HospitalInspections.org

Based on document review, interview and clinical record review on 07-22-11 and 08-05-11 it was determined the Condition of Patient Rights is not met. This decision was based on the following:

A. Based on document review, interview, clinical record review and observation it was determined the facility failed to provide care in a safe setting for 1 (#1) of 1 (#1) patient on the Academy Unit. This failed practice resulted in actual harm to Patient #1 and had the potential to affect the other 24 patients on the Academy Unit. See A 144

B. Based on interview, policy and procedure review, and clinical record review, it was determined 3 of 3 patients on the Academy Unit were placed in seclusion without an order from the physician. The failed practice had the potential of placing patients in seclusion who did not exhibit violent or self destructive behaviors that immediately jeopardized the physical safety of patients, staff or others. The failed practice affected 3of 3 sampled patients and had the potential to affect all patients in the facility. See A162

Based on document review and clinical record review it was determined the facility failed to provide care in a safe setting for 1 (#1) of 1 (#1) patient on the Academy Unit. That failed practice resulted in actual harm to Patient #1 and had the potential to affect the other 24 patients on the Academy Unit. The findings follow:

A. Documentation in the clinical record of Patient #1 revealed:

07-17-11-1800-Pt became angry with peer..... requested return to Unit.....continually in doorway-asked by staff to step back on carpet......preceded to walk out of his room without permission towards staff cursing, displaying a threatening posture with angry voice. Refused to return to his room staff approached him, he pushed them and attempted to trip them. He was escorted to his room and assisted to the ground with a protective hold. It was noted he had some swelling with petechiae to his right eye.

B. Documentation of interview with Staff #1 by Facility Staff on 07-18-11 revealed:

Dated 07-18-11-0900-Staff #1-Patient #1 making threats to Patient #2 while Patient #2 was in the time away room. Both cussing at each other........Patient #1 ran out of his room and set in chair....... Staff #1 says he prompted him at least 4 times to go to his room. Staff #1 said he tapped him on his shoulder and Patient #1 tightened up his body in chair and wouldn't move. Staff #1 said he pulled the chair out from under him and Patient #1 just sat on the floor. Staff #1 reports he picked him up and in a escort position walked him to his room.......Staff #1 said when he and Patient #1 got in patient room Patient #1 started swinging him arm and cursing.........Staff #1 said he then tightened his grip Patient #1 then tried to push off the wall with his feet. Staff #1 says they went down to the floor. Staff #1 said he held him there till he calmed down..........Staff #1 said Patient #1's right eye was bleeding a little above the brow.

C. A letter dated 08-05-11, signed by the Administrator revealed:

Staffing for the Academy Unit included Staff #1 worked 7AM to 7PM on 07-19-11, 07-18-11, 07-19-11 and 07-20-11. The Academy Unit has a bed capacity of 28 and a census of 24.