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Based on review of medical records, staff interviews, review of facility policies and procedures and review of personnel records it was determined that the facility failed to ensure that nursing services assessed and documented any changes in condition for Patient #7 on 1/13/2020 following nursing standards of practice and facility policies after a physical confrontation between Patient #7 and a staff member.

Findings included:

A review of Patient #7's medical record revealed that was admitted to the facility on 1/9/2020 at 11:21 a.m. with a diagnosis of paranoid schizophrenia. He had been transferred from an acute care hospital emergency department on a 1013 (order for involuntary admission or hold). Continued review of a progress note dated 1/13/2020 revealed that the Director of Nursing (DON JJ) was notified at 5:08 a.m. that Patient #7 had been involved in a physical and verbal altercation with staff. DON JJ instructed staff to interview Patient #7 and ensure that a physical assessment was completed by the nurse. DON JJ was informed that Patient #7 had requested that a police report be filed. Further review of the progress note revealed that a medical consult had been requested. At 8:20 a.m., Patient #7's father was notified of the altercation.

Review of the record failed to reveal Nursing Progress Notes for the shift from 1/12/20 at 11:00 p.m. to 1/13/2020 at 7:00 a.m. A review of the Q 15 Nursing Flow Sheet revealed that documentation of 'Behavior' and 'Location' were illegible for 2:15 a.m. through 3:00 a.m. on 1/13/2020. A review of the Nursing Progress Notes dated 1/13/2020 for 7:00 a.m. to 3:00 p.m. by RN PP revealed that Patient #7 reported 'seeing people like they are two' and it was reported that Patient #7 had been involved in an altercation with staff. The patient had been assessed and orders were written for a medical consult and x-rays.

A review of the Psychiatric Progress Notes dated 1/13/2020 revealed that Patient #7 reported to the psychiatrist that he had had a confrontation with the staff when he got up in the middle of the night and tried to call his mother. This led to a physical and verbal altercation between the staff and Patient #7. Patient #7 told the psychiatrist that he did not feel that his actions necessitated the staff's reaction. Patient #7 denied suicidal or homicidal thoughts. A review of the Psychiatric Progress Note dated 1/15/2020 revealed that Patient #7 denied suicidal or homicidal thoughts or visual and auditory hallucinations (hearing voices). Patient #7 reported that he felt physically well and denied dizziness, double vision. Patient #7 was offered the opportunity to be assessed by a medical provider and he (Patient #7) stated that he did not feel that he had a concussion and would follow up if necessary, once discharged. Continued review of the Psychiatrist Progress Note revealed that Patient #7 had met his treatment goals and would be discharged on that day (1/15/2020). Continued review of progress notes revealed that Patient #7 was discharged to home on 1/15/2020 at 4:00 p.m. Patient #7 denied suicidal and homicidal ideations (thoughts) at discharge. Discharge instructions, safety plan and prescriptions were provided to Patient #7.

Interviews

During the exit conference on 12/9/2020 at 4:00 p.m. in the conference room, DON JJ acknowledged that a nursing assessment was not found in Patient #7's medical record for the shift 11:00 p.m. to 7:00 a.m. on 1/13/2020.

Policy and Procedure Review

A review of the facility's policy number PC.008 titled 'Patient Comprehensive Triage and Assessment', last reviewed/revised 08/2019 revealed that all patients were assessed/triaged and evaluated. Results of assessments were reviewed and integrated by the multidisciplinary treatment team to prioritize identified problems within the Master Treatment Plan.
Procedures included:

1.0 At the beginning of the shift, the Charge Nurse was responsible for assigning staff to perform patient observation rounds and documented the assignments on the staffing sheet. The Charge Nurse and the assigned patient nurse ensured rounds occurred as ordered and documented accurately and timely.

1.2 Staff assigned to perform patient observation rounds reviewed and updated the nursing flow sheet which documented the patient rounds. The nursing flow sheet was updated to reflect changes in the patient's precautions level, room change, and new admissions or discharges as they occur.

2.0 Staff verified each patient they are assigned to perform observation rounds on by the patient's armband, patient photo, asking the patient for their name and/or date of birth, or by having another staff member verify the patient's identity.

3.0 Patients were observed at least every fifteen (15) minutes and/or according to the precaution level which was documented on the nursing flow sheet in an accurate and timely manner. Documentation included the patient's location and behavior.

3.3 Document legibly including staff name printed and initials.

5.0 Nursing Assessment

A comprehensive nursing assessment was performed by a registered nurse within 8 hours of the inpatient admission and within 24 hours of the partial hospitalization program admission. Following review of the previous assessment and validation of information with the patient, the nursing assessment included the following information:

5.1 Admission/Orientation - identifying information, vital signs, weight, height, color of hair, eyes, skin assessment, information regarding patient/family orientation to the system, disposition of personal belongings, and general appearance. These data may be obtained by the RN, LPN, MHA, or NA.

5.2 Physical Status Database - information regarding medical/surgical history, pain assessment, current medications, nicotine and caffeine usage, nutritional screening, sleep assessment, fall risk assessment, functional assessment, substance abuse, self-care deficits, body identification, any pre-existing medical conditions or limitations that would place a patient at risk if placed in seclusion or restraints.

5.3 Emotional/Behavioral Database - Mental status assessment included thought disorder, social interactions, hyperactivity, anxiety, depression, post-trauma response, loss/grief, aggression and assessment for special precautions including any special behavior management considerations, as well as triggers for problematic behaviors and effective interventions.

5.4 Summary - Anticipated special discharge plans/instructions and other comments/ summary information.

5.5 Assessment of Learning Needs, Abilities, Preferences, and Barriers (see Patient/Family Educational Assessment)

5.7 Formal nursing assessments were performed and documented by registered nurses upon admission. The assessments were based on specialized knowledge and substantiated by a variety of subjective and formal/measurable assessment tools. The assessment process was ongoing and served as the rationale for care delivery decisions and was the basis for evaluation of the patient's progress in treatment. Significant changes in a patient's condition or diagnosis resulted in re-assessment of the patient. Nursing staff attempted to contact family/previous care provider for collateral information when the patient was unable provide this information. The daily nursing note served as a reassessment of patient needs.