HospitalInspections.org

Based on record review and interview the hospital failed to ensure care in a safe setting. The deficient practice is evidenced by failure of a staff member acknowledge and assist a patient after a fall.
Findings:

Review of hospital policy number AS-12 last revised 11/16/2022 titled "Fall Assessment/ Re-Assessment and Precautions" revealed in part: POLICY: Inpatient: 1. All patients will be assessed and identified for the potential of being at risk for falls within the first 8 hours of admission at the time of their initial nursing assessment, immediately after a fall, or change in mobility status, and/or every 7 days if identified as "at risk for falls".

Review of Patient #2's medical record revealed Patient #2 was admitted on 04/02/2025 with Major Neurocognitive Disorder with behavioral disturbances and psychosis. On 04/16/2025 Patient #2 was assaulted by MHT resulting in fall to the ground.

Review of the Self-Report involving Patient #2 revealed the following:
Date of Incident: 04/16/2025, time: 5:12 PM, Type of occurrence: Alleged Physical Abuse
Describe the facts of the occurrence: Patient #2 fell to the floor, breaking her fall with her left hand. Later Patient #2 stated the staff pushed her.
Initial Actions: Upon assessment of Patient #2, S8RNCN noted deformity to Patient #2's left middle finger. The provider was notified and orders were received to transfer Patient #2 to the local ED. S6MHT was suspended pending investigation.
Investigation Results: The allegation of abuse is unable to be substantiated due to lack of evidence.

On 04/23/2025 at 1:05 PM video footage was reviewed for the incident involving Patient #2 that occurred on 04/16/2025 navigated by S1DON. Review of the video footage revealed the following:
17:11:32 PM- Patient #2 seen in hallway talking to a patient sitting in wheelchair. S6MHT sitting in hallway.
17:11:38 PM- Patient #2 seen in hallway pushing patient in wheelchair
17:11:49 PM- Patient #2 pushing patient in wheelchair and looks back at S6MHT
17:12:04 PM- S6MHT gets up from sitting in hallway and walks toward Patient #2 pushing patient in wheelchair
17:12:06 PM- S6MHT grabs wheelchair and stops Patient #2 from pushing patient in wheelchair
17:12:29 PM- S6MHT seen walking Patients #2 backward away from the patient in the wheelchair
17:12:32 PM- S6MHT holding Patient #2's arms while standing in doorway when S6MHT pulls away from Patient #2 with her right arm and pushes Patient #2 with her left arm causing Patient #2 to fall to ground.
17:12:45 PM- S7MHT steps over Patient #2 to empty patients' meal tray in the trashcan in the hallway without offering care to Patient #2 assistance
17:13:05 PM- S7MHT talking with Patient #2 sitting on the floor and S6MHT walks to nurses' station talking with S8RNCN
17:13:22 PM- S8RNCN seen talking with Patient #2 who is still sitting on the ground
17:14:02 PM- S8RNCN assist Patient #2 to a standing position
17:14:27 PM- S8RNCN, S9MHT, and Patient #2 seen walking down hallway toward Patient #2's room

In an interview on 04/23/2025 at 1:15 PM, S1DON verified S7MHT did not assess or assist Patient #2 after her fall.

Based on record review and interview, the hospital failed to recognize factors related to patient safety and quality improvement. This deficient practice was evidenced by failure to accurately self-report an incident which involved a patient and an employee.
Findings:

A review of hospital policy No. QAPI-004 titled, "Incident Reporting," last revised 08/01/2024, revealed in part: "Information to Provide in the Incident Report: 1. The Incident Report shall be limited to factual statements (who, what, where, and when) related to the patient safety incident and any interventions take to reduce the risk of future incidents and promote safety."

Review of Patient #2's medical record revealed Patient #2 was admitted on 04/02/2025 with Major Neurocognitive Disorder with behavioral disturbances and psychosis. On 04/16/2025 Patient #2 was assaulted by MHT resulting in fall to the ground.

Review of the Hospital / Licensed Provider Abuse/ Neglect Initial Report finalized on 04/17/2025 revealed the following documentation:
Incident type documented as: Alleged Patient Abuse; Staff to Patient Assault
Date/Time Incident: 04/16/2025 at 5:12 PM
Patient Information documented on report included:
Patient #2 documented as both being the victim
Incident Details:
First Employee aware of the allegation and how they became aware of the allegation: S6MHT was redirecting Patient #2 from pushing another patient's wheelchair when Patient #2 fell to the ground.
Describe the alleged incident: Patient #2 fell to the floor, breaking her fall with her left hand. Patient #2 later stated to staff that she was pushed.
List-all x-rays/test conducted and results: X-ray taken at local ED revealed fracture of phalanx of left middle finger and fracture of fifth metacarpal bone of left hand
Did the aggressor have a history of this behavior: N/A
Video Surveillance information documented on report included:
Video surveillance at incident site: yes
What was revealed on video? Answer: At 5:12 PM, S6MHT seen sitting on chair in the hallway. Patient #2 is standing nearby, talking to a peer who is sitting in a wheelchair. Several seconds later, Patient #2 begins to push the peer's wheelchair. S6MHT stands up to intervene, initially by grasping the wheelchair. Patient #2 can be seen grabbing onto S6MHT's hand. S6MHT pushes Patient #2's hand back away from her, causing Patient #2 to fall backward. We are unable to see Patient #2 land on the floor due to the angle of the camera.
Comments documented on report included:
Upon review of the camera footage, it was noted that S6MHT did not use an approved grasp-release technique for which she was trained, which resulted in Patient #2 losing her balance during the encounter. Patient #2 was promptly assessed by the charge nurse and transferred to the ED for further evaluation and treatment. Upon return from the ED, Patient #2 reported to S2ADON, that she had been pushed but believed it was an accident. S6MHT was also interviewed during the investigation process and maintained that the fall was accidental. She was ultimately terminated from employment on 04/17/2025 for violation of policy. S8RNCN did not witness the incident. No other staff members were present in the hallway when the event occurred.
Investigation Results:
The allegation of abuse is unable to be substantiated due to lack of evidence.

On 04/23/2025 at 1:05 PM video footage was reviewed for the incident involving Patient #2 that occurred on 04/16/2025 navigated by S1DON. Review of the video footage revealed the following:
17:11:32 PM- Patient #2 seen in hallway talking to a patient sitting in wheelchair. S6MHT sitting in hallway.
17:11:38 PM- Patient #2 seen in hallway pushing patient in wheelchair
17:11:49 PM- Patient #2 pushing patient in wheelchair and looks back at S6MHT
17:12:04 PM- S6MHT gets up from sitting in hallway and walks toward Patient #2 pushing patient in wheelchair
17:12:06 PM- S6MHT grabs wheelchair and stops Patient #2 from pushing patient in wheelchair
17:12:29 PM- S6MHT seen walking Patients #2 backward away from the patient in the wheelchair
17:12:32 PM- S6MHT holding Patient #2's arms while standing in doorway when S6MHT pulls away from Patient #2 with her right arm and pushes Patient #2 with her left arm causing Patient #2 to fall to ground.
17:12:45 PM- S7MHT steps over Patient #2 to empty patients' meal tray in the trashcan in the hallway without offering care to Patient #2 assistance
17:13:05 PM- S7MHT talking with Patient #2 sitting on the floor and S6MHT walks to nurses' station talking with S8RNCN

In an interview on 04/23/2025 at 1:15 PM, S1DON verified S6MHT pulls away from Patient #2 with her right arm and pushes Patient #2 with her left arm causing Patient #2 to fall to the ground. Furthermore, S1DON verifies S6MHT has been terminated and is the only intervention done related to the above incident.

Based on record review and interview, the hospital failed to ensure the Registered Nurse supervised and evaluated the care of each patient on an ongoing basis, in accordance with the accepted standards of nursing practice and hospital policy. This deficient practice is evidenced by:
1)Failure of the Registered Nurse to follow a MD order to perform a tasks for 2 (#2, #3) of 3(#1-#3) patients reviewed;
2)Failure of the Registered Nurse to document patient observations every 2 hours per hospital policy for 2 (#2, #3) of 3 (#1-#3) Patient Observation Check Sheets reviewed;
3)Failure of the Registered Nurse to assign Observation Levels for 3 of 3 (#1-#3) Patients' Observation Check Sheets reviewed;
4)Failure of the Registered Nurse to supervise staff to ensure timely observation rounds performed for 1 (#3) of 3 (#1-#3) Patients' Observation Check Sheets reviewed; and
5)Failure of the Registered Nurse to supervise staff to ensure preventative/comfort measures were performed every 2 hours for 1 (#1) of 3 (#1-#3) Patients' Observation Check Sheets reviewed.
Findings:

1)Failure of the Registered Nurse (RN) to follow a MD order to perform a task.

Patient #2
Review of Patient #2's medical record revealed Patient #2 was admitted on 04/02/2025 with Psychosis with Dementia. Review of Patient #2's MD orders revealed the following orders:
-On 04/03/2025 MD ordered Clonidine 0.1mg 1 tablet by mouth every 4 hours PRN for systolic BP > 160; Diastolic BP >90 with the indication for administration listed as hypertension.
-On 04/02/2025 MD ordered Motrin 200mg 1 tablet by mouth every 6 hours PRN give with 400mg- 600mg with the indication for administration listed as pain.
Further review of Patient #2's MAR revealed RN administered the following medications:
-On 04/14/2025 at 7:00 AM, the nurse administered Clonidine 0.1mg 1 tablet by mouth for BP 118/73.
-On 04/14/2025 at 9:43 AM, the nurse administered Motrin 400mg by mouth for Pain 0/10
-On 04/18/2025 at 10:00 AM, the nurse administered Clonidine 0.1mg 1 tablet by mouth for BP 142/86.

In an interview on 04/23/2025 at 1:34 PM, S1DON verified the nurse performed the above mentioned tasks without following the MD orders.

Patient #3
Review of Patient #3's medical record revealed Patient #3 was admitted on 02/05/2025 with Major Neurocognitive Disorder with Psychosis and Behavioral Disturbances. Review of Patient #3's MD orders revealed an order dated 02/06/2025 for Zyprexa 10mg by mouth one time only indication Hallucinations. Further review of Patient #3's MAR did not reveal that the nurse administered the Zyprexa 10mg one time only as ordered by the provider.

In an interview on 04/24/2025 at 11:08 AM, S1DON verified the nurse did not follow the above mentioned MD order.

2) Failure of the Registered Nurse to document patient observations every 2 hours per policy.

Patient #2
Review of the Patient #2's Observation Check Sheet failed to reveal documentation that the patient observations were completed every 2 hours within the timeframes below by the RN:
-04/02/2025 between 11:00 PM to 6:45 AM on 04/03/2025 RN observations were not performed
-04/09/2025 between 7:00 PM to 11:00 PM RN observations were not performed
-04/11/2025 between 7:00 PM to 6:45 AM on 04/12/2025 RN observations were not performed
-04/15/2025 between 7:00 PM to 1:00 AM on 04/16/2025 RN observations were not performed
-04/21/2025 between 7:00 PM to 11:00 PM RN observations were not performed

In interview on 04/23/2025 at 1:58 PM, S1DON confirmed that the RN did not document that observations were performed every 2 hours per hospital policy.

Patient #3
Review of Patient #3's Observation Check Sheets failed to reveal documentation that the patient observations were completed every 2 hours within the timeframes below by the RN:
-On 02/06/2025 at 9:00 PM and 5:00 AM on 02/07/2025 RN observations were not performed
-On 02/10/2025 between 7:00 PM to 6:45 AM on 02/11/2025 RN observations not performed
-On 02/14/2025 at 5:00 PM RN observations not performed
-On 02/16/2025 between 7:00 PM to 6:45 AM on 02/17/2025 RN observations not performed

In interview on 04/24/2025 at 11:30 AM, S1DON confirmed that the RN did not document that observations were performed every 2 hours per hospital policy.
3)Failure of the Registered Nurse to assign Observation Levels for 3 (#1-#3) of 3 (#1-#3) Patients' Observation Check Sheets reviewed.

Patient #1
A review of the Patient Observation Check Sheet for Patient #1 dated 02/27/2025, 03/05/2025 and 03/14/2025 failed to reveal an assigned observation level checked per physician order by the Registered Nurse.

In interview on 04/23/2025 at 3:35 PM, S1DON confirmed that the RN did not assign observation level per physician order on the above observation check sheet per hospital policy.

Patient #2
A review of the Patient Observation Check Sheets for Patient #2 dated 04/03/2025, 04/05/2025, and 04/09/2025 failed to reveal an assigned observation level checked per physician order by the Registered Nurse.

In interview on 04/23/2025 at 1:44 PM, S1DON confirmed that the RN did not assign observation level per physician order on the above observation check sheets per hospital policy.

Patient #3
A review of the Patient Observation Check Sheets for Patient #3 dated 02/15/2025, failed to reveal an assigned observation level checked per physician order by the Registered Nurse.

In interview on 04/24/2025 at 11:34 AM, S1DON confirmed that the RN did not assign observation level per physician order on the above observation check sheets per hospital policy.

4)Failure of the Registered Nurse to supervise staff to ensure timely Mental Health Technician (MHT) observation rounds performed every 15 minutes for 1 (#3) of 3 (#1-#3) Patients' Observation Check Sheets reviewed.

Review of Patient #3's Observation Check Sheets revealed the RN did not ensure timely MHT observation rounds every 15 minutes per hospital policy. Further review failed to reveal rounds performed by the MHT on 02/18/2025 between 1:45 AM to 6:45 AM

In interview on 04/24/2025 at 11:35 AM, S1DON confirmed that the MHT did not document observation rounds every 15 minutes on the above observation check sheets per hospital policy.


5)Failure of the Registered Nurse to supervise staff to ensure preventative/comfort measures were performed every 2 hours for 1 (#1) of 3 (#1-#3) Patients' Observation Check Sheets reviewed.

Review of Patient #1's medical record revealed Patient #1 was admitted on 02/27/2025 with Major Depressive Disorder with psychotic features and to rule out Dementia vs Delirium. Review of Patient #1's Nursing Admission Assessment dated 02/27/2025 at 11:14 AM revealed Patient #1's genitourinary neuromuscular dysfunction with paralysis to left side with recent falls and wheelchair bound. Further review of Patient #1's Observation Check Sheets revealed the MHT did not offer the patient water, perform incontinence care, or reposition every 2 hours on the following dates/times:

-On 02/27/2025 between 9:00 PM to 02/28/2025 6:45 AM MHT did not document that Patient #1 was repositioned every 2 hours.
-On 02/28/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/01/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours.
-On 03/01/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/02/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours.
-On 03/02/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/03/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours.
-On 03/03/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/04/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours.
-On 03/04/2025 at 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/05/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours.
-On 03/05/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/06/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours.
-On 03/06/2025 between 9:00 PM to 03/07/2025 6:45 AM MHT did not document that Patient #1 was repositioned every 2 hours.
-On 03/07/2025 between 9:00 PM to 03/08/2025 6:45 AM MHT did not document that Patient #1 was repositioned every 2 hours.
-On 03/08/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/09/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours.
-On 03/09/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/10/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours.
-On 03/10/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/11/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours.
-On 03/11/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/12/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours.
-On 03/12/2025 between 7:00 PM to 9:00 PM MHT did not document that Patient #1 was offered water every 2 hours and between 7:00 PM to 03/13/2025 6:45 AM Patient #1 was not repositioned or toileted every 2 hours.
-On 03/13/2025 between 11:00 PM to 03/14/2025 6:45 AM MHT did not document that Patient #1 was repositioned every 2 hours.

In an interview on 04/23/2025 at 3:27 PM, S1DON verified above findings mentioned.

Based on record review and interview, the hospital failed to ensure that the nursing staff developed, and kept a current, and individualized nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs. This deficient practice is evidenced by the failure to update the care plans of 2 (#1, #4) of 5 (#1-#5) patient reviewed for completed and updated care plans.
Findings:

A review of the hospital's policy, "Treatment Planning: Integrated/Multidisciplinary," Policy Number: CS-02, revised date of 07/01/2024, revealed in part: PURPOSE: To document and implement treatment objectives/interventions, services necessary and discharge planning activities for the identified goals derived from the assessment process throughout the course of the patient's treatment to promote positive patient outcomes. The documentation also serves as a resource for reviewing the efficacy of care provided. PROCEDURE: 2. The admitting nurse is responsible for the following: formulating the initial treatment plan based on physician's orders/ initial plan and findings and conclusions from the Pre-admission Assessment, Nursing Assessment, related measurement-based tools and family/significant other information within 24 hours of admit or sooner if patient's needs warrants immediate action. 4. The treatment plan shall be signed by all members of the interdisciplinary team (IDT). If the patient is unable and/or unwillingness shall be documented in the patient's medical record.

A review of the hospital's policy number NSG-39 last revised 10/01/2023 titled, "Skin/Wound Care", revealed in part: PURPOSE: To identify patients at risk for skin break down and pressure injury formation and skin abnormalities and provide interventions for the prevention, assessment, and treatment of such. PROCEDURE: Braden Scale Risk Assessment: 2. If the Braden score is less than 18, the start of care skin care guideline will be initiated. 3. An impaired skin integrity treatment plan will be initiated or updated according to the patient's assessed results.

Patient #1
Review of Patient #1's medical record revealed Patient #1 was admitted on 02/27/2025 with Major Depressive Disorder with psychotic features and rule out Dementia vs Delirium. Patient #1 is wheelchair bound with a past medical history of CVA with residual left hemiplegia. Review of Patient #1's plan of care did not address potential for impaired skin integrity even though Patient #1's Braden Scale II done on 02/27/2025 scored a 17 and on 03/14/2025 scored a 15 which both scores indicates mild risk to develop pressure injuries.

In an interview on 0/424/2025 at 10:04 AM, S1DON verified the above mentioned findings.

Patient #2
Review of Patient #2's medical record revealed Patient #2 was admitted on 04/02/2025 with the following diagnosis Psychosis with dementia. Patient #2 sustained a fall on 04/16/2025 and was evaluated in the ED and diagnosed with a closed displaced fracture of left middle finger and 5th finger. Patient #2 had splint with ace wrap to left hand and Tylenol ordered PRN pain. Review Patient #2's plan care revealed no updates made regarding fall and diagnosis of closed displaced fracture of left middle finger and 5th finger.

In an interview on 04/23/2025 at 2:21 PM, S1DON verified the above mentioned findings.
Patient #3
Review of Patient #3's medical record revealed Patient #3 was admitted on 02/05/2025 with Major Neurocognitive Disorder with Psychosis and Behavioral Disturbances. Review of Patient #3's MD orders revealed the following orders:
02/20/2025 Consult for Forced Medications due to ongoing medication noncompliance with decompensation
02/23/2025 Cheeking Precautions
02/24/2025 Provide additional snacks TID
02/24/2025 Assist with meals
02/26/2025 Weight patient twice a week on Wednesday and Friday
Review of Patient #3's plan of care did not reveal updates of the above mentioned provider orders.

In an interview on 04/24/2025 at 11:35 AM, S1DON verified the above mentioned things.

Based on record review and interview, the hospital failed to ensure all patients treatments were within compliance of particular aspects of the patients' individualized treatment program as evidenced by failure to have signed master treatment plan by the members of the interdisciplinary team (IDT) on 1(#1) of 3(#1-#3) patients' treatment plans reviewed for the sample.
Findings:

A review of the hospital policy number PC-018 last reviewed 11/11/2021 titled, "Multidisciplinary Treatment Plans," revealed in part: PURPOSE: To establish guidelines for the development of multidisciplinary treatment plans that provide direction for the patient's course of treatment, utilize input from all disciplines, establish ongoing individualized treatment, and promote progress during treatment. PROCEDURE: 3. The multi-disciplinary treatment team is comprised of the physician, nurse, licensed therapist, and recreational therapist. Outside agencies/caregivers may also be included as appropriate. The plan shall be approved and signed by the physician to ensure continuity of care, coordination, and integration of services provided. 4. The treatment plan shall be signed by all members of the interdisciplinary team (IDT).

Review of Patient #1's medical record revealed Patient #1 was admitted on 02/27/2025 for Major Depressive Disorder on a PEC/CEC. Further review of Patient 1's Multidisciplinary Integrated Master Treatment Plan initiated on 02/27/2025 or Treatment Plan Update dated 03/10/2025 did not reveal a signature by a nurse.

In an interview on 04/24/2025 at 10:04 AM, S1DON confirmed Patient #1's Multidisciplinary Integrated Master Treatment Plan and Treatment Plan Update were not signed by a nurse.