HospitalInspections.org

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 Nursing Services was out of compliance.

A-0395 - A registered nurse must supervise and evaluate the nursing care for each patient. Based on document review and interviews, the facility failed to ensure nursing care was provided and met the continuous care needs of the patient. Specifically, the facility failed to ensure peripheral intravenous catheters (PIVC) were monitored and maintained according to policy and nationally recognized guidelines for one of one medical records reviewed of a patient with a PIVC infiltration (Patient #2). In addition, the facility failed to ensure the patient's physician and facility leadership were notified when a mental health patient alleged she had been sexually assaulted while at the facility. Specifically, the facility failed to determine whether the patient experienced a change in mental health status or whether the patient had been sexually assaulted while at the facility for one of one medical records reviewed of a patient with paranoid delusions (Patient #3).

Based on document review and interviews, the facility failed to ensure nursing care was provided and met the continuous care needs of the patient. Specifically, the facility failed to ensure peripheral intravenous catheters (PIVC) were monitored and maintained according to policy and nationally recognized guidelines for one of one medical records reviewed of a patient with a PIVC infiltration (Patient #2). In addition, the facility failed to ensure the patient's physician and facility leadership were notified when a mental health patient alleged she had been sexually assaulted while at the facility. Specifically, the facility failed to determine whether the patient experienced a change in mental health status or whether the patient had been sexually assaulted while at the facility for one of one medical records reviewed of a patient with paranoid delusions (Patient #3).

Findings include:

Facility policies:

Peripheral Intravenous Therapy, PIV (Peripheral Intravenous) policy read, this policy applies to nursing, IV therapy, competency validated- radiology techs, critical care techs, paramedics, licensed respiratory care practitioner (LRCP), and licensed practitioners (LPs). The purpose is to outline the management and care of the patient receiving peripheral intravenous therapy. Staff role is to assess for IV phlebitis, infiltration, tenderness, patency, redness, edema, pain with flushing, increased resistance when flushing catheter, extravasation, and numbness. Recommended monitoring of insertion site is every four hours for patients receiving non-irritant/non-vesicant infusions who are alert and oriented.

The Abuse of Patients: Verbal, Physical, and Sexual Allegations policy read, the purpose of the policy is to outline the steps to be taken when there is a report of abuse or alleged abuse of a patient. If a patient makes an allegation of abuse, it is to be reported immediately to the manager/supervisor. Document the event(s) in the occurrence reporting system. Secure the patient making the allegation, and make sure the person accused of abuse is not in contact with the patient. If the alleged abuser is an associate/staff member at the facility, they may be suspended immediately pending the outcome of the investigation. Notify the following staff in the event of an allegation: the Director/manager of the unit/department, the patient safety manager, administrative managers (the Nursing Supervisor if after hours), and security (if needed). A complete and thorough investigation is to be conducted by the director/manager in conjunction with the patient safety manager, Human Resources, and other pertinent departments. The allegation is to be reported to the local police, local or state health department, and other agencies, boards, etc. as appropriate. Sexual Abuse allegation is defined as any occurrence involving bodily abuse of a patient which must include knowingly acting, consent not given, sexual intrusion or penetration, or touching intimate parts or the clothing covering the intimate parts, or examining/treating resident/patient for other than bonafide medical purposes, or observes or photographs another person's intimate parts, without consent and with physical force or the threat thereof.

Facility References:

El Sevier Short Peripheral Catheter Insertion, provided by the facility, read, for monitoring and care, observe the patient, inspect the color and check for swelling of the insertion site at least every four hours and document the integrity and patency of the system.

El Sevier Maintenance and Dressing change, provided by the facility, read, peripheral intravenous catheters (PIVCs) and infusion therapy are frequently associated with local or systemic infections, phlebitis, and infiltration. Diligent IV site care and management help to minimize or prevent complications. Assessment: Assess the dressing for moisture and intactness. Assess the skin around the access site for signs and symptoms of skin impairment.

Infusion Nurses Society (INS) (2021) Infusion therapy standards of practice, provided by the facility, read, the entire infusion system, from the VAD insertion site to the solution container, is routinely assessed for system integrity, infusion accuracy and identification of complications. In inpatient and nursing facilities, assess PIVCs at least every four hours.

1. The facility failed to implement measures to prevent injuries and tissue damage for a patient receiving intravenous fluids.

a. Patient #2's medical record was reviewed and revealed she was admitted to the facility on 2/21/23. Patient #2 had a right forearm PIVC placed on 2/22/23 at 12:42 a.m. A sodium chloride 0.9% infusion was started on 2/22/23 at 12:42 a.m. at 125 ml per hour at the same time the PIVC was placed. Patient #2 had a heparin (a medication which thins the blood) IV drip infusing in her left arm which was initiated 2/21/23 at 9:29 p.m. Site assessments, phlebitis (inflammation of the walls of a vein) assessments, and infiltration assessments (inadvertent administration of solution or medication into surrounding tissues) were not documented throughout the time this PIVC was in place. This was in contrast to facility policy and national standards which stated PIVCs were to be assessed at least every four hours.

Patient #2's medical record revealed the right forearm PIVC was discontinued on 2/22/23 at 8:00 a.m., with the documented reason of infiltration. Patient #2 had an orthopedic consult due to increased pain and swelling in her right arm for possible compartment syndrome (A painful and dangerous condition caused by pressure buildup from internal bleeding or swelling of tissues) on 2/22/23 at 4:38 p.m. Patient #2 received surgery on her right arm for compartment syndrome on 2/23/23 at 6:05 p.m., 2/27/23 at 1:58 p.m., and 3/2/23 at 3:46 p.m.

b. On 5/3/23 at 7:57 a.m., an interview was conducted with registered nurse (RN) #7. RN #7 stated PIVCs were to be assessed every four hours for non invasive fluids (non- irritating to tissue) and documented every shift and as needed. RN #7 stated she remembered Patient #2 and normal saline (sodium chloride 0.9%) was infused in her right side PIVC. RN #7 stated during shift hand off report at the bedside on 2/22/23, Patient #2's right side PIVC was noted to be infiltrated and she turned off the infusing IV fluids. RN #7 stated Patient #2 had to have surgery on her right arm for compartment syndrome, which was an obstruction causing lack of blood flow to the lower portion of the extremity. RN #7 stated Patient #2 returned to the inpatient nursing unit from surgery with a wound vac (a vacuum type of therapy to help wounds heal) in place.

c. On 5/1/23 at 10:53 a.m., an interview was conducted with RN #8. RN #8 stated IVs were to be assessed every hour and documented one time per shift. RN #8 stated a PIVC assessment included assessing the dressing which covered the PIVC, checking for phlebitis (inflammation of a vein near the surface of the skin), and checking for infiltration, redness, and swelling at the insertion site. RN #8 stated if redness or swelling was present she would not continue to use the PIVC.

d. On 5/1/23 at 10:58 a.m., an interview was conducted with RN #9. RN #9 stated patient PIVC sites were assessed every two hours and documented once a shift. RN #9 stated a PIVC assessment included checking the insertion site for redness, checking for inflammation or red streaks, and making sure the dressing was intact. RN #9 stated if a patient were to have redness, swelling, or pain at the insertion site, she would discontinue the PIVC and place a new one.

e. On 5/4/23 at 3:19 p.m., an interview was conducted with RN #10. RN #10 stated she assessed PIVC sites every time she went into a patient's room and documented the findings once a shift. RN #10 stated she checked PIVC sites for bleeding, leaking, infiltration, redness, and swelling. RN #10 stated if a PIVC were to infiltrate, it could cause tissue damage, sloughing, open wounds, infection, or sepsis. RN #10 further stated sepsis could cause organs such as the kidney and liver to shut down and could be life-threatening.

f. On 5/3/23 at 2:38 p.m., an interview was conducted with the director of quality (Director) #11. Director #11 stated Patient #2's medical record had been reviewed by the facility. Director #11 stated a PIVC was placed in patient #2's right arm on 2/22/23 at 12:42 a.m. and removed on 2/22/23 at 8:00 a.m. and there were only two times documentation was completed related to this PIVC, which was when it was inserted and when it was removed. Director #11 stated after staff interviews it was her understanding there was no medication infusing into the right PIVC. Director #11 stated it was policy and expectation for PIVC sites to be assessed and documented every four hours for non-vesicant (non-irritating to tissue) IV fluids infusing and once a shift if not being actively used.

These interviews were in contrast to national standards and facility policy to monitor and observe IV insertion sites, assess the skin around the access site for signs and symptoms of skin impairment, inspect the color and check for swelling at least every four hours and document the integrity and patency of the system.

2. The facility failed to notify the patient's physician and facility leadership when a mental health patient alleged she was sexually assaulted while at the facility to determine if the patient had a change in mental health status or whether the patient had been sexually assaulted.

a. Medical record review revealed on 2/27/23 at 6:36 p.m., Patient #2 was brought in by ambulance to the Emergency Department (ED) for a psychiatric evaluation (assessment of a patient's mental health). According to the Behavioral Health Evaluation (psychiatric evaluation) performed at 8:25 p.m. by licensed professional counselor (LPC) #3, Patient #3 appeared paranoid, calm, and cooperative and her thoughts were disorganized. Patient #3 had coherent and tangential (constant deviation to irrelevant topics) speech, and she spoke quickly and rambled.

i. Review of the ED Provider Note entered by Physician #1 on 2/27/23 at 9:22 p.m. revealed Patient #3 had psychosis (inability to interpret and understand reality), paranoid thoughts, was suicidal (thoughts and ideas about ending one's own life) and gravely disabled (unable to provide for his or her basic personal needs). According to Physician #1, LPC #3 was in agreement with his assessment, and Patient #3 would be transferred to an inpatient psychiatric facility for further evaluation, stabilization, and mental health treatment.

ii. The Psychological Assessments performed by nursing staff on 2/28/23 revealed Patient #3 experienced a mental health status change after the psychiatric evaluation was performed by LPC #3. According to the Psychological Assessments performed by RN #4 on 2/28/23 at 7:00 a.m., Patient #3 began experiencing paranoid sexual delusions.

Additionally, Patient #3's medical record revealed no evidence RN #4 informed Physician #1 the patient had started having paranoid sexual delusions and hallucinations.

b. Interviews conducted with staff revealed physicians and the psychiatric emergency triage team (PETT) team were required to be notified when a mental health patient experienced a change in their mental health status. In addition, allegations of sexual assault were required to be reported to facility leadership.

i. On 5/2/23 at 2:37 p.m., an interview was conducted with RN #4. RN #4 stated sexual assault allegations made by patients were required to be reported to facility leadership and to the patient's physician. RN #4 stated any allegation of sexual assault was investigated by the facility.

RN #4 stated he cared for Patient #3 the morning of 2/28/23 after he arrived for his shift in the ED. RN #4 stated when he performed the psychological assessments at 7:00 a.m., Patient #3 was physically upset and stated to him she had been sexually assaulted while in the ED and he determined Patient #3 was actively experiencing paranoid sexual delusions and hallucinations. RN #4 stated he had not notified Physician #1 or LPC #3 of the allegations Patient #3 made. RN #4 stated he did not believe Patient #3 could have been sexually assaulted since Patient #3 had a safety sitter with her.

RN #4 stated even though Patient #3 had repeatedly stated to him she was sexually assaulted while at the ED, he had not notified Patient #3's physician or facility leadership. RN #3 stated he had not documented the sexual assault allegation in Patient #3's medical record since he determined Patient #3 was experiencing paranoid sexual delusions and hallucinations.

RN #4 further stated the PETT team and the patient's physician were required to be notified when patients experienced mental health changes. RN #4 stated when he determined Patient #3 started having paranoid sexual delusions and hallucinations he did not inform Physician #1.

This interview was in contrast with the Abuse of Patients: Verbal, Physical, and Sexual Allegations policy which stated, patient allegations of abuse must be immediately reported to the department director or manager, the patient safety manager and administrative managers at the facility. Additionally, staff were required to document the patient's allegation in the occurrence reporting system.

ii. On 5/3/23 at 1:46 p.m., an interview was conducted with assistant nurse manager (ANM) #6. ANM #6 stated it was important for nurses to perform psychological assessments to assess the mental health status of patients on a regular basis and to provide an overall picture of the patient's current mental health.

ANM #6 stated if a patient began experiencing paranoid sexual delusions it would be considered a change in the patient's mental health status. ANM #6 stated the patient's physician and the PETT team should have been notified and a nursing note should have been placed in the patient's medical record for a patient who experienced a change in mental health status.

iii. On 5/2/23 at 8:18 p.m., an interview was conducted with LPC #3. LPC #3 stated Patient #3 informed her she had been sexually assaulted and raped by a physician while in the ED. LPC #3 stated Patient #3 was unable to identify who specifically had raped and assaulted her. LPC #3 stated after Patient #3 had informed her of the sexual assault and rape, LPC #3 had not reported the allegation and she had not performed a mental health reevaluation with Patient #3. LPC #3 stated she had not documented the sexual assault and rape allegation made by Patient #3 and following further reflection she should have.

LPC #3 stated any allegation of sexual assault and rape was required to be reported to facility leadership and documented in the patient's medical record. However, LPC #3 stated she did not document the sexual assault allegation and rape allegation in Patient #3's medical record and she did not report the allegation to facility leadership.

iv. On 5/3/23 at 4:13 p.m., an interview was conducted with the PETT Clinical Manager (Manager) #5. Manager #5 stated any time a mental health patient experienced changes in behavior a mental health reevaluation needed to be performed by the PETT team. Manager #5 stated anytime a change in condition occurred, the patient's medical record should have reflected a follow-up mental health evaluation.

Manager #5 stated all healthcare professionals were considered mandatory reporters (persons legally required to report abuse) and were required to report any sexual assault allegations which occurred at the facility. Manager #5 stated mental health clinicians could not determine whether a patient had been sexually assaulted and mental health clinicians were required to report the sexual assault allegations directly to facility leadership.