HospitalInspections.org

Based on document review and interview, the facility failed to ensure a patients family was notified after a patient-to-patient encounter in two (2) instances (Patient # 4 & Patient # 14).

Findings include:

1. The hospital policy titled, "Patient Rights and Responsibilities", PolicyStat ID 10359862, indicated patients had the right to receive care in a safe setting. This policy was last revised in 09/2021.

2. The hospital policy titled, "Patient Abuse and Neglect", PolicyStat ID 13034136, indicated physical abuse was a willful act that potentially could result in pain. This policy was last revised in 01/2023.

3. Patient # 4's medical record (MR) indicated the following:
a. The patient was a 64 year/old (y/o) admitted on 02/27/2023 with a diagnosis of bipolar disorder, anxiety, and depression.
b. Daily Nursing Narrative dated 03/05/2023 at 6:20 pm, indicated another patient took him/her to the ground and wrapped his/her arms around patient # 4's neck.
c. The MR lacked documentation related to patient # 4's family, healthcare representative, and/or power of attorney (POA) being notified about the incident.

4. Patient # 14's medical record (MR) indicated the following:
a. The patient was a 28 y/o admitted on 03/12/2023 with a diagnosis of bipolar disorder and schizoaffective disorder.
b. Daily Nursing Narrative dated 03/17/2023 at 5:58 pm, indicated patient calm and cooperative. No behaviors.
c. The MR lacked documentation related to the patient-to-patient altercation and documentation of patient # 14's family, healthcare representative (HCR), and/or power of attorney (POA) being notified about the incident/injury.

5. In interview on 04/19/2023 at approximately 3:00 pm with administrative staff member A # 4 (Director of Quality), confirmed he/she was on the unit and had witnessed the incident with patient # 4. He/she further indicated that he/she had filed the incident report and the family wasn't notified.

6. In interview on 04/20/2023 at approximately 2:00 pm with administrative staff member A # 4, confirmed training staff on documenting notification of family after an incident and/or injury. If it's not documented it's not done.

Based on document review and interview, the registered nurse failed to ensure a patient was on an every 5 minute observation per physician order in one (1) instance. (patient # 15)

Findings include:

1. The hospital policy titled, "Patient Observation", PolicyStat ID 12931622, indicated observation levels could be increased or decreased by a physician order. All patients on Level II (every 5 minutes) observation at a minimum due to increased risk. The location of the patient should be known to staff at all times. Positive engagement with the patient is a integral for the level. This policy was last revised in 01/2023.

2. Patient # 15's MR indicated the following:
a. The patient was a 71 y/o admitted on 01/20/2023 with a diagnosis of unspecified dementia with severe behavioral disturbances.
b. Daily Nursing Narrative dated 03/17/2023 at 6:50 pm, indicated patient # 15 defensive and hit peer in face. Patient redirected.
c. The Provider Orders dated 03/17/2023 at 7:20 am, indicated the patient to be placed on every 5 minute observation until they were discontinued on 03/21/2023 at 10:21 am. The patient was placed on a 1:1 at that time.
d. The MR lacked documentation the patient was an every 5 minute observation on 03/18/2023, 03/19/2023 and 03/20/2023.

3. In interview on 04/20/2023 at approximately 2:00 pm with administrative staff member A # 4 (Director of Quality), confirmed H # 2 had been training staff on documenting notification of family, after an incident, and/or injury. If it's not documented, it's not done.