HospitalInspections.org

Based on interview and record review, the hospital failed to protect and promote each patient's rights when:

1. Four of five patients (Patient 2, Patient 3, Patient 4, and Patient 84) were not protected from physical and sexual abuse and/or emotional trauma. Patient 2 was physically assaulted in the middle of the hallway by Patient 1 and there was no staff member monitoring the hallway to ensure adequate supervision in accordance with hospital policy and procedure. Patient Care Technician (PCT) 1 manually stimulated Patient 3's penis to an erection in order to apply a condom catheter (a urine collection device that fits like a condom over the penis). Registered Nurse (RN) 4 slapped Patient 4 while she provided patient care in the Emergency Department (ED). Staff were aware of Patient 84's past medical history of sexually induced post traumatic stress incident and inappropriately awakened Patient 84, who was intubated and under sedation, and Patient 84 was asked to consent for a procedure already consented. The actions taken by staff triggered an unavoidable situation where Patient 84 experienced post-traumatic stress incident resulting in anxiety and mental anguish. (Refer to A145)

2. Patient 84's right to make informed decisions about her care was not protected and promoted. On 9/14/22 Patient 84, while still intubated (mechanically ventilated with a tube in the throat) and having stopped a sedative/anesthetic medication (Propofol) and a strong opioid medication for pain (Fentanyl) for four minutes, staff awakened and asked Patient 84 to consent for a surgical procedure that was previously consented. Patient 84 was asked to consent for the procedure by nodding her head. (A131)

3. The facility failed to ensure restraints were assessed per the hospital protocol for one of 70 sampled patients (Patient 3). Non-violent restraints (restraints applied to support the management of care when the patient is interfering with medical treatment and safety) were applied on Patient 3 while in the Neuro ICU step down unit (Step-down units are sometimes used to provide an intermediate level of care for patients whose illness severity may not warrant intensive care, but who are not stable enough to be treated in the medical surgical unit) and Patient 3 was not monitored every two hours on 9/2/22 which had the potential to cause injury. (Refer to A175)

The cumulative effect of these systemic problems resulted in failure to ensure patients were cared for in a safe manner, and their rights were protected and promoted at all.

Based on interview and record review the hospital failed to ensure a patient's right to make informed decisions about care when the hospital obtained consent inappropriately for one of 14 surgical patients (Patient 84) when on 9/14/22 Patient 84, while still intubated (mechanically ventilated with a tube in the throat) and having stopped a sedative/anesthetic medication (Propofol) and a strong opioid medication for pain (Fentanyl) for four minutes, staff awakened and asked Patient 84 to consent for surgical procedure that was previously consented. Patient 84 was asked to consent for the procedure by nodding her head.

This failure denied Patient 84 of her right to make informed decisions about her care and triggered a post-traumatic stress incident which resulted in additional anxiety and mental anguish for Patient 84.

Findings:

During a telephone interview on 1/27/23, at 10:48 a.m., with Patient (Pt) 84, Pt 84 stated she was admitted to the hospital, on 9/13/22, for a planned bilateral (both sides) breast reconstruction surgery (surgical process of rebuilding the shape and look of breast). Pt 84 stated the surgeon explained to her the entire procedure could take one to two days to complete and reviewed the risks and benefits of consecutive surgeries. Pt 84 stated she consented to the surgery and signed a consent form (a legal document that verifies that the informed consent discussion between the surgeon and the patient took place). Pt 84 was intubated during operative day one, then transferred to the Intensive Care Unit (ICU- a unit in a hospital providing specialized care for critically ill or injured patients) to stabilize prior to operative day two. Pt 84 stated she was taken off Propofol (anesthetic- prevent patient from feeling pain and a sedative - used to help patients relax or sleep before and during surgery and while being intubated) and Fentanyl on 9/14/22, when she was awakened to sign a second consent form for the same procedure performed on operative day one, while still intubated and sedated in the ICU. Pt 84 stated she did not understand what occurred nor why she had to sign a second consent form for a procedure previously discussed and consented with her surgeon. Pt 84 stated when she was awakened, she felt the breathing tube in her throat and fought to take it out, but she was "tied down." Pt 84 stated the situation triggered her "back to me being raped and the man forcing his penis down my throat." Pt 84 stated that she was still triggered from this incident and attempted to get counseling but was told because she was not suicidal, she would have to be placed on a waiting list. Pt 84 cried during the interview. Pt 84 stated "a friend" was her designated emergency contact person and staff should have contacted her friend to obtain the second consent.

During a review of Pt 84's face sheet (FS- a document that includes demographic information for patients when admitted to the hospital, contact information, date of birth, insurance, emergency contacts and more) dated 1/27/23, the FS indicated Pt 84 was admitted on 9/13/22 at 4:51 a.m. for "Acquired Absence of Breast Bilateral" and discharged on 9/28/2022 at 6:52 p.m.

During a review of Pt 84's "Plastic & Reconstructive Surgery History and Physical" (H&P- the physician's initial evaluation and examination of a patient), dated 9/7/22 at 2:07 p.m., the H&P indicated, "[Pt 84's name] is a 39 y.o. (year old) female with history of right breast IDC [Invasive ductal carcinoma- cancer that happens when abnormal cells growing in the lining of the milk ducts change and invade breast tissue] and TP53 [the most frequently mutated gene in breast cancer] gene mutation ... s/p [status post] bilateral nipple sparing mastectomy [removal of breasts] ... Patient is interested in proceeding with autologous breast reconstruction [uses tissue from one's own body to rebuild the breast] ... PAST MEDICAL HX [history]: ... Anxiety [feelings of fear, dread, and uneasiness that may occur as a reaction to stress] not ongoing but can be "triggered" from a previous Sexual post-traumatic stress incident ..."

During a review of Pt 84's "Plastic Surgery Progress Note" (PN), dated 9/14/22, at 7:09 a.m., the PN indicated, " ... She presented on 9/13/22 for a planned bilateral breast reconstruction with an abdominal flap. She is s/p right breast reconstruction ... by [name of surgeon 1] on 9/13/22 ... Procedure: bilateral breast reconstruction with abdominal based free flap, deep inferior epigastric perforator vs superficial inferior epigastric arterial flap. Was unable to obtain consent for this procedure as patient was intubated and unable to answer questions. However, she was awake and alert this AM and agreed to move forward with surgery by nodding yes. Her emergency contact, which was her friend was also contacted who stated patient did not wish to involve family since they have been estranged and have no idea of what she is currently going through. She believed patient would not want this discussed with them. [Surgeon 1 and Surgeon 2's names] discussed the risks and benefits of surgery and determined that proceeding would be in the best interest of the patient. Will plan to move forward with surgery today ..." The PN note was signed by General Surgery Resident (GSR) 1 and cosigned by Surgeon 1.

During a review of Pt 84's "Medication Administration Record" (MAR), dated 9/14/22, the MAR indicated Pt 84 was on the following two medications:
"Propofol (Brand Name) infusion 10 mg/mL (units of measure- milligrams/milliliter) Ordered Dose 5-80 mcg/kg/min (unit of measure-microgram/kilogram/minute)- at 0033 New Bag 80 mcg/kg/min; at 0150 Rate Changed 75 mcg/kg/min; at 0200 Rate Changed 70; 0214 Rate Changed 65; 0221 Rate Changed 60; 0228 Rate Changed 55; 0304 New Bag 55 mcg/kg/min; 0312 Rate Changed 50; 0320 Rate Changed 45; 0333 Rate Changed 40; 0416 Rate Changed 35; 0639 New Bag 35 mcg/kg/min; 0750 Partial Bag 35; 0751 Stopped; 0929 Rate Changed 25 mcg/kg/min -Fentanyl Citrate in NS (normal saline fluid) (PF) (Fentanyl Citrate brand name) 20 mcg/mL infusion Dose 0-300 mcg/hr 0-15 mL/hr Intravenous: CONTINUOUS- 0311 Rate Verify 100 mcg/hr; 0403 Rate Change 125 mcg/hr; 0515 Rate Change 150 mcg/hr; 0725 Handoff 150 mcg/hr; 0749 Canceled; 0750 Partial Bag 150 mcg/hr; 0751 Rate Changed 150 mcg/hr; 0942 Rate Changed 100 mcg/hr; 1123 Stopped"

During a concurrent interview and record review on 1/27/23, at 11:30 a.m., Pt 84's MAR, dated 9/14/22, was reviewed with the Manager of Four and Five Intensive Care Unit (LNS) 1. The LNS 1 stated the patient (Pt 84) was already consented and staff should not have woken her up, four minutes was not enough time to have the Propofol out of her system to consent or verify consent.

During a concurrent interview and record review on 1/27/23, at 12 p.m., Pt 84's "Authorization for and Verification of Consent to Surgery, Administration of Anesthetics and Rendering of Other Medical Services" (Verification of Consent to Surgery), dated 9/14/2022 at 07:55 a.m. and MAR, dated 9/14/22, was reviewed with the Certified Registered Nurse Anesthetist (CRNA- nurse in charge of sedation of patient). The CRNA stated she remembered Pt 84 was intubated and staff stopped her medications to get "the consent" signed. The CRNA stated she was on Pt 84's first procedure on 9/13/22. The CRNA stated they (referring to the hospital) needed to get consent for that day 9/14/22, stating, "they are all about the consent being valid." The CRNA stated the average time a patient should be off Fentanyl was a couple of hours before obtaining consent and patients once taken off Propofol, which is short acting, should be given at least 15 minutes before attempting to obtain consent. The CRNA stated based on the stop time of the Propofol on 9/14/22 at 7:51 a.m. she did not believe the patient was off the medication long enough to obtain consent. The CRNA stated patients were "rarely" woken up for consent if they were under sedation. The CRNA stated, "We usually will get consent from the family, but this patient had instructions not to have her family contacted but she did have a friend as her emergency contact, and I didn't reach out to her and don't know if she was contacted."

During a review of Pt 84's physician order "Restraints Non-Violent or Non-Self Destructive", the order had a start time of 9/14/22 at 2:40 a.m. and a canceled time of 9/14/22 at 8:36 p.m. for "Restraint Type: Soft Restraint. Location of Soft Restraints: Left Wrist Right Wrist Restraint Reason: Interference with medical treatment." The "Restraint Documentation," dated 9/14/22, indicated the left and right wrist restraints were placed on Pt 84 at 1:36 a.m. and they were checked and monitored at 4 a.m. and 6 a.m. and at 8 a.m. the only documentation is "Other".

During a concurrent interview and record review on 1/27/23, at 3:30 p.m., Pt 84's "Verification of Consent to Surgery" (consent form), dated 9/13/22 at 5:29 a.m. and "Verification of Consent to Surgery", dated 9/14/22 at 7:55 a.m., were reviewed with the Manager of Surgery (MS). The MS stated both consents read the same (meaning consents had the same procedure written out). The MS stated the nurses in her department were trained to ensure a "Verification of Consent" was obtained before "rolling the patient back into the operating room". The MS stated this was why the nurses did so (obtained a second consent) "because it was necessary."

During a review of both consent forms, the signature of Pt 84 was legible on the consent form dated 9/13/22 and had one witness signature. The consent form dated 9/14/22 was not legible and had two witness signatures.

During an interview on 1/27/23, at 3:20 p.m., with the Supervisor of Licensing, Accreditation and Safety (SLA), the SLA stated she attempted to get a hold of the Surgeons involved in this case, but they were not available for interviews. SLA also stated she could not get a hold of the night nurse assigned to Pt 84 on 9/13/22 and 9/14/22.

During a review of the facility's Policy and Procedure (P&P) titled, "Consent," dated 10/6/22, the P&P indicated, " ... To describe the principles of consent, protect the rights of patients, and to prevent potential allegations of false imprisonment, defamation, invasion of privacy and battery ... To clarify the responsibilities of the hospital for consent to services and verification of informed consent ... The role of the hospital is limited to verifying that the physician has obtained the patient's informed consent before the physician performs the procedure ... Hospital Staff Responsibilities ... Confirmation of physician documentation of informed consent prior to commencement of procedure/surgery. ii. Hospital employees involved with the patient care process verbally confirm with the patient or legal representative that informed consent has taken place ... f. Consent Duration/Consent for multiple same treatments/procedures. i. Informed consent may be considered to have continuing force and effect until the patient revokes the consent or until circumstances change ... H. Difficulty obtaining patient's signature on the consent form, particularly a Verification of Informed Consent for Surgery, should be referred promptly to the Manager/Clinical Supervisor/Registered Nurse (RN) on duty ... The physician must also be notified of the problem. In circumstances where there is a difference of opinion regarding the need for informed consent, excluding those circumstances expressly mandated in this policy, the decision to obtain informed consent will rest with the physician ..."

During a review of a professional reference titled RxList for PROPOFOL Brand Name: (Brand Name), Propofol Drug Class: Sedatives, General Anesthetics, Systemic, reviewed on 3/23/22, indicated, "WHAT IS PROPOFOL AND HOW DOES IT WORK? Propofol is an intravenous (IV) sedative-hypnotic agent that can be used for initiation and maintenance of Monitored Anesthesia Care (MAC) sedation, combined sedation and regional anesthesia, induction of general anesthesia, maintenance of general anesthesia, and intensive care unit (ICU) sedation of intubated, mechanically ventilated patients ... ICU Patient ... Discontinuation: Avoid discontinuation prior to weaning or for daily evaluation of sedation levels; may result in rapid awakening with associated anxiety, agitation, and resistance to mechanical ventilation ... WHAT OTHER DRUGS INTERACT WITH PROPOFOL?... Serious Interactions of propofol include: ... fentanyl ..." Retrieved from: https://www.rxlist.com/consumer_propofol_diprivan/drugs-condition.htm

During a review of a professional reference titled RxList for FENTANYL CITRATE INJECTION Generic Name: fentanyl citrate injection Brand Name: Fentanyl Citrate Injection Drug Class: Opioid Analgesics, Opioids Last updated 4/41/22, indicated, " ... The most common side effects ... include: dizziness, mild drowsiness, depressed mood, sleep problems (insomnia- inability to sleep), headache, weakness, anxiety, nausea, vomiting ... INDICATIONS Fentanyl Citrate Injection is indicated for: analgesic action of short duration during anesthetic periods, premedication, induction and maintenance, and in the immediate postoperative period (recovery room) as the need arises ... The onset of action of fentanyl is almost immediate when the drug is given intravenously; however, the maximal respiratory depressant effect may not be noted for several minutes ... The terminal elimination half-life (the amount of time required for 50% of the drug to be removed from the blood) is 219 minutes ..."

Based on interview and record review, the hospital failed to ensure patients were free from abuse, harassment, and neglect for four of five patients (Patient 2, Patient 3, Patient 4, and Patient 84) when:

1. Patient 1 assaulted Patient 2 in the middle of the hallway on Nurse's Unit 2 on 9/7/22 in the hospital's behavioral center (specialized unit for psychiatric of mental illness), and there was no staff member monitoring the hallway to ensure adequate supervision. This failure resulted in Patient 2 sustaining a two inch vertical laceration (cut) on his right side of the head. Patient 2 had tonic clonic seizure (condition in which a person loses consciousness and has violent muscle contractions) lasting approximately one minute. Patient 2 lost consciousness that prompted Registered Nurse (RN) 1 to initiate cardiopulmonary resuscitation (CPR-emergency procedure consisting of chest compressions often combined with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who's heart has stopped) to achieve ROSC (Return of spontaneous circulation- the resumption of a sustained heart rhythm that perfused [supplied the body with blood] the body after cardiac arrest).

2. Patient Care Technician (PCT) 1 manually stimulated Patient 3's penis while attempting to place a condom catheter (a urine collection device that fits like a condom over the penis, and also has a tube that goes to a collection bag strapped to the leg) on Patient 3 on 9/22/22 in the Neuro ICU step down unit (Step-down units are sometimes used to provide an intermediate level of care for patients whose illness severity may not warrant intensive care, but who are not stable enough to be treated in the medical surgical unit). This failure had the potential to result in Patient 3 to experience emotional trauma from sexual assault and violated Patient 3's rights to be free from physical abuse.

3. Registered Nurse (RN) 4 slapped Patient 4 in the Specialty Care Unit in the Emergency Department (SCU-unit in the emergency department for patients with behavioral diagnosis that are harm to themselves or others) on 9/13/22. This failure violated Patient 4's right to be free from physical abuse and had the potential to result in serious bodily harm and emotional trauma.

4. Staff were aware of Patient 84's history of sexual post traumatic stress incident and inappropriately awakened her from sedation while Patient 84 remained intubated (mechanically intubated with a tube in the throat). The reason to awaken her was to verify consent for a procedure she had already consented for the day before. Staff was aware and had an emergency contact who could have verified consent for the patient. This failure resulted in Patient 84 feeling like she was being forced to relive the trauma of being raped.

Findings:

1. During a review of Patient 1's "DHCS 1801" (Department of Health Care Services- form which allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) dated 8/12/22, the DHCS 1801 indicated, "Placed on 1799 hold (emergency medical care in general acute care hospitals can place a patient on a 1799 hold to detain the person for 24 hours) in ED (Emergency Department) for mental health evaluation due to homicidal ideation ... continues to report thought of hurting others with plan to set things on fire ..."

During a review of Patient 2's "History and Physical" (H&P), dated 9/7/22, the H&P indicated, "... Patient appears to be experiencing an acute mental health crisis at this time and would benefit from inpatient psych (psychiatric) placement for further evaluation and stabilization. Patient is an imminent risk to harm self ... Patient continues to meet criteria for 5150 hold (allows an adult who is experiencing a mental health crisis to be involuntarily detained for a 72- hour psychiatric hospitalization when evaluated to be a danger to others, or to himself or herself, or gravely disabled) ..."

During an interview on 1/26/23 at 10 a.m., with RN 1, RN 1 stated on 9/7/22 he was the charge nurse for the day on Nurse Unit 2. RN 1 stated sometime in the afternoon, he was at the nurse's station speaking to co-workers when he heard a loud sound. RN 1 stated he turned to look down the hall, and saw Patient 1 standing over Patient 2. RN 1 stated he ran to see what was happening. RN 1 stated he directed Patient 1 to go to the quiet room (room used for seclusion and restraints) and was cooperative. RN 1 stated Patient 1 told him that Patient 2 was mocking and laughing at Patient 1. RN 1 stated when he returned to assess Patient 2, there were other staff to assist. RN 1 stated Patient 2 was on floor bleeding from the back of his head and was putting pressure to stop the bleeding. RN 1 stated Patient 2 began to have a tonic clonic seizure that lasted approximately one minute. RN 1 stated Patient 2 began to become lethargic and lost consciousness. RN 1 stated he began to perform chest compressions (CPR) on Patient 2. RN 1 stated Patient 2 regained consciousness. RN 1 stated Patient 2 was taken the Emergency Room (ED) for further treatment and evaluation. RN 1 stated he did not remember seeing a staff member at the back of the hallway. RN 1 stated he did not see the initial strike from Patient 1 to Patient 2. RN 1 stated he was the first staff member to the location of the incident. RN 1 stated there should have been a staff member towards the end of the hallway monitoring patients.

During an interview on 1/25/23, at 10 a.m., with RN 2, RN 2 stated on 9/7/22 she was at the nurse's station when she heard a loud noise. RN 2 stated she followed RN 1 to Patient 1 and Patient 2. RN 2 stated she observed blood on the doorway of a patient room near Patient 2. RN 2 stated she observed blood on the back of Patient 2's head. RN 2 stated a staff member had brought her supplies to care for Patient 2's cut on his head. RN 2 stated she observed Patient 2 not breathing and lost consciousness. RN 2 stated chest compressions were started on Patient 2 and regained consciousness. RN 2 stated Patient 2 was taken to the ED via an ambulance for further treatment. RN 2 stated she had not seen the actual strike from Patient 1 to Patient 2. RN 2 stated she did not know where the mental health workers were at the time Patient 1 hit Patient 2. RN 2 stated she did not remember observing a staff member at the end of the hallway near the patients' rooms. RN 2 stated there should have been a mental health worker at the end of the unit observing all patients.

During an interview on 1/25/23, at 10:30 a.m., with Mental Health Worker (MHW) 1, MHW 1 stated she was at the nurse's station on Unit 2 on 9/7/22. MHW 1 stated she was assisting a new patient admission with completing the inventory of their belongings. MHW 1 stated she did not observe Patient 1 hitting Patient 2. MHW 1 stated she heard yelling and was told by staff to push the Code Gray button (situation in which a patient is being aggressive, abusive, violent, or displaying threatening behavior). MHW 1 stated a staff member would have been doing 15 minute observation checks on all patients. MHW 1 stated she was not assigned to be doing checks at the time as she was assisting the new patient admission. MHW 1 stated there should have been a staff member observing patients at both ends of the hallway to ensure patient safety and know their whereabouts.

During an interview on 1/26/23, at 10 a.m., with RN 3, RN 3 stated she was working on Unit 2 on 9/7/22 as an MHW that day and not as an RN. RN 3 stated she was assigned to document 15 minute observation checks on the unit that day. RN 3 stated she was at the nurse's station near the day room, when she heard a loud noise. RN 3 stated she had her back turned and was facing the nurse's station while she was documenting patient observations. RN 3 stated she did not see the actual hit from Patient 1 to Patient 2. RN 3 stated she immediately went to the scene to see what was occurring. RN 3 stated RN 1 and RN 2 were first to assess Patient 2. RN 3 stated she observed Patient 2 with blood on the back of his head lying on the floor. RN 3 stated Patient 2 had a seizure and became unresponsive. RN 3 stated RN 1 began chest compressions on Patient 2. RN 3 stated RN 1 had asked to get the defibrillator (devise that sends an electric shock to the heart to restore a normal heartbeat) due to Patient 2's heart stopping. RN 3 stated Patient 2 regained consciousness and was taken to the ED for further treatment and evaluation. RN 3 stated it was the expectation to observe all the patients whereabouts on the unit to ensure safety of everyone. RN 3 stated there needed to be two staff members monitoring the hallway and day room by having one staff member at each end. RN 3 stated another staff member would have needed to replace the staff member if they needed a break to ensure there was always someone monitoring the end of the hallway. RN 3 stated she did not know who would have been assigned to monitor the end of the hall on 9/7/22.

During a concurrent interview on 1/26/23, at 11 a.m., with the Nurse Manager (NM), and the Director of Behavioral Health (DBH), the NM stated the expectation for staff to be supervising patients' whereabouts, was to do 15 minute observations checks, and document on the "Constant Care Form." The NM stated the hospital's policy was for there to be two staff members, typically MHWs, to monitor both ends of the hallway. The NM stated there needed to be an MHW at the end of the hallway observing any potential violent or aggressive situation between Patient 1 and Patient 2. The NM stated there was no RN nor MHW that saw the incident between Patient 1 and Patient 2 and there was no staff member at the end of the hallway near the patients' rooms when Patient 1 hit Patient 2. The NM stated it was the responsibility of the hospital to ensure no patient is violent with another patient nor hit another patient. The DBH stated patients should have been free from abuse and physical harm while in the behavioral center.

During a review of Patient 2's "Significant Event"(SE) note, dated 9/7/22, the SE indicated, "[Patient 2] was seen lying on the ground holding his head with another patient standing over him yelling "help me!" Staff approached [Patient 2] and assessed that he was bleeding from mouth and posterior (back) head. Code blue (hospital emergency code used to describe the critical status of a patient requiring resuscitation of the patient) was called. House supervisor notified. Staff applied pressure to the wound and began to assess his vitals (clinical signs used to indicate the status of the body's vital functions). Patient had tonic clonic seizure that lasted 1 min. After seizure ended his vital signs were assessed, BP: (blood pressure) 100/60, HR (heart rate): 80, O2%: (oxygen rate) 75% and RR: (respiration rate) 20. Patient had weak peripheral pulses (palpation of the high-pressure wave of blood moving away from the heart through vessels) and was in and out of consciousness. 8L (liters of oxygen) NC (nasal cannula) applied to patient and patient stimulated by sternal rub (technique is performed by rubbing the knuckles of a closed fist firmly and vigorously on the patient's sternum for assessing the neurological status of an individual). Patient continued to not be responsive and carotid pulse (pulse found in the neck area on the side of the windpipe) was not felt, staff began chest compressions, but after one compression patient regained consciousness and was responsive. Patients' HR increased to 105 and his O2 saturation increased to 95%, 911 called and patient was transferred to [hospital] ED ..."

During a review of Patient 2's "ED Provider Notes" (PN), dated 9/7/22, the PN indicated, " ... [Patient 2] was assaulted by another pt [Patient 1] at [name of hospital] that pushed [Patient 2] causing him to hit the back of his head and on the metal frame of the door, approximately 2 inch vertical laceration to right occipital scalp (area of the back of the head), seizure s/p (status post) assault lasting approximately 1 minute tonic clonic ...+ oral trauma (plus bleeding from the mouth)."

During a review of Patient 2's "Procedure Orders" (PO), dated 9/7/22, the PO indicated, "Laceration Repair ... Repair method: Sutures ... Number of sutures: 5 ..."

During a review of the hospital policy and procedure (P&P) titled "Patient and Safety & Observation Policy" dated 9/14/22, indicated, " ... B. With the use of patient safety observations, it is our policy to protect the patient from self-injury or injury to/from others while affording the patient an opportunity to manage their own behavior in a therapeutic environment. Every patient is placed on the appropriate level of observation at all times during their stay at [name of hospital] ..."

During a review of hospital undated P&P titled, "Hallway Monitoring", indicated, "1. A clear assignment of each MHW's designated time to be in the hallway needs to be completed by the charge RN in OptiLink (internal database) and posted on the unit. 2. One staff member will be positioned inside the double doors leading to the bedrooms and stay there in between rounding while any patients are in their room. 3. The second staff member is the "circulator" staying in the day room/nurse's station area unless rounding or responding to patient request ..."

During a review of the hospital P&P titled, "Patient Rights and Responsibilities", dated 2/10/22, indicated, " ... Policy ... C. [hospital name] respects the rights of patient, recognizes that each patient is an individual with unique healthcare needs, and because of the importance of respecting each patient's personal dignity, provides considerate, respectful care focused upon the patient's individual needs ... IV. Patient Rights ...the hospital shall provide process to support the following patient rights ... 2. To receive considerate and respectful care, be made comfortable and maintain dignity in safe setting, free from verbal or physical abuse or harassment ..."

2. During a review of Patient 3's "Progress Note" (PN), dated 9/23/22, the PN indicated, " ... Admission Date: 8/30/22 ...[Patient 3] presented with acute onset left sided weakness. On arrival was found to be hypertensive (blood pressure that is higher than normal), with left sided weakness, and slurred speech. CT head revealed right thalamus hemorrhage with extension to ventricles and ventricles and midline shift (caused by a blood clot blocking blood flow or bleeding from a blood vessel in the part of the brain responsible for motor and sensory signals, sleep, wakefulness, consciousness, learning and memory) ..."

During an interview on 1/27/23, at 7:30 p.m., PCT 2, stated she was assisting PCT 1 place a condom catheter on Patient 3 on 9/22/22 on the 10th floor in the Neuro ICU step down unit, at approximately 4-5 a.m. PCT 2 stated PCT 1 asked her to get some lube to place the condom catheter. PCT 2 stated she got packets of lube for PCT 1, and then saw PCT 1 manually stimulating Patient 3's penis. PCT 2 stated she told PCT 1 it was inappropriate to do that. PCT 2 stated she went to report what she saw to Registered Nurse Supervisor (RNS) 1. PCT 2 stated Patient 3 was not alert to know what was going on as he was a GCS of 14 (Glasgow Coma Scale-is used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients. The scale assesses patients according to three aspects of responsiveness: eye-opening, motor, and verbal responses. 14 meaning mild impaired consciousness). PCT 2 stated PCT 1 did not understand why it was wrong to apply condom catheter by erecting Patient 3's penis. PCT 2 stated she had not seen any PCT perform a condom catheter application by erecting a male patient's penis.

During a review of Patient 3's "Head to Toe Summary", dated 9/21/22, indicated Patient 3 was a GCS of 14.

During an interview on 10/4/22, at 12:07 p.m., with Patient 3, in Patient 3's room in the Neuro ICU Step down floor, Patient 3 shook his head when asked about feeling sexually assaulted when PCT 1 attempted to place a condom catheter on 9/22/22. Patient 3 did was not cognitive to comprehend questions.

During an interview on 1/27/23, at 7:35 a.m., with RNS 1, RNS 1 stated he had asked PCT 1 to apply a condom catheter to Patient 3, due to the condom catheter repeatedly coming off Patient 3. RNS 1 stated PCT 2 came up to him and informed him of PCT 1 attempting to erect Patient 3's penis to apply the condom catheter. RNS 1 stated he had never heard of any PCT attempting to erect a male patient's penis to apply a condom catheter. RNS 1 stated he asked PCT 1 if he had applied the condom catheter on Patient 3, and PCT 1 stated he tried to erect Patient 3's penis to apply the condom catheter. RNS 1 stated he informed PCT 1 that erecting a patient's penis could be considered sexual assault and was not appropriate to do. RNS 1 stated he informed the Clinical Supervisor (CS) on the next night shift on 9/22/22 at 7 p.m. RNS 1 stated he had not dealt with an incident involving sexual inappropriateness or sexual assault. RNS 1 stated he should have informed the CS immediately as soon as he was informed by PCT 2.

During an interview on 1/27/23, at 7:40 a.m., with CN 1, CN 1 stated RNS 1 notified him about PCT 1 erecting Patient 3 to place a condom catheter on the night of 9/22/22. CN 1 stated Patient 3 was still a GCS of 14 when he spoke to him about the incident. CN 1 stated Patient 3 had no recollection of what had occurred. CN 1 stated PCT 1 should have known how to place a condom catheter on Patient 3. CN 1 stated PCT 1 should not have attempted to erect Patient 3 to place a condom catheter on as it was sexual assault.

During an interview on 1/27/23, at 7:45 a.m., with the Nurse Manager (NM) 1, NM 1 stated PCT 1 should not have attempted to erect Patient 3's penis to place a condom catheter. NM 1 stated the orientation competency check list did not contain education on placing condom catheters. NM 1 stated there should have been training on how to place condom catheters on patients to ensure PCT 1 knew how to properly place a condom catheter on a patient. NM 1 stated erecting a male patient to place a condom catheter should be considered sexual assault on patient with impaired consciousness.

During a review of PCT 1's "Orientation Skills List Verification", dated 4/28/22, indicated there was no education on placing condom catheters.

During a review of the hospital's directions of condom catheter placement, dated July 2021, indicated, " ... Condom catheter device ... 6. Assess the condition of the penis. Use the manufacturer's measuring guide to measure the diameter of the penis in a flaccid state ... 8. After perineal care, apply a skin-protecting film or barrier wipes to the penis, if prescribed. Allow the protectant to dry before applying the condom. Avoid barrier creams ... 10. Apply the sheath. a. Ensure the sheath is the appropriate size for the patient's penis. b. With the nondominant hand, grasp the penis along the shaft. c. With the dominant hand, hold the condom sheath at the tip of the penis and smoothly roll it onto the penis. d. Allow some space between the tip of the glans penis and the end of the condom catheter ... 12. Apply an appropriate securing device for the sheath according to manufacturer's directions. a. Self-adhesive condom catheters: After application, apply gentle pressure on the penile shaft to secure the catheter. b. Outer securing strip-type condom catheters: Spiral-wrap the penile shaft with supplied elastic adhesive strip ..."

During a review of the hospital P&P titled, "Patient Rights and Responsibilities", dated 2/10/22, indicated, " ... Policy ... C. [hospital name] respects the rights of patient, recognizes that each patient is an individual with unique healthcare needs, and because of the importance of respecting each patient's personal dignity, provides considerate, respectful care focused upon the patient's individual needs ... IV. Patient Rights ... the hospital shall provide process to support the following patient rights ... 25. To be free from ... sexual abuse ..."

During a review of the hospital P&P titled, "Dependent Adult and Elder Abuse", dated 10/10/29, indicated, "Purpose ... D. To define the training provided to all staff regarding the identification of suspected adult/elder abuse ... Definitions ... D. Dependent Adult ... any person between the ages of 18-64, who has physical or mental limitations that restrict his or her ability to carry out normal activities or to protect his or her rights ... Dependent adult also includes any person between the ages of 18-64 who is an inpatient in an acute care hospital ... M. Physical abuse includes ... 4. Sexual assault including ... lewd or lascivious act ... B. Staff provided education on dependent adult/elder abuse during the orientation process and on an ongoing basis by completing annual mandatory education on a computer-based training system ..."

3. During a review of Patient 4's "Emergency Department Notes" (EDN), dated 9/13/22, the EDN indicated, " ... Per/report, pt [Patient 4] was aggressive and combative. Pt swung and was spitting on EMS (emergency medical services) ... Pt appeared agitated and does not verbally contract to remain calm and cooperative. Pt placed in 4 point restraints (restrain both arms and both legs, usually are reserved for violent patients who pose a danger to themselves or others) for pt and staff safety at this time ..."

During an interview on 1/26/23, at 2 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated approximately around 1 p.m., she was attempting to change Patient 4's clothes and became more agitated. LVN 1 stated RN 4 came to assist with changing Patient 4's clothes when Patient 4 spit on RN 4. LVN 1 stated RN 4 then slapped Patient 4 in the face while holding Patient 4's face on the gurney to prevent Patient 4 from spitting again. LVN 1 stated she felt it was not okay to slap another patient. LVN 1 stated she reported the incident to the Emergency Department Director (EDD).

During a concurrent interview on 1/26/23, at 2:11 p.m., with the EDD, Emergency Department Manager (EDM) 1, and 2, the EDD stated he was notified of the incident on 9/13/22 and contacted the Human Resources Department (HR) to get involved. The EDD stated he spoke to RN 4 about the incident and had admitted to slapping Patient 4. The EDD stated RN 4 should not have slapped Patient 4 as it violated the patients' rights to be free from physical abuse. The EDD stated HR determined the action of RN 4 to be a terminable offense due to the violating the standards of conduct for hospital employees.

During a review of the hospital P&P titled, "Patient Rights and Responsibilities", dated 2/10/22, indicated, " ... Policy ... C. [hospital name] respects the rights of patient, recognizes that each patient is an individual with unique healthcare needs, and because of the importance of respecting each patient's personal dignity, provides considerate, respectful care focused upon the patient's individual needs ... IV. Patient Rights ... the hospital shall provide process to support the following patient rights ... 2. To receive considerate and respectful care, be made comfortable and maintain dignity in safe setting, free from verbal or physical abuse or harassment ..."

During a review of the hospital P&P titled, "Dependent Adult and Elder Abuse", dated 10/10/29, indicated, "Purpose ... D. To define the training provided to all staff regarding the identification of suspected adult/elder abuse ... Definitions ... D. Dependent Adult ... any person between the ages of 18-64, who has physical or mental limitations that restrict his or her ability to carry out normal activities or to protect his or her rights ... Dependent adult also includes any person between the ages of 18-64 who is an inpatient in an acute care hospital ... M. Physical abuse includes ... 2. Battery ..."

During a review of the hospital P&P titled, "Standards of Conduct", dated 3/13/17, indicated, " ... Policy Detail ... Employees are required to comply with all [hospital name] policies, procedures, and professional standards of conduct. Every disciplinary situation is different ... the types of misconduct that may lead to disciplinary action ... actual or threatening physical violence ..."

4. During an interview on 1/27/23, at 10:48 a.m., with Patient 84, Patient 84 stated she was admitted on 9/13/22 for a planned Bilateral breast reconstruction surgery. Patient 84 stated her surgeon had explained that the procedure could take one to two days to complete and reviewed the risks and benefits of the surgery and she had signed consent. Patient 84 stated on 9/14/22 she was weaned off Propofol (anesthetic- prevent patient from feeling pain and a sedative - used to help patients relax or sleep before and during surgery and while being intubated) and Fentanyl (opioid-strong pain medication), while she was still intubated and asked to sign consent for the same procedure, she had already signed for on the first day. Patient 84 stated she did not understand why she had to be taken off the medication to sign a consent she had already discussed with her surgeon and approved, she stated she could feel the breathing tube in her throat, and she felt like she was fighting to take it out, but she was tied down and the situation triggered her "back to me being raped and the man forcing his penis down her throat." Patient 84 stated that she is still triggered from this incident and has attempted to get counseling but was told because she was not suicidal, they would have to put her on a waiting list. Patient 84 was heard crying on and off throughout the interview. Patient 84 stated she had a friend designated as her emergency contact and staff could have contacted her to confirm the consent.

During a review of Patient 84's face sheet (document that includes demographic information for patients when admitted to the hospital, contact information, date of birth, insurance, emergency contacts and more) dated 1/27/23, indicated Patient 84 was admitted on 9/13/2022 at 4:51 a.m. for Acquired Absence of Breast Bilateral and discharged on 9/28/2022 at 6:52 p.m.

During a review of Patient 84's H&P, dated 9/7/22 at 2:07 p.m. was reviewed. The H&P was titled Plastic & Reconstructive Surgery History and Physical and it indicated, "[Patient 84's name] is a 39 y.o. (year old) female with history of right breast IDC (Invasive ductal carcinoma- cancer that happens when abnormal cells growing in the lining of the mild ducts change and invade breast tissue) and TP53 (the most frequently mutated gene in breast cancer) gene mutation ... s/p (status post) bilateral nipple sparing mastectomy (removal of breasts) ... Patient is interested in proceeding with autologous breast reconstruction (uses tissue from one's own body to rebuild the breast) ... PAST MEDICAL HX (history): ... Anxiety not ongoing but can be "triggered" from a previous Sexual post traumatic stress incident ..."

During a review of Patient 84's Progress Note (PN) titled Plastic Surgery Progress Note dated 9/14/22, at 7:09 a.m., was reviewed. The PN indicated, " ... She presented on 9/13/22 for a planned bilateral breast reconstruction with an abdominal flap. She is s/p right breast reconstruction ... by [name of surgeon 1] on 9/13/22 ... Procedure: bilateral breast reconstruction with abdominal based free flap, deep inferior epigastric perforator vs superficial inferior epigastric arterial flap Was unable to obtain consent for this procedure as patient was intubated and unable to answer questions. However, she was awake and alert this AM and agreed to move forward with surgery by nodding yes. Her emergency contact, which was her friend was also contacted who stated patient did not wish to involve family since they have been estranged and have no idea of what she is currently going through. She believed patient would not want this discussed with them. [Surgeon 1 and Surgeon 2's names] discussed the risks and benefits of surgery and determined that proceeding would be in the best interest of the patient. Will plan to move forward with surgery today ..." The PN note was signed by General Surgery Resident (GSR) 1 and cosigned by Surgeon 1.

During a review of Patient 84's Medication Administration Record (MAR), dated 9/14/22, the MAR indicated Patient 84 was on the following two medications:
-Propofol (Brand Name) infusion 10mg/mL (units of measure- milligrams/milliliter) Ordered Dose 5-80 mcg/kg/min (unit of measure-microgram/kilogram/minute)- at 0033 New Bag 80 mcg/kg/min; at 0150 Rate Changed 75 mcg/kg/min; at 0200 Rate Changed 70; 0214 Rate Changed 65; 0221 Rate Changed 60; 0228 Rate Changed 55; 0304 New Bag 55 mcg/kg/min; 0312 Rate Changed 50; 0320 Rate Changed 45; 0333 Rate Changed 40; 0416 Rate Changed 35; 0639 New Bag 35 mcg/kg/min; 0750 Partial Bag 35; 0751 Stopped; 0929 Rate Changed 25 mcg/kg/min
-Fentanyl Citrate in NS (normal saline fluid) (PF) (Fentayl Citrate Brand Name) 20 mcg/mL infusion Dose 0-300 mcg/hr 0-15 mL/hr Intravenous: CONTINUOUS- 0311 Rate Verify 100 mcg/hr; 0403 Rate Change 125 mcg/hr; 0515 Rate Change 150 mcg/hr; 0725 Handoff 150 mcg/hr; 0749 Canceled; 0750 Partial Bag 150 mcg/hr; 0751 Rate Changed 150 mcg/hr; 0942 Rate Changed 100 mcg/hr; 1123 Stopped

During a review of Patient 84's Order titled Restraints Non-Violent or Non-Self Destructive, was reviewed. The Order had a start time of 9/14/22 at 2:40 a.m. and a canceled time of 9/14/22 at 8:36 p.m. and was for "Restraint Type: Soft Restraint. Location of Soft Restraints: Left Wrist Right Wrist Restraint Reason: Interference with medical treatment. During a review of Patients document titled "Restraint Documentation," dated 9/14/22, indicated the left and right wrist restraints were place on Patient 84 at 1:36 a.m. and they were checked and monitored at 4 a.m. and 6 a.m. and at 8 a.m. the only documentation is Other.

During a concurrent interview and record review on 1/27/23, at 11:30 a.m., Patient 84's MAR dated 9/14/22 was reviewed with the Manager of four and five Intensive Care Unit (LNS) 1. The LNS 1 stated if the patient was already consented then they should not have woken her up, four minutes is not enough time to have the Propofol out of her system to consent or verify consent.

During a concurrent interview and record review on 1/27/23, at 12 p.m., Patient 84's Authorization for and Verification of Consent to Surgery, Administration of Anesthetics and Rendering of Other Medical Services (Verification of Consent to Surgery), dated 9/14/2022 at 07:55 a.m. and Medication Administration Record (MAR) dated 9/14/22, was reviewed with the Certified Registered Nurse Anesthetist (CRNA- nurse in charge of sedation of patient). The CRNA stated she remembers Patient 84 being intubated and they had stopped her medications to get the consent signed. The CRNA stated she was on Patient 84's first procedure on 9/13/22. The CRNA stated they needed to get consent for that day 9/14/22, stating, "they are all about the consent being valid." The CRNA stated the average time a patient should be off Fentanyl is a couple hours before getting consent and patients once taken of Propofol which is short acting should be given at least 15 minutes before attempting to get consent. The CRNA stated based on the stop time of the Propofol on 9/14/22 at 7:51 a.m. she did not believe the patient had been off this medication long enough to obtain consent. The CRNA stated patients are rarely woken up for consent if they are under sedation, "we usually will get consent from the family, but this patient had instructions not to have her family contacted but she did have a friend as her emergency contact, and I didn't reach out to her and don't know if she was contacted."

During an interview on 1/27/23, at 3:20 p.m., with the Supervisor of Licensing, Accreditation and Safety (SLA), the SLA stated she had attempted to get a hold of the Surgeons involved in this case and none had responded. The surgeons were not available for interviews. SLA stated she attempted to get a hold of the night nurse who took care of Patient 84 on 9/13-9/14/22 to 7 a.m. but has not heard a response back.

During a concurrent interview and record review on 1/27/23, at 3:30 p.m., Patient 84's Verification of Consent to Surgery,

Based on interview, and record review the hospital failed to ensure restraints were assessed per the hospital protocol for one of 62 sampled patients (Patient 3), when non-violent restraints (restraints applied to support the management of care when the patient interfered with medical treatment and safety) were not monitored every two hours for Patient 3 on 9/2/22 while in the Neuro ICU step down unit (Step-down units were sometimes used to provide an intermediate level of care for patients whose illness severity may not warrant intensive care, but who were not stable enough to be treated in the medical surgical unit).

This failure had the potential for Patient 3 to have safety of restraints not assessed and possibly lead to an injury.

Findings:

During a review of Patient 3's "Progress Note" (PN), dated 9/23/22, the PN indicated, " ... Admission Date: 8/30/22 ...[Patient 3] presented with acute onset left sided weakness. On arrival was found to be hypertensive (blood pressure that is higher than normal), with left sided weakness, and slurred speech. CT head revealed right thalamus hemorrhage with extension to ventricles and ventricles and midline shift (caused by a blood clot blocking blood flow or bleeding from a blood vessel in the part of the brain responsible for motor and sensory signals, sleep, wakefulness, consciousness, learning and memory) ..."

During a review of Patient 3's "Order Detail" (OD), dated 8/30/22, the OD indicated, "... Restraints Non-Violent or Non-Self Destructive ... Frequency CONTINUOUS ... Restraint Type: Soft Restraint: Location of Soft Restraints: Left Wrist ... Right Wrist ... Restraint Reason: Interference with medical treatment ..."

During a concurrent interview and record review on 1/27/23, at 7:50 a.m., with the Clinical Supervisor (CS) 1, and Nurse Manager (NM) 1, Patient 3's "Restraint Documentation", dated 9/2/22, indicated, " ... Non Violent Restraints: Q2H (every two hours) Monitoring ... 1600 (4 p.m.) ...Visual Check ... [nurse initials] ... 2000 (8 p.m.). CS 1 stated non-violent restraints were to be assessed every two hours to ensure safety of the patient. NM 1 stated it was important to assess for any potential injury such as bruising on the wrists and ensure there was circulation around the restraints. CS 1 stated there needed to be an assessment of restraints on Patient 3 at 6 p.m. as there was missing documentation from the nurse.

During a review of the policy and procedure (P&P) titled, "Restraint and Seclusion", dated 8/19/21, the P&P indicated, "... Purpose ... A. To provide a standardized process in the use of restraints and seclusion while protecting and preserving patients' rights, dignity, safety and well-being ... 6. Ongoing Assessment Requirements ... b. Assessment - is conducted by a licensed RN that has been educated and has documented competency i. Frequency - at least every two hours .... I. Visual check II. Patient's circulation. III. Patient's level of distress and agitation. IV. Skin assessment for injury at site of restraint. V. Patient's general care needs including eating, hydration/fluids, toileting, and range of motion. VI. Less restrictive restraints alternatives attempted ..."

Based on interview and record review, the hospital failed to ensure nursing care was provided to meet the needs of 3 of 62 sampled patients (Patient 25, Patient 57, and Patient 58) when the nursing care plans (goals of treatment for safe nursing care) did not include nursing interventions (actions that were performed to help patients reach their goals of care) corresponding to the primary diagnoses and treatments of each patient.

These failures had the potential to result in necessary nursing care not being provided and the potential for patient harm.

Findings:

During a concurrent interview and record review of Patient (Pt) 58's electronic health record (EHR- digital collection of medical information) on 1/25/23, at 3:00 p.m., with Informatics Nurse (IN) 1 and Licensed Nurse Supervisor (LNS) 1, IN 1 stated Pt 58 was admitted to the hospital on 1/23/23, with a primary diagnosis (the main condition treated or investigated during the hospital episode) of cardiogenic shock (life-threatening condition in which the heart cannot pump enough blood and oxygen to vital organs). Physician orders indicated Pt 58 was on continuous infusions (method of putting fluid or drugs into the blood stream) of Norepinephrine bitartrate-NS (medicine used to treat life-threatening low blood pressure), Amiodarone (medicine to prevent abnormal heart beats), and Heparin (blood thinner used to prevent and treat blood clots). LNS 1 reviewed Pt 58's nursing care plan and stated it did not address Pt 58's critical cardiac (relating to the heart) status. LNS 1 stated an appropriate nursing care plan for Pt 58 would include cardiac management interventions (i.e., assess for swelling, monitor intake and output, labs, weight, etc.) and measures to monitor effectiveness and/or side effects of the intravenous (in a vein) medications.

During a concurrent interview and record review of Pt 57's EHR, on 1/25/23, at 3:35 p.m., with IN 1 and LNS 1, IN 1 stated Pt 57 was admitted to the hospital on 1/15/23, status post all-terrain vehicle (ATV- motorized off-highway vehicle) accident, causing injury. Pt 57 suffered multiple fractures and internal injuries to the bladder (an organ that stores urine) and rectum (stores stool). Physician orders indicated Pt 57 was prescribed oral (mouth) and continuous infusion pain medications. LNS 1 reviewed Pt 57's nursing care plan and acknowledged it did not contain interventions to appropriately monitor and manage Pt 57's urine, bowel (stool), and pain.

During a concurrent interview and record review of Pt 25's EHR on 1/26/22, at 11:40 a.m., with IN 2, Medical Surgical Manager (MSM) 2 and Medical Surgical Director (MSD), the physician orders indicated Pt 25 had an order for Morphine (pain medicine) injection (shot) 2 milligrams (mg) every four hours as needed for severe pain. Pt 25's medical record indicated Pt 25 was admitted on 1/13/23, with an admitting diagnosis of "Cellulitis and abscess Left Leg" (a deep infection of the skin and fat) and did not have an active pain care plan. MSM 2 stated Pt 25 should have had an active pain care plan but did not. MSD stated the expectation was that all patients that had pain medications prescribed had an active pain care plan.

During an interview on 1/27/23, at 8 am, with the Assistant Chief Nursing Officer (ACNO), the ACNO stated nursing care plans were individualized plans of care established by nurses to direct the nursing care of each patient. The ACNO stated the significance of the care plans was that it established measurable goals based on the diagnoses and conditions of each patient. The ACNO stated every nursing care plan should be routinely evaluated and updated to accurately reflect the condition of the patient and appropriately measure the effectiveness of treatments. The ACNO stated nursing care plans were important communication tools used by nurses to help meet the needs of patients.

During a review of the facility document titled, "Job Description" for Clinical Nurse 1, Clinical Nurse 2, Clinical Nurse 3, and Clinical Nurse 4, undated, the documents indicated, " ... Reflects the job's main responsibilities ... Collects and prioritizes data in a systemic and ongoing process based on the patient's immediate condition or anticipated needs ... RN [registered nurse] develops, implements, and coordinates a plan in a timely manner that prescribes strategies and alternatives to attain expected outcomes ... develops and updates an individualized plan of care ... to meet the patient's individualized needs ... evaluates the effectiveness of the patient's plan of care in an ongoing, systematic and criterion based process ..."

During a review of the facility policy and procedure (P&P) titled "Interdisciplinary Plan of Care", dated 12/10/20, the P&P indicated, " ... Care Plan/ Plan of Care: A comprehensive, interdisciplinary approach to patient care from entry into the system until discharge. Phases of care are designed to address individual patient problems, expected outcomes, and an interdisciplinary treatment plan ... The Plan of Care is to be used for all patients admitted to [name of hospital] with time measurable goals evaluated daily ... A Plan of Care is to be initiated as soon as possible and completed within 24 hours of admission or prior to any procedure ... Patient goals and plan of action are updated by the individual who identified the problem, other by other health care team members in line with their expertise and credentials ..."

Based on interview and record review, Registered Nurses failed to ensure assigned nursing personnel were competent to care for patients according to patients' needs (use of condom catheter) for one of two Patient Care Technicians (PCT) when PCT 1 was assigned to the care of Patient (Pt) 3, who needed a condom catheter (a urine collection device that fits like a condom over the penis which had a tube that went into a collection bag strapped to the leg), was observed to manually stimulate Pt 3's penis to be erect in order to place the condom catheter.

This failure resulted in inappropriately stimulating Pt 3's penis which lead to sexual abuse and placing all patients who may need condom catheters at risk of sexual abuse and emotional distress and trauma.

Findings:

During an interview on 1/27/23, at 7:30 p.m., PCT 2, stated she was assisting PCT 1 place a condom catheter on Patient 3 on 9/22/22 at approximately 4 a.m. to 5 a.m. PCT 2 stated PCT 1 asked her to get some lube to place the condom catheter. PCT 2 stated she got packets of lube for PCT then saw PCT 1 manually stimulating Patient 3's penis. PCT 2 stated she told PCT 1 it was inappropriate to do that. PCT 2 stated she had not seen any other PCT perform a condom catheter application by erecting a male patient's penis.

During an interview on 1/27/23, at 7:40 a.m., with Clinical Supervisor (CS) 1, CS 1 stated Registered Nurse Supervisor (RNS) 1 notified him about PCT 1 erecting Patient 3 to place a condom catheter on the night of 9/22/22. CN 1 stated PCT 1 should have known how to place a condom catheter on Patient 3. CN 1 stated PCT 1 should not have attempted to erect Patient 3's penis to place a condom catheter. CN 1 stated all PCTs should have known the proper technique to place condom catheters on male patients.

During an interview on 1/27/23, at 7:45 a.m., with the Nurse Manager (NM) 1, NM 1 stated PCT 1 should not have attempted to erect Patient 3's penis to place a condom catheter. NM 1 stated the orientation competency check list did not contain education on placing condom catheters. NM 1 stated there should have been training on how to place condom catheters on patients to ensure PCT 1 knew how to properly place a condom catheter on a patient.

During a review of PCT 1's "Orientation Skills List Verification", dated 4/28/22, indicated there was no education on placing condom catheters.

During a review of the hospital's directions of condom catheter placement, dated July 2021, indicated, " ... Condom catheter device ... 6. Assess the condition of the penis. Use the manufacturer's measuring guide to measure the diameter of the penis in a flaccid state (part of the body that is soft and hanging loosely or limply) ... 8. After perineal care (involves washing the genital and rectal areas of the body), apply a skin-protecting film or barrier wipes to the penis, if prescribed. Allow the protectant to dry before applying the condom. Avoid barrier creams ... 10. Apply the sheath. a. Ensure the sheath is the appropriate size for the patient's penis. b. With the nondominant hand, grasp the penis along the shaft. c. With the dominant hand, hold the condom sheath at the tip of the penis and smoothly roll it onto the penis. d. Allow some space between the tip of the glans penis and the end of the condom catheter ... 12. Apply an appropriate securing device for the sheath according to manufacturer's directions. a. Self-adhesive condom catheters: After application, apply gentle pressure on the penile shaft to secure the catheter. b. Outer securing strip-type condom catheters: Spiral-wrap the penile shaft with supplied elastic adhesive strip ...."

Based on interview and record review the hospital failed to follow their policy for "Pain Assessment and Management" for two of 62 sampled patients (Patient 24 and Patient 79) when nurses did not assess or re-assess the patients for pain before or after the administration of pain medication.

This failure had the potential to leave patients with uncontrolled pain and/or oversedation.

Findings:

During a concurrent interview and record review of Patient (Pt) 24's electronic health record (EHR- digital collection of medical information) on 1/26/23, at 11:32 a.m., Pt 24's orders in the Medication Administration Record (MAR), and pain assessments were reviewed with the Medical/Surgical Manager (MSM) 1 and Medical/Surgical Director (MSD). Pt 24's orders indicated Pt 24 had an order for Oxycodone (strong oral pain medication) immediate release (IR) tablet 5 milligram (mg- unit of measure) every six hours as needed for pain. Pt 24's MAR indicated the patient received Oxycodone IR 5 mg on 1/12/23 at 0131, 1/12/23 at 2128, 1/22/23 at 0417, and on 1/26/23 at 0627. Each time the medication was given the patients pain was assessed on a numeric scale from 0-10 with 0 as no pain. MSM 1 and MSD validated Pt 24's pain was not documented as being re-assessed for any of the listed pain medication administrations.

During an interview on 1/27/23, at 8 a.m., Licensed Vocational Nurse (LVN) 2 stated she worked at the facility for over a year. LVN 2 stated she was trained to recheck pain 30 minutes (min) after an intravenous medication (given directly into a blood vessel) and 60 min after an oral (mouth) medication. LVN 1 stated pain must be re-checked after every pain medication administration.

During an interview on 1/27/23, at 8:05 a.m., Registered Nurse (RN) 7 stated she administered oral pain medications to patients at the facility. RN 7 stated patients must be reassessed after every pain medication administration. RN 7 stated the correct time to reassess a patient after an oral administration of Oxycodone is 30-60 minutes after the patient takes the medication.

During a review of Pt 79's Order for Pain Medication Titled Oxycodone ([Oxycodone Brand Name] - strong pain medication) immediate release 5 mg (unit of measure- milligram), dated 1/22/23 9:01 a.m., indicated, "Ordered Dose: 5 mg Route: Oral Frequency: EVERY 4 HOURS PRN (as needed) for SEVERE pain ..."

During a review of the hospital document titled "Pain Monitoring", dated 1/25/23, the document indicated "Oxycodone 5 mg Tab" was administered to Pt 79 on 1/25/23 at 1225 (12:25 p.m.).

During a concurrent interview and record review of Pt 79's EHR on 1/27/23, at 8:14 a.m., physician orders and the "Pain Monitoring Flowsheet" were reviewed with the Director of Inpatient Cardiac Services (DCS). DCS stated the Pain Monitoring sheet did not have a pain score for the oxycodone that was given on 1/25/23 at 1225, nor did it have a reevaluation pain score for the patient after the medication was given. DCS stated the expectation was for staff to reassess pain on patients every four hours with vital signs and when staff give pain medication. DCS stated the importance of reassessing pain after pain medication was given was to make sure the patient was not having signs or symptoms of oversedation and to make sure the patients pain was controlled. DCS stated oral pain medication should be reassessed 30 minutes after being given and IV (intravenous- in the vein) pain medication 15-30 minutes after it was given.

During an interview on 1/27/23, at 8:10 a.m., the Assistant Chief Nursing Officer (ACNO) stated pain should be checked before and after all pain medication administration, every time without exception. The ACNO stated nurses were expected to assess patient pain levels to help determine the effectiveness of the pain medications. The ACNO stated pain was not appropriately managed and had the potential for under or over medication when the nurses did not assess pain. The ACNO stated it was important to assess pain to help ensure patients achieved their pain goal and comfort levels.

During a review of the facility policy and procedure (P&P) "Pain Assessment & Management - Patients 14 and Older", dated 4/8/21, the P&P indicated, " ... To demonstrate [name of facility] commitment to a patient's right to effective pain management ... Pain screen is used to determine if pain is present or absent or if there is a recent history of pain by utilizing verbal acknowledgement of pain by a patient/family/caregiver or utilizing a pain measurement tool ... Assess and reassess pain using one of the following scales as appropriate ... Patients receiving oral pain medication are reassessed within 60 minutes after administration of oral pain medication, and patients receiving intravenous pain medication are reassessed within 30 minutes after administration of intravenous pain medication ... Evaluate and reassess for side effects of treatment and risk factors for adverse events caused by the treatment ..."

Based on interview and record review, the hospital failed to ensure restraints were ordered by a physician for one of 62 sampled patients (Patient 61), when Patient 61 was placed in four point restraints (restrains on both arms and both legs, usually reserved for violent patients who posed a danger to themselves or others) on 1/21/23 without a physician's order.

This failure had the potential to violate Patient 61's rights of being free of restraints and causing physical harm.

Findings:

During a review of Patient 61's "Violent Restraint Documentation" (VRD), dated 1/20/23, the VRD indicated Patient 61 was in four point restraints from 2105 (9:05 p.m.) to 2220 (10:20 p.m.). Patient 61 was in restraints for one hour and 15 minutes.

During a review of Patient 61's "Significant Event" (SE), dated 1/21/23, the SE indicated, "2045 (8:45 p.m.) RN (registered nurse) [5] was informed by MHW (mental health worker) that patient was crying and hitting her [head] on the wall while she was in the room. RN approached patient and attempted to calm the patient. Patient continued to bang her head against the wall. After multiple attempts to calm patient down, patient stated, "kill me already" and began to hit her head on the wall. The patient refused to contract to safety, for the safety of the patient, the patient was place in restraints at 2105 ..."

During a concurrent interview and record review on 1/26/23, at 9:35 a.m., with Medical Doctor (MD) 1, Patient 5's clinical record was reviewed. MD 1 stated he stated he ordered restraints for patients exhibiting violent behaviors that posed harm to themselves or others. MD 1 stated RN 5 had called him at home and gave a brief description about Patient 61's behaviors of hurting self. MD 1 stated he gave the okay to apply four point restraints to Patient 5. MD 1 stated there was no physician order in Patient 61's clinical record. MD 1 stated patient restraints required a physician order. MD 1 stated restraint orders needed to be completed by physicians to ensure the safety of patients. There was no indication of a physician order from MD 1 in Patient 5's clinical record.

During an interview on 1/26/23, at 11:30 a.m., with RN 5, RN 5 stated Patient 5 was placed on four point restraints for behavior of hurting self on 1/20/22, at 9:05 p.m. RN 5 stated he had called MD 1 about description of Patient 5's behavior. RN 5 stated he had documented on the SE of restraints being applied but had no documented verbal order from MD 1 in Patient 5's chart. RN 5 stated there should have been a physician order from MD 1 indicating restraint use for Patient 5.

During a review of the hospital policy and procedure (P&P) titled, "Restraint and Seclusion", dated 8/19/21, the P&P indicated, "... Purpose ... A. To provide a standardized process in the use of restraints and seclusion while protecting and preserving patients' rights, dignity, safety and well-being ... G. Requirements for all Restraint and Seclusion Orders ... 1. An order from a provider responsible for a restraint or seclusion is required prior to restraint or seclusion application ... When the need for a restrain or seclusion intervention occurs so quickly that an order cannot be obtained prior to application, the order must be obtained either during the emergency application of the restraint or seclusion, or immediately afterward ... 2. Orders can be initiated by a provider as defined by per [hospital name] bylaws and physician privilege ... 4. Restraint or Seclusion Protocols cannot be serve as a substitute for obtaining a physician's orders ... 2. Order Requirements: a. Order must include the reason for restraint or seclusion, the type of restraint and the duration of restraint or seclusion ..."

During a review of the P&P titled, "Provider Orders", dated 12/13/22, indicated, "Purpose ... C. To provide guidelines for the receipt, documentation, authentication and use of verbal or telephone orders ... H. When verbal or telephone orders are issued, they must be read back to the prescriber (ordering provider) ... 1. The person accepting the verbal or telephone order enters the order directly into the EHR (electronic health record) and reads it back to the ordering provider ... I. All verbal and telephone order must be cosigned by the ordering provider within 48 hours from the date and time the order was entered ..."

Based on observation, interview, and record review, the hospital failed to maintain a clean and sanitary environment for patients and staff when used laryngoscope handles (medical devices used to examine the back of the throat, voice box, and windpipe) used to examine patients in the Emergency Department (ED) were stored in the ED's clean storage room.

This failure placed patients and staff at risk for transmission of infections (a transfer of an infectious agent from a reservoir [source] to a susceptible host) and cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one object to another, with harmful effect) and increased the potential for hospital acquired infections and illnesses.

Findings:

During a concurrent observation and interview, on 1/24/23, at 2:30 p.m., in the ED, Emergency Department Manager (EDM) 1 and EDM 2 provided an escorted tour of the clean storage room located next to the Special Care Unit (provides focused care for patients with behavior and mental health issues). The room stored clean and sterile (free from germs) supplies. Behind the door was a gray commercial trash bin with a lid. On the lid was written "Dirty laryngoscopes ..." EDM 1 stated the ED stored the used laryngoscope handles in the trash bin. EDM 1 stated storage of the laryngoscope handles in the clean storage room "was not ideal" because of potential transmission and cross contamination of infectious (disease causing) materials to the clean and sterile supplies in the room.

During an interview on 12/27/23, at 8 am, with the Assistant Chief Nursing Officer (ACNO), the ACNO stated he was notified when the "dirty" trash bin was identified in the clean storage room. The ACNO stated "dirty" supplies should not have been stored with the "clean" supplies. The ACNO stated the practice of storing "dirty" equipment in "clean" storage areas increased the potential of cross contamination and the spread of disease.

During a review of the facility policy and procedure (P&P) titled "Equipment- Cleaning and Disinfection of Respiratory Equipment", dated 9/13/22, the P&P indicated, " ... To minimize transmission of infection to patients ... Non-disposable items will be placed inside a sealed biohazard bag, transported to the nearest soiled/ dirty/ utility ... Process ... Removal of non-disposable equipment ... Location ... Dirty Utility ... Instructions ... Place in biohazard bag and transport to nearest dirty utility room ..."