patient #1 revealed the patient was involuntarily admitted to the psychiatric hospital on 02/19/22 with diagnoses including schizoaffective disorder bipolar type and post traumatic stress disorder. Review of an incident report dated 03/01/22 revealed the patient was involved in inappropriate sexual behaviors with another patient. The nurse obtained a verbal order for transfer to the emergency department for further evaluation. The medical record lacked a written order signed by the practitioner for the transfer to the hospital.

This finding was confirmed with Staff C on 03/10/22 at 10:54 AM.

Based on review of QSO memo 22-09-ALL, Attachment D, review of facility COVID-19 vaccination records, staff interview, and review of the facility policy, the facility failed to ensure a contingency plan and/or procedures were in place for unvaccinated staff, failed to ensure 100% of staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted qualifying exemption, or identified as having a temporary delay as recommended by the Center for Disease Control (CDC) (A792).

Based on review of QSO memo 22-09-ALL, Attachment D, review of facility COVID-19 vaccination records, staff interview, and review of the facility policy, the facility failed to ensure a contingency plan and/or procedures were in place for unvaccinated staff, failed to ensure 100% of staff have received at least one dose of COVID-19 vaccine, or have a pending request for, or have been granted qualifying exemption, or identified as having a temporary delay as recommended by the Center for Disease Control (CDC). The facility's percentage of vaccinated staff for COVID-19 was 95.3%. This affected 8 of 170 staff members (Staff J, K, L, M, N, O, P, and Q). The active census was 48.

Findings include:

Review of QSO memo 22-09-ALL, dated 01/14/22, revealed within 30 days of issuance of this memorandum, 100% of staff have received at least one dose of COVID-19 vaccine or have a pending request for, or have been granted a qualifying exemption, or are identified as having a temporary delay as recommended by the Center for Disease Control and Prevention (CDC).

Review of the facility policy titled, "Covid-19 Vaccination & Workplace Requirements," effective 01/01/22, revealed staff were to have received one dose of the COVID-19 vaccine prior to 02/14/22 and a second dose of the COVID-19 vaccine no later than 03/15/22. The policy also revealed all eligible staff must meet vaccination requirements for all locations that participate in the Medicare and Medicaid Programs. Further review of the facility's policy revealed no contingency plan and/or procedures for unvaccinated staff working at the facility.

Review of staff vaccination tracking on 03/09/22 at 10:07 AM revealed there were no COVID-19 vaccinations or exemptions on file for the following employees who provided direct patient care, Staff J, K, L, M, N, O, P, and Q.

Interview with Staff I on 03/09/22 at 11:06 AM confirmed the staff identified above had not received the COVID-19 vaccination or had an exemption on file. Staff I stated the facility plan, according to the policy, was that 100% of employees would be vaccinated by 03/15/22 or have exemptions on file. Staff I confirmed the ploicy/procedure did not include a contingency plan unvaccinated staff. Staff I stated if staff had not started the vaccination series or received an exemption, they would be removed from the schedule and/or terminated. Staff also stated those with exemptions who would not receive the vaccination would be required to wear an N95 at all times while in the building.