HospitalInspections.org

Based on interview and record review, the facility failed to conduct a thorough review of a patient's complaint, when the facility failed to review all the nursing documentation, to determine the patient had been self-harming while at the facility. This failure prevented the facility from addressing a Patient's grievance and ensure the future safety of patients at risk of self-harming.

Findings include:

Review of the facility provided policy, Complaint/Grievances, (dated 11/7/2019), reflected, "Patient complaints that become grievances also include situations where a patient or a patient's representative telephones the hospital with a complaint regarding his/ patient care or with an allegation of abuse or neglect, or failure of the hospital to comply with one or more CoPs, or other CMS requirements.
H. After thorough research has been conducted the Patient Advocate will work in tandem with staff identified as key individuals critical to the problem resolution for the specific identified concern. All efforts will be made to effectively and expeditiously resolve the patient's grievance."

During a telephone interview, on the morning of 12/09/21, Patient #11's father stated, "We took Patient #11 to our primary physician on the day of discharge. The physician said Patient #11 had new wounds to the lower left forearm. When I asked Patient #11 where the wounds came from, Patient #11 said he had been cutting himself in the facility with a spring found in the bathroom; Patient #11 said they gave the spring to the staff several days later. I talked to Staff #2, Quality Director, he said the injury did not happen at the facility."

On 12/09/21, during an interview in the facility conference room, Staff #2, Quality Director stated, "I interviewed the discharging nurse; she said the injuries were old." Staff #2 confirmed the incident reports are used to track and trend for the Quality Program.

Review of Patient #11's medical records reflected the following:
On 11/19/21 the Nursing Admission Assessment reflected the Skin/Skin Integrity assessment showed four scars to the upper left forearm and a puncture to the left wrist.
On 11/26/21 at 8:05 am, Nursing Assessment reflected, "Having thoughts of self-harm via cutting but agreed to seek staff support for safety prior to cutting. Dressed superficial cut wounds to L-hand & L-lower FA per pt's [sic] request. 'because it scared one of the little kids when they saw it the other day.' No open/skin/bleeding noted."
On 11/29/21 at 6:30 am, the Nursing Assessment reflected, "Pt. gave MHT [mental health technician] a metal spring that she states came from the soap dispenser in the bathroom in her room. Dispenser is intact, working."
On 11/29/21 at 11:50 am, the Nursing Assessment reflected, "No fresh injuries to arms + knuckles- a few days old."

On 12/09/21, during an interview in the facility conference room, Staff #1, Administrator stated, "The nurse must have thought it was an old injury; there wasn't any bleeding, so she just wrapped it. The problem is the patient was admitted on another unit. They only do the full body assessment on admission. We rarely have to move patients to different units... The end of shift report needs to be revised to include skin changes."

Based on interview and record review, the facility failed to a provide care in a safe setting when a patient self-harmed themselves in the facility, and the staff did not investigate the source of the injuries, to prevent further injuries.

Findings include:

During a telephone interview, on the morning of 12/09/21, Patient #11's father stated, "We took Patient #11 to our primary physician on the day of discharge. The physician said Patient #11 had new wounds to the lower left forearm. When I asked Patient #11 where the wounds came from, Patient #11 said he had been cutting himself in the facility with a spring found in the bathroom; Patient #11 said they gave the spring to the staff several days later."

Review of Patient #11's medical records reflected the following:
On 11/19/21 the Nursing Admission Assessment reflected the Skin/Skin Integrity assessment showed four scars to the upper left forearm and a puncture to the left wrist.
On 11/26/21 at 8:05 am, Nursing Assessment reflected, "Having thoughts of self-harm via cutting but agreed to seek staff support for safety prior to cutting. Dressed superficial cut wounds to L-hand & L-lower FA per pt's [sic] request. 'because it scared one of the little kids when they saw it the other day.' No open/skin/bleeding noted."
On 11/29/21 at 6:30 am, the Nursing Assessment reflected, "Pt. gave MHT a metal spring that she states came from the soap dispenser in the bathroom in her room. Dispenser is intact, working."
On 11/29/21 at 11:50 am, the Nursing Assessment reflected, "No fresh injuries to arms + knuckles- a few days old."

Patient #11's medical records did not include an incident report, which would have included a Re-assessment of the patient's skin or a description of the wounds and would have instructed the staff to contact the Physician and Parents.

On 12/09/21, during an interview in the facility conference room, Staff #2, Quality Director stated, "I interviewed the discharging nurse; she said the injuries were old." Staff #2 reported an incident report should have been completed.

On 12/09/21, during an interview in the facility conference room, Staff #1, Administrator stated, "The nurse must have thought it was an old injury; there wasn't any bleeding, so she just wrapped it. The problem is the patient was admitted on another unit. They only do the full body assessment on admission. We rarely have to move patients to different units ...The nurse should have written an incident report...We do environmental rounds every morning. We had to change out the soap dispensers." When asked if the rooms are checked before a patient is placed in it or after maintenance has worked in the room, Staff #1 stated, "No."