HospitalInspections.org

Based on review of policies, documents, and medical records, and interview with patients and staff, the staff working in the psychiatric unit failed to follow hospital policies at the time a patient reported an incident of inappropriate physical contact with another patient (Patient #7). The psychiatric unit's Program Director reported the psychiatric unit had a census of 8 patients at the time Patient #7 reported the incident.

Failure to follow the hospital's policies related to patient complaints resulted in a delay of an internal investigation of the reported incident until the allegation was reported to the hospital by an outside source. The failure to follow hospital policies potentially allowed the inappropriate behavior to continue in the unit.

Findings include:

1. Patient #7's medical record included the following information. The history and physical, dated 12/1/14, included diagnoses of major depressive disorder and extensive history of abuse. The patient's attending psychiatric physician (Practitioner B) documentation on 11/30/14 at 7:13 AM included the statement "the patient does get anxious around a peer who is restless."

Nursing progress notes, dated 11/29/14 at 1:42 PM, revealed Patient #7 made a comment at breakfast about not feeling safe around one of the other patients of the opposite sex. A nursing progress notes, dated 11/29/14 at 6:23 PM, revealed the patient was crying in dinning room. The nurse administered an anti-anxiety medication at the time. Later, Patient #7 came back up to the desk and reported the anxiety was caused by another patient and about the way he was holding his walker."

The nursing flow sheets documented the Patient #7's level of consciousness as alert and oriented to person from the time of Patient #7's admission to the hospital on 11/26/14 until the time of discharge on 12/2/14 .

2. The hospital had policies in place for staff to follow when potential incidents of abuse were witnessed or reported.

a. The policy titled "Patient Rights and Responsibilities, revised 2/13, revealed the following guidance. Patients have the right to be free from all forms of abuse and to voice concerns to direct caregivers where care is rendered.

b. The policy titled, "Assessment and Plan of Care of the Patient", revised 12/13, revealed the following guidance for screening abuse. If the patient indicates a feeling of being threatened or abused, a referral to Social Services should be made and a physical reassessment should be completed in response to a change in condition or status.

c. The policy titled "Reporting Occurrences or Events" revised 9/13, revealed the following guidance. Every employee is responsible for completing an occurrence report when appropriate. The risk manager will be called immediately with reports of a sexual assault on a patient. A document titled "Competency Assessment/Job Description" included the guidance for the psychiatric staff responsibilities. "...assess for signs and symptoms of abuse." The policy titled, "Child/Dependent Adult Abuse" reviewed 7/14, included guidance for all staff. General criterion is used for the purpose of identifying signs of potential abuse including unusual fearful behavior by the patient.

3. During a telephone interview with Patient #7 on 1/13/15 at 1:30 PM, the patient reported being on the psychiatric unit at the hospital in December (2014) when a patient of the opposite sex touched him/her inappropriately. Patient #7 was unable to identify the name of the other patient but reported the patient walked with a walker. Patient #7 reported telling one of the staff what happened. Patient #7 was unable to identify the name of the staff member.

During an interview on 1/13/15 at 7:00 AM, Staff C, Director of Quality, said the competency based assessment are reviewed upon hire, at ninety days, at one year, and annually. During an interview on 1/20/14 at 12:45 PM, Staff C verified all hospital staff received education on documentation of unusual events and any reports of inappropriate touching and/or sexual assault upon hire and annually. Staff C said they would expect all staff to complete an occurrence report if a patient reported inappropriate touching.

During an interview on 1/13/15 at 7:40 AM, Staff C acknowledged the hospital received the report of patient to patient suspected abuse that occurred on the psychiatric unit in November of 2014. The hospital staff was contacted by the facility where Patient #7 resided after discharge from the hospital. Staff C reported the incident was investigated after receiving the report and determined it was unfounded. The staff reported the allegations to the police.

During an interview on 1/14/15 at 8:45 am, Staff O, MHT (Mental Health Tech), reported the following information. On 11/30/14, Patient #7 told her about inappropriate physical contact with another patient and feeling scared. Staff O reported telling Staff Q, a Licensed Practical Nurse (LPN) and Staff U, Registered Nurse (RN), about the patient's report but Staff O did not document the report in the patient's medical record or complete an occurrence report because the patient had attention seeking behaviors. Staff O acknowledged failing to follow hospital policies for reporting the report of inappropriate physical contact between the two patients.

During an interview on 1/14/15 at 9:35 AM, Staff P, Program Director of the Psychiatric Unit, reported the hospital was contacted on 12/2/14 regarding a complaint of inappropriate and unwanted contact with a patient of the opposite sex from Patient #7 after discharge. Staff P said they began an investigation and discovered the patient had informed the unit staff of the incident while the patient was still in the hospital.

During an interview on 1/14/15 at 11:00 AM, Staff Q, LPN said Patient #7 told her on 11/30/13 at approximately 8:00 PM that another patient made him/her feel nervous and afraid. Staff Q said Staff O told her that Patient #7 reported another patient had touched him/her inappropriately later on in the shift that night. Staff Q acknowledged she failed to file and incident report, assess the patient to determine if there were any injuries, and contact the nursing supervisor and the Program Director of the psychiatric unit. Staff Q said the patient had a history of attention seeking behaviors and she felt there was no "validity" to the patient's complaint.

During an interview on 1/14/15 at 2:55 PM, Staff U, RN reported overhearing a conversation between Staff O and Staff Q regarding a complaint from Patient #7 of inappropriate contact with another patient. Staff U said as the charge nurse that night he failed to follow up with both staff to ensure they documented the incident on an incident report and contact the Program Director for the psychiatric unit. Staff U acknowledged he failed to follow hospital policies including patient rights, incidents, and abuse. Staff U said the patient was attention seeking and he "knew" it didn't happen.

Based on review of policies, documents and medical records, and interview with a patient, a family member, and staff, the medical surgical nursing staff failed to follow their policy to obtain a physician's order for the use of behavioral restraints for 1 of 1 surgical patient hospitalized at the time of the complaint investigation(Patient #3) and the intensive care staff failed to follow their policy and obtain a physician order for the use of behavioral restraints for 2 of 2 intensive care patients within the past year. (Patient #1 and #2).

The Medical Surgical Nursing Director identified one open medical record of a patient with behavioral restraints (Patient #3). There were no other patients with behavioral restraints on the Medical Surgical Unit within the past year. The Director of Quality identified two closed medical records for patients with behavioral restraints while receiving care in the intensive care unit for the past year (Patients #1 and #2).


Findings include:

1. The hospital policy titled "Patient Rights and Responsibilities" revised 2/13, revealed the following in part, ..."as a patient...you have the right to...be free from restraints."

The Medical Staff Policies and Procedures, revised 12/09, revealed the following in part, ..."Orders for restraints and care of patients in restraints must comply with current hospital policy."

The policy titled "Restraints in the Hospital and Application Patient Care" revised 6/14, revealed the following in part, ..."all usage of restraints...require a Physician or Advanced Registered Nurse Practitioner order."

2. Patient #3's medical record lacked evidence of a physician's order for application of 4-point behavioral restraints on 1/10/15. A nursing progress note dated 1/10/15 at 9:00 PM written by Staff J, Registered Nurse (RN), indicated the staff went to patient's room to reposition the patient and give medications. The patient refused to be repositioned and take medications. Then the patient started getting very agitated. The documentation described the patient as aggressive, kicking, arms swinging, verbally loud, and removing the O2 (oxygen). The nurse activated Code Strong, a security measure activating a group of employees to respond to the area where a potential patient safety concern may be occurring. Staff N, RN and House Supervisor, called the patient's spouse. The patient's spouse came to the hospital and stayed at the bedside trying to calm the patient.

Practitioner A, a physician, was notified on 1/10/15 at 9:30 PM. The physician documented in Patient #3's medical record...Tonight, the patient is agitated. The nursing staff notified the physician because of Patient #3's agitation.

3. During an interview with Patient #3 on 1/12/15 at 8:50 AM, the patient reported wanting to know why nursing staff tied his/her arms and legs to the bed last Saturday night, 1/10/15. Patient #3 reported being appalled that the staff could to that, had no idea why they did it, and felt demoralized at the time. Patient #3 recalled pleading with the staff to release the restraints and it was only after the patient's spouse arrived that the restraints were removed.

During an interview on 1/13/15 at 5:15 PM, Patient #3's spouse reported receiving a call from the hospital on 1/10/15 at 10:00 PM. The caller requested that the patient's spouse come to the hospital to help the patient calm down. The patient's spouse came to the hospital, arriving at approximately 10:30 PM. Patient #3's arms and legs were tied down to the bed and there were 6 staff members standing around the bed. The patient appeared frightened. The patient's spouse recalled leaving the hospital earlier that day at 6:30 PM. The patient was still groggy from a sedative given earlier that day for tests. The patient's spouse thought it very likely the patient became startled when the nurse came to the room that evening to give medications causing the staff to believe the patient was agitated. The staff removed the restraints within 10-15 minutes after the patient's spouse arrived at the bedside.

4. During an interview on 1/12/15 at 1:00 PM, Staff H, RN said behavioral restraints are used when a patient is exhibiting out-of-control behavior that may compromise the patient's safety or their ability to treat the patient's underlying problems. Staff H said the types of restraints most frequently use throughout the hospital were the soft release Velcro restraints that may be applied to the patient's lower and upper limbs by their wrists and ankles and then tied to the bed frame.

During an interview on 1/14/15 at 6:25 AM, Practitioner A acknowledged responding to a Code Strong for Patient #3 on 1/10/15 at approximately 10:30 PM. Practitioner A reported Patient #3 was restrained with 4-point restraints and the patient was clearly upset. Practitioner A acknowledged he failed to place an order for behavioral restraints in the patient's medical record according to hospital policy. Practitioner A said the patient's spouse asked him to remove the restraints because the patient appeared to be calm. They removed the restraints. Practitioner A said when he left the unit it was 10:40 PM, and the patient was alert, and stable, but remained extremely upset over the incident.

During an interview on 1/14/15 at 7:15 AM, Staff J, RN, said she provided care and services for Patient #3 on 1/10/15 from 6:30 PM to 7:00 AM on 1/11/15. She said the patient was groggy most of the shift until 9:30 PM when the nursing staff went in to reposition the patient in bed and administer medications. She said the patient appeared very weak and very sleepy. When attempting to complete their tasks, the patient's arms and legs were flailing, the patient started yelling, and removing the oxygen. The patient refused to take medications or cooperate with repositioning. Staff J left the patient's room, informed Staff K, RN, about the patient's status, and a Code Strong was activated. Staff applied behavioral restraints applied. Staff J administered an injection of Haldol to help calm the patient. The patient cooperated with the injection but was still yelling "leave me alone, please don't tie me down". She said the patient's spouse arrived at 10:30 PM, spoke with the patient and shortly afterwards the restraints were removed. Staff J acknowledged she failed to obtain a physician's order for restraints according to hospital policy.

During an interview on 1/14/15 at 9:10 AM, Staff K, RN, reported he entered Patient #3's room and the patient's arms and legs were flailing, the patient was screaming, removing the oxygen, and hitting staff. Staff K attempted to engage the patient in conversation however the patient's behavior continued to escalate and they were concerned for the patient's safety. Staff activated Code strong and applied 4-point behavioral restraints. Staff K acknowledged failing to obtain a physician's order for restraints according to policy.

During an interview on 1/14/15 at 2:20 PM, Staff L, Nursing Director for the Unit, said she was not aware nursing staff had applied behavioral restraints for Patient #3 on 1/10/15 until 1/13/15. Staff L acknowledged nursing staff failed to obtain a physicians order and follow the hospital restraint policies.

During an interview on 1/15/15 at 12:30 PM, Staff N, RN/House supervisor reported responding to a Code Strong on the night of 1/10/14. When Staff N arrived she observed Patient #3 restrained by 4 point behavioral restraints and the patient appeared very agitated. She recalled telling Staff J and K to obtain a physicians order and document what occurred in the patient's medical record.

5. Patient #1's medical record included the following information. The History and Physical, dated 4/2/14, revealed the patient presented to the emergency room with confusion and agitation after a fall. The patient was admitted to the intensive care unit at 4:00 PM for care.

A restraint flow-sheet, dated 4/2/14, included documentation showing nursing staff applied 2-point behavioral restraints to Patient #1's right and left wrist at 9:00 PM related to restlessness, hallucinations, confusion, verbal threats to staff, and physical aggressive behaviors towards staff. Nursing staff continued to monitor the patient until the behaviors until the behaviors improved and the restraints were discontinued at 1:00 AM on 4/3/14.

Patient #1's medical record lacked a physician's order for the use of behavioral restraints. During an interview on 1/20/15 at 1:05 PM, Staff M, RN, acknowledged the Patient #1's medical record lacked a physicians order for use of behavioral restraints.

6. Patient #2's medical record revealed the following information. The History and Physical documentation, dated 3/5/14, revealed the patient presented to the emergency room accompanied by police for due to altered mental status. The patient was admitted to ICU at 4:47 PM for further treatment and evaluation and management of an episode of altered mental status, anxiety and manic behaviors.

A restraint flow-sheet, dated 3/5/14 at 4:47 PM, indicated that 4 point behavioral restraints were used on Patient #2's upper and lower extremities for aggressive and verbally abusive behaviors, hallucinations, delusions and imminent harm to self. The nursing staff continued to monitor the patient until the the lower extremity restraints were removed on 3/5/14 at 10:00 PM. The patient was in the 4-point restraints for a total of 5 hours 13 minutes hours. The upper extremity restraints removed on 3/6/14 at 4:30 AM.

Patient #2's medical record lacked a physicians order for use of the behavioral restraints.

During an interview on 1/20/15 at 1:40 PM, Staff S, RN, said she provided nursing care and monitored Patient #2 when admitted to the ICU on 3/5/14 through the morning of 3/6/14. Staff S said the patient had the restraints on when the patient arrived in the ICU unit from the emergency room. Staff S acknowledged she failed to check the medical record for a physicians order for the restraints and failed to follow the restraint policy. Staff S said nursing staff are responsible for contacting the physician if they can not locate an order for restraints.

During an interview on 1/20/15 at 1:50 PM, Staff M, acknowledged Patient #2's medical record lacked a physicians order for use of behavioral restraints and the physician failed to follow the hospital's restraint policy.

Based on review of policies and medical records, and staff interviews intensive care physicians failed to reassess and evaluate the continued need for behavioral restraint use for 1 of 1 closed Intensive Care Unit (ICU) patients (Patient #2).

The Director of Quality identified two patients in behavior restraints while in the the ICU during the past year.

Findings include:

1. Review of Medical Staff Policies and Procedures, revised 12/09, revealed the following in part, ..."Orders for restraints and care of patients in restraints must comply with current hospital policy."

Review of policy titled "Restraints in the Hospital and Application Patient Care" revised 6/14, revealed the following in part, ..."all usage of restraints...require a physician, Advanced Registered Nurse Practitioner (ARNP) or a qualified Physician's Assistant orders for violent and self destructive behaviors must be time specific with a maximum limitation for...4 hours for adults...the evaluation of the patient's medical condition would include a complete review of systems assessment, behavioral assessment, as well as review and assessment of the patient's history, drugs, medications, most recent lab results etc. The purpose would be to complete a comprehensive review of the patient's condition to determine other factors...that may be contributing to the patient's violent or self-destructive behavior.

2. Patient #2's medical record revealed the patient presented to the emergency room due to altered mental status on 3/5/14. The patient was admitted to the ICU at 4:47 PM for further treatment and evaluation and management of an episode of altered mental status, anxiety and manic behaviors.

Patient #2's restraint flow-sheet, dated 3/5/14 at 4:47 PM, revealed 4-point behavioral restraints were applied to Patient #2's upper and lower extremities for aggressive and verbally abusive behaviors, hallucinations, delusions and imminent harm to self. Nursing staff continued to monitor the patient until the the lower extremity restraints were removed on 3/5/14 at 10:00 PM. The upper extremity restraints removed on 3/6/14 at 4:30 AM.

The patient's medical record lacked a physician's revaluation of the patient every 4 hours after the application of the 4 point behavioral restraints and a physician's renewal order for continued need of behavioral restraints.

3. During an interview on 1/15/15 at 11:00 AM, Staff M, RN, confirmed the medical record lacked renewal orders from the physician for continued use of the restraints. During a follow up interview on 1/20/15 at 1:45 PM, Staff M, acknowledged the Patient #2's medical record lacked a physician's revaluation/reassessment of the patient's condition and a renewal order for behavioral restraints.

Based on review of policies, review of closed medical records, and staff interviews the intensive care physicians failed to conduct a face-to-face evaluation within 1 hour after the initiation of behavioral restraints for 2 of 2 patients receiving care in the Intensive Care Unit (Patients #1 and #2).

The Director of Quality reported there two closed medical records with behavioral restraint records at the time of the investigation (Patient #1 and #2) on the intensive care unit for the past year.

Findings include:

1. The Medical Staff Policies and Procedures, revised 12/09, revealed the following in part, ..."Orders for restraints and care of patients in restraints must comply with current hospital policy."

The policy titled "Restraints in the Hospital and Application Patient Care" revised 6/14, revealed the following in part, ..."all usage of restraints...require a physician, Advanced Registered Nurse Practitioner (ARNP) or a qualified Physician's Assistant must conduct a face-to-face evaluation within 1 hours after the initiation of a restraint."

2. Patient #1's medical record revealed the following information.

The History and Physical documentation, dated 4/2/14, revealed the patient presented to the emergency room with confusion and agitation after a fall. The patient was admitted to the Intensive Care Unit (ICU) at 4:00 PM for evaluation and management of acute encephalopathy and severe hypokalemia.

A restraint flow-sheet, dated 4/2/14, revealed nursing staff applied 2 point behavioral restraints to Patient #1's right and left wrists at 9:00 PM related to restlessness, hallucinations, confusion, verbal threats to staff, and physical aggressive behaviors to staff. Nursing staff continued to monitor the patient until the behaviors until the behaviors improved and the restraints were discontinued at 1:00 AM on 4/3/14.

The patient's medical record lacked a face-to-face evaluation within 1 hour after the initiation of the restraints and a physician's review of the patient's condition to determine factors that may be contributing to the patient's violent or self destructive behavior.

During an interview on 1/20/15 at 1:05 PM, Staff M, Director of Critical Care, acknowledged the Patient #1's medical record lacked a physician's face to face within one hour after application of the behavioral restraints and revaluation of the patient by the physician to to determine if there were other factors contributing to the patient's behaviors. Staff M acknowledged the physician failed to follow hospital policies.

3. Review of Patient #2's medical record revealed the following information.

The History and Physical, dated 3/5/14, documentation revealed the patient presented to the emergency room accompanied by police due to an altered mental status. The patient was admitted to ICU at 4:47 PM for further treatment, evaluation, and management of the patient's altered mental status, anxiety, and manic behaviors.

A restraint flow-sheet, dated 3/5/14 at 4:47 PM, 4 point behavioral restraints applied to Patient #2's upper and lower extremities for aggressive and verbally abusive behaviors, hallucinations, delusions and imminent harm to self. Nursing staff continued to monitor the patient until the the lower extremity restraints removed on 3/5/14 at 10:00 PM. The upper extremity restraints removed on 3/6/14 at 4:30 AM.

The patient's medical record lacked a face-to-face evaluation within 1 hour after the initiation of the restraint and a physician's comprehensive review of the patient's condition to determine factors that may be contributing to the patient's violent or self destructive behavior.

During an interview on 1/20/15 at 1:45 PM, Staff M, verified Patient #2's medical record lacked a physician's face-to-face within one hour after application of the behavioral restraints and a revaluation of the patient by the physician to to determine if there were other factors contributing to the patient's behaviors.