HospitalInspections.org

Based on observation, interview and record review, it was determined the hospital failed to promote and protect each patients' rights.

Findings include:

The hospital failed to ensure all patients received care in a safe setting. (Refer to tag A-0144)

Based on observation, interview, and record review, it was determined that the hospital did not ensure all patients received care in a safe setting. Specifically, for 3 out of 13 patient medical records that were reviewed, patients did not get medications timely, did not have appropriate assessments completed, and/or were not kept safe from harm from themselves or other patients. (Patient identifiers: 5, 12, and 13)

Finding include:

Patient 5 was admitted on 1/21/23 around 2:00 AM, with a diagnosis of suicide attempt.

1. Patient 5's medical record was reviewed and revealed the following:

In an Intake Assessment dated 1/21/23 and timed 2:30 AM, it was documented that patient 5 was currently taking Lactulose three times a day, Rifaximin twice a day, and Spironolactone daily for liver disease.

In a document titled, "PATIENT BELONGINGS" dated 1/21/23 and timed 2:45 PM, it was documented patient 5 had the three medications along with several others in her possession on admit.

In a patient document titled, "PM GOALS" and dated 1/22/23, patient 5 wrote, "let (sic) me take all my meds".

Patient 5's medication orders, profile, and medicine administration were reviewed. The three medications listed were not ordered by a physician until 1/23/23 at 3:00 PM. On a handwritten medication administration record it was documented patient 5 received one dose of Lactulose on 1/23/23 but not the other two medications. It was documented patient 5 got her first doses of Rifaximin and Spironolactone on the morning of 1/24/23. Abilify was ordered on 1/21/23 at 12:30 PM. Note: Abilify is not known to cause hepatotoxicity. Patient 5 was discharged on the 1/25/23.

In a nursing assessment dated 1/23/23 and possibly timed 8:00 AM (the handwriting was unclear), it was documented, "Sent to U of U ER (emergency room) for lethargy, very drowsy, appears dehydrated, some edema." In a nursing assessment dated 1/23/23 and timed 11:11 PM, it was documented, "Pt (patient) returned from ER. Pt feeling tired and wanted to go to bed and rest." There was no further documentation in her medical record regarding her ER visit.

On 5/3/23 at 1:48 PM, an interview was conducted with the director of nursing (DON). The DON stated patient 5 should have started receiving the three medications Lactulose, Rifaximin, and Spironolactone, on 1/22/23. The DON further stated patient 5 should have had a full assessment with vital signs completed upon her return from the ER. The DON stated patient 5's vital signs were not checked until around 7:00 AM on 1/24/23. She further stated there should have been a nurse-to-nurse report document in the medical record detailing the ER visit. There was no documented evidence of a full assessment being completed. There was also no documented evidence of a diagnosis or what treatments were carried out in the ER.

2. On 5/17/23, patient 12's medical record review was completed and revealed the following:

Patient 12 was admitted on 4/29/23, with a diagnosis of psychosis.

On 5/8/23 at 9:38 PM, it was documented in a nursing note that patient 12 was not sleeping and refusing bed. It was also documented in this assessment that patient 12 had a wound on his chin, there was no mention of how patient 12 obtained the wound. The next 3 assessments did not include the wound on his chin.

On 5/9/23 at 9:50 PM, it was documented in a nursing note that the patient was pacing the hallway and may need to go on one to one observations.

On 5/10/23 at 9:20 PM, it was documented in a nursing note that patient 12 was concerned about sleepwalking and injuring himself. (Note: This was the only mention of sleepwalking in patient 12's record.)

There was no documented evidence in patient 12's medical record of an order for increased observations or any interventions to prevent harm to patient 12 or other patients.

An email was sent from the facility's risk manager on 5/15/23 at 11:27 AM and stated the following, "As for documentation related to the intervention (sic), since we did not go to a 1:1 there would not be a note in the order. They discussed in treatment team and shift change how to provide more supervision for him at night, however, the intervention is not documented."

a. A review of the facility's incident log was completed on 5/17/23.

On 5/8/23, there was an incident of patient 12 walking into patient 13's room.

A summary of the investigation was provided: there were no interviews documented with staff or patients' 12 and 13, it was not documented that the video footage was reviewed, and there was no documentation of what was done to immediately protect both patients.

There was no documented evidence of any incident in patient 12's medical record.

b. On 5/17/23, surveillance footage was reviewed in the hallway where patient 12 and patient 13 stayed.

On 5/7/23 at 11:42 PM, patient 12 went into a room that appeared to be patient 13's. Patient 12 was in the room for approximately 20 seconds. On 5/8/23 at 12:11 AM, patient 12 went into the same room for approximately 10 seconds.

From approximately 11:00 PM on 5/7/23 through approximately 1:00 AM on 5/8/23, patient 12 was observed to be intermittently wandering the halls and was extremely unsteady on his feet. Patient 12 was observed running into the walls and had four separate falls. One on 5/7/23 at 11:20 PM; then on 5/8/23 at 12:03 AM, 12:20 AM, and 12:24 AM. On the last fall patient 12 hit his face on the wall and remained on the floor. Patient technician 2 slowly walked down the hall and said a few words to patient 12. Technician 2 left patient 12 on the floor and walked away. The technician appeared to leave the unit. At 12:26 AM, technician 2 returned to the unit and patient 12 was still laying on the floor. She then helped patient 12 off the floor. Patient 12 continued to wander around stumbling and eventually went back to his own room. At 1:01 AM, patient 12's roommate exited the room and spoke to technician 1. At 1:03 AM technician 1 and a registered nurse entered patient 12's room for a few minutes.

On 5/17/23 at 1:10 PM, technician 1 was interviewed. She stated patient 12's roommate came out in the early morning of 5/8/23 and said there was blood on patient 12's pillow. Technician 1 stated she went to get the nurse to assess patient 12. She stated patient 12 had gotten a wound on his chin or lip that night. She stated she did not see it happen.

3. Patient 13 was admitted on 5/5/23, with a diagnosis of suicidal ideation. Patient 13's medical record was reviewed. There was no documented evidence that patient 13 had been interviewed regarding two incidents involving patient 13 entering her room during the night. In an email on 5/15/23 at 11:15 AM, the risk manager confirmed that no one spoke with patient 13.

On 5/16/23 at 10:30 AM, the DON was interviewed. The DON stated the incidents should have been documented in both patient's charts. She further stated if patient 13 felt unsafe a therapist should have evaluated her. The DON confirmed that patient 13 was not evaluated by a therapist. Patient 13 left with her family the morning after the incident against medical advice.