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Based on review of medical records, policies/procedures, tour, and staff interviews, the facility failed to deliver Quality Nursing care as per the facility's policy and procedures for P#2 out of six sampled patients by not ensuring a skin product was assessed and approved for safe use by the medical treatment team before handing the product over to P#2.



Findings:

A review of Patient (P)#2's medical record revealed that P#2 arrived at the facility on 10/10/23 at 8:30 a.m. P#2 signed her consent for treatment and received her notice of rights. P#2's admitting diagnosis was schizoaffective disorder, bipolar type (feelings of euphoria, racing thoughts, increased risk behavior, and symptoms of mania).
P#2 is a 32-year-old African American female.

P#2 was placed on routine observation which was 30-minute checks.

On 11/27/23, the nurse practitioner noted P#2 was requesting triamcinolone cream for eczema on the neck. The nurse practitioner documented that P#2 did have a history of eczema and reported triamcinolone worked well for her in the past. P#2 denied using any new skin products that exacerbated eczema.

On 11/30/23, the health service technician documented that P#2 was asking about the skin cream that was supposed to be ordered. The staff informed the medication nurse about it.

On 12/1/23 at 1:02 p.m., PA S2 documented that P#2 reported a vitiligo-like reaction on her face and chest. P#2 reported she had been using a cosmetic called Caro-lite to lighten her skin. PA S2 documented on examination that the ingredients of the Caro-lite contained hydroquinone, a chemical that can cause leukoderma (partial or total loss or absence of pigmentation that is marked especially by white patches of skin).

On 12/1/23, PA JJ documented a late entry stating that P#2 had been using bleaching cream. PA JJ also reported that she explained to P#2 that she was not allowed to have this type of cream, and things such as this would need to be approved through her treatment team. Documentation revealed that P#2 willingly gave PA JJ the bleaching cream.

On 12/5/23, RN II documented that P#2 continued to state she was Caucasian and not African American. Documentation revealed that P#2 stated she scrubbed her skin so her actual color would return.

P#2 was still admitted to the facility during the survey.


A review of the "Individual's Rights" policy #24-104, reviewed 1/24/23, revealed the department recognized and respected the rights of all individuals. "Individual" refers to persons seeking, applying for, or currently receiving intellectual disability, developmental disability, mental health, or substance use services in community settings. All providers and staff were required to be knowledgeable about and respectful of human rights issues that pertained to their specific work responsibilities.


A review of the "Levels of Observation for Individuals" policy #03-501, reviewed 5/17/22, revealed the hospital used established procedures for three levels of observation that were appropriate for the clinical care needs of individuals being served. Routine Observation was maintaining a general awareness of the individual's whereabouts status by visually observing the individual at least every 30 minutes.


A tour of Forensic Unit 4 took place on 1/30/24 at 2:30 p.m. with the Quality, Risk, Incident, and Investigations Director (QRID) AA. It was observed that the day area was rectangular and surrounded by patient rooms. There was a sink and cabinets behind the station with products identified as a large bottle of liquid hand soap, a container of sanitizing wipes, and a box of laundry soap. The sanitizing wipes and laundry soap were removed to be placed in a secure location during the tour. It was further observed that there was a housekeeping closet in each hallway between the male and female sides of the unit. The closet was locked.


A telephone interview occurred in the conference room on 1/30/24 at 9:32 a.m. with Health Aide (HA) EE, who stated that P#2 usually said she was not black and her skin only had sunburns. HA EE stated that P#2 often took a lot of showers to try and wash off the 'blackness' on her skin because she (P#2) thought she was white. HA EE also stated that the domestic staff usually stored cleaning items, and the patients could not access the supplies.

A telephone interview occurred in the conference room on 1/30/24 at 9:40 a.m. with Registered Nurse (RN) FF, who stated that P#2 thought she was a white lady and wanted to bleach her skin. RN FF stated there was a rumor that a staff member allegedly gave P#2 some bleaching cream, but he (RN FF) did not personally witness it.

An interview occurred in the conference room on 1/30/24 at 11:15 a.m. with Health Aide (HA) MM, who stated that P#2 was very delusional. HA MM stated that P#2's skin was normal, but she had some skin discoloration, which she (HA MM) thought was vitiligo. HA MM also stated that P#2 thought she (P#2) was white and wanted to bleach her skin.

An interview occurred in the conference room on 1/30/24 at 11:40 a.m. with Registered Nurse (RN) HH, who stated that P#2 was very delusional and stated that she (P#2) was a white woman, but her skin got burnt. RN HH stated that P#2 liked to bleach her skin and had a bleaching agent with her (P#2). RN HH stated that she gave the product to P#2 because she (RN HH) thought it was just a lotion, and she checked the label to ensure the product did not contain alcohol. RN HH stated that she got a report that the product had been taken away from P#2 a few days later because it was a bleaching agent and was causing skin reactions.

An interview occurred in the conference room on 1/30/24 at 11:45 a.m. with Nurse Manager (NM) LL, who stated that during the treatment team meeting, the medical staff noticed that P#2's skin was getting lighter, especially her face, but the skin did not look irritated. NM LL stated that PA JJ had discovered a bleaching agent with P#2 and identified that RN HH gave it to P#2.
NM LL stated that families were allowed to bring in items for patients, but the staff had to ensure the products were safe before giving them to the patient. NM LL also stated that patients can purchase items online, but the social worker must supervise it; however, she (NM LL) did not think P#2 had the money to make an online purchase.

An interview occurred in the conference room on 1/30/24 at 12:51 p.m. with Registered Nurse (RN) II, who stated that P#2 was using a bleaching cream, and the staff was unaware. RN II stated that P#2's family mailed the item to P#2, and a staff member gave it to her. RN II stated that on the product's container, it did not state bleaching but whitening product. RN II stated that the product should have gone through the treatment team to decide if P#2 could have it, but the staff member failed to do so.

An interview occurred in the conference room on 1/30/24 at 1:38 p.m. with Physician Assistant (PA) JJ, who stated that P#2 was very delusional, and she (PA JJ) noticed her (P#2) skin was getting dry. PA JJ stated that there were some circular patterns on P#2's face, which looked like scrub patterns and P#2 stated it might be a sunburn. PA JJ stated that P#2's skin issue was mentioned several times in the treatment team meetings, but nobody could figure out what was happening. PA JJ stated that P#2 stated her mum sent her the cream when she (P#2's mum) sent some clothing to her (P#2), and the nurse gave it to her (P#2). PA JJ stated that the cream was collected from P#2, and she (P#2) was told why she could not use the cream.

Based on medical record review, video surveillance, incident reports, and staff interviews; nursing services failed to observe two out of six patients (P#1 and P#5) according to facility policy, physician's orders, and the individual's care needs.

Review of the "Levels of Observation for Individuals" policy #03-501, reviewed 5/17/22, revealed the hospital used established procedures for levels of observation that were appropriate for the clinical care needs of individuals being served. One-to-one (1:1) Observation was maintaining continuous knowledge and awareness of the individual's whereabouts with at least one assigned staff that remained in such proximity to the individual as to be able to intervene and prevent actions that were unsafe to the individual and others. The observer was not assigned other responsibilities during the time she was providing 1:1 observation. The observer remained with the individual until responsibility of the individual was transferred from one staff member to another. There would be no physical barriers between the individual and assigned staff.

Medical Record review revealed that P#6 was admitted to the facility on 3/2/23 at 10:05 a.m. for a comprehensive evaluation. Review of an order by the Physician's Assistant (PA) JJ on 11/9/23 at 10:59 a.m. to 11/14/23 at 10:58 a.m. revealed that P#6 was on one-to-one (1:1) continuous (24 hours/day) observation for aggressive behavior.

Review of the observation flow sheet for 11/13/23, 12:00 a.m. to 7:15 a.m., revealed that P#6 was on continuous 1:1 monitoring every 15 minutes for aggression. The Mental Health Aide (MHA) CC initialed the flow sheet every 15 minutes from 12:00 a.m. to 7:15 a.m.

Review of video surveillance took place in the small conference room on 1/29/24 at 4:47 p.m. with the Quality Risk and Incidents Director (QRID) AA. Video footage revealed that on 11/13/23 at 6:46 a.m., MHA CC was seated in the day area in front of the television with no other patients or staff present. QRID AA explained that MHA CC was supposed to be monitoring P#6, and review of video surveillance was how an allegation of neglect was discovered.

Review of an Investigative Summary completed on 12/6/23 by the certified investigator (CI) QQ revealed that on 11/12/23 at 11:00 p.m., MHA CC was assigned to monitor P#6 during the night shift, who was on one-to-one observation for assaultive behaviors. MHA CC failed to provide 1:1 observation for P#6 as required by policy.

An interview took place with the Nurse Manager (NM) LL on 1/30/24 at 11:15 a.m. NM LL said 1:1 observation would be based on the provider's order, but typically MHAs were expected to be at an individual's door when the individual was in bed so the MHA could visually see the individual and intervene quickly.

A telephone interview took place with the Charge Nurse (CN) RR on 1/31/23 at 9:40 a.m. CN RR said that the area near the television was too far from P#6's room for MHA CC to maintain 1:1 observation. MHA CC would have instructed MHA CC to move to the chairs directly outside P#6's room if she had observed MHA CC near the television.