HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 3 patients' (Pt.#2) clinical records reviewed for nursing assessments, the hospital failed to ensure that the nurse supervised and evaluated patients' care by failing to complete the nursing reassessments after an injury due to an altercation (patient to patient) and to notify the medical doctor.

Findings include:

1. The Registered Nurse Job Description, dated 1/1/2020, included, "Responsible for providing professional nursing care to patients... Essential Functions... Provide and coordinate care by assessing physical and behavioral needs of patients... Ensure patients' status is assessed on an ongoing basis and pertinent information gathered is documented... Notify physician of significant changes in status... etc. "

2. The hospital's policy titled, "Change in Condition" (revised 06/2022) was reviewed and required, " ... Registered Nurse will provide assessment data to the physician/covering practitioner who will then give orders for treatment or additional assessment ... 22. Any concerns regarding the patient's medical condition where nursing staff believes a delay may cause a negative outcome."

3. The hospital's policy titled, "Assessment and Reassessment" (revised 06/2022) was reviewed and required, " ... 9b. Reassessments are completed by the Registered Nurse (RN) on day and evening shifts and documented on the Nursing Reassessment form ... the RN will document more descriptive details in the progress portion of the note ... In addition, each patient is reassessed as necessary based on the patient's plan for care or change in their condition ..."

4. Incident Report Form (completed by E#3/RN), dated 02/10/2025, at 6:30 PM, "Incident Date/Time/Location: 2/10/25 at 5:44 PM, Day Room 2-East ... Witnesses ... (name of Behavioral Health Associate/BHA E#9) ... Other Parties Directly Involved: (names of Pt.#6 and Pt.#7) ... Physical Confrontation: Patient attacked by other Patient ... Facts Summary of Event: Patients were in dayroom watching TV. Per BHA (E#9) (Pt.#2) made remarks ... peers run up to (Pt.#2) and hit multiple times ... (Pt.#2) refused to get sent out. Request ice pack ... request to call 911 and report incident ... (name of MD#5/psychiatrist) notified 2/10/25 at 6:50 PM." The incident form lacked documentation that the nurse assessed (Pt.#2) for pain or any injuries observed and that a medical physician was notified.

5. On 04/08/2025 at approximately 12:45 PM, the video footage from the dayroom in 2-East on 02/10/25 at 5:26 PM to 5:52 PM was reviewed. The video footage showed the following:
-At 5:17 PM, (Pt.#2) and other patients are observed in the dayroom having dinner. There is a Behavioral Health Associate (BHA/E#9) in the day room observing the patients and another staff is observed doing safety rounds.
-At 5:27:29 PM. (Pt.#2) is sitting closer to the television, there are other patients watching TV and appear to be having a conversation. Two patients (Pt.#6 and Pt.#7) approach (Pt.#2) while (Pt.#2) is sitting on a chair and start to hit (Pt.#2). At 5:27:35 PM, (E#9) is observed running out the door and returns at 5:27:59 PM (24 seconds later) with two other staff (RN/E#10 and BHA/E#20). The staff separate the patients and remove all the patients except (Pt.#2) from the day room.
-At approximately 5:31 PM, two staff enter the dayroom (E#3 and E#10) and speak with (Pt.#2). (Pt.#2) removes their shirt the two nurses (E#3 and E#10) appear to inspect (Pt.#2) then exit the day room.

6. The clinical record for Pt.#2 was reviewed on 04/08/2025. Pt.#2 was admitted to the Acute Adult Male unit 2-East on 02/04/2025 and discharged on 02/10/2025. Nursing Notes were reviewed for dates 02/10/2025 day shift (7AM to 7PM), night shift (7PM to 7AM), and 02/11/2024. The nursing notes lacked documentation that (Pt.#2) was involved in an altercation and sustained injuries, a post incident nursing assessment, and that (Pt.#2) was offered a medical evaluation and refused. The nursing notes did not include documentation that the psychiatrist or medical physician were notified of the incident.

7. An interview was conducted with a Licensed Social Worker (E#8) on 04/08/2025 at 9:40 AM. E#8 was told by another patient that (Pt.#2) was hit by another patient while they were watching a movie in the day room. The other residents (Pt.#6 and Pt.#7) became upset over a comment made by (Pt.#2). E#8 spoke with (Pt.#2) about the incident (Pt.#2) had bruising on forehead and redness to upper left face area. E#8 stated that (Pt.#2) had refused to get treatment by staff or physician. However (Pt.#2) did filed a police report.

8. An interview was conducted with an RN (E#23) on 04/09/2025 at 9:40 AM. E#23 stated that for patient-to-patient altercations, staff will separate them as soon as possible. The patients are assessed for injury and the attending psychiatrist and the on-call medical physician are notified. The medical physician will evaluate the and decide if the patient needs to be sent out for further medical evaluation. The patient has the right to refuse a medical examination, the nurse is required to document in the progress note that the patient refused. The nurse should document if there were any visible injuries in the clinical record.

9. An interview was conducted with a Nurse Practitioner (E#24) on 04/09/2025 at 11:07 AM. E#24 stated that they met with (Pt.#2) briefly on the day of discharge. E#24 did not recall any facial bruising on (Pt.#2) and was not aware of an altercation the previous day. E#24 stated that staff are expected to report any situation with altercations involving patients to the providers.