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JACKSON MEMORIAL HOSPITAL 1611 NW 12TH AVE MIAMI, FL 33136 April 7, 2016
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record/policy review and interview the facility failed to report/respond to an allegation of abuse and ensure the patient right to receive care in a safe setting and free from all forms of abuse in 1 of 2 sampled patients (SP#2).


Findings:

Review of Sampled Patient (SP) #2 medical record showed that she was admitted on [DATE] under Baker Act (BA) and later became voluntary. Review of the progress notes dated 02/25/2016 at 18:50 pm reported that patient (SP#2) states she was hit in head by another patient (was not observed by staff). This writer assessed the head/face and no injury was observed. Tylenol was given. Dr. [named], charge nurse and other team members were notified. This patient is closely monitored by staff. Review of the progress notes dated 02/25/2016 at 19:34 pm reported that patient appears to be doing good, but she got mad in the beginning because another patient apparently hit her in her forehead and her shoulder. She seemed to be okay.

The Nurse Manager of Behavioral Tower (BT)3 on 04/6/2016 at 3:15 PM stated that SP #2 said that another patient hit her. This was reported. Nursing assessment showed no bruising. The other patient was put back in the quiet room after he punched her. Psychiatrist was notified; Tylenol was ordered.
Review of the facility's reporting system on 04/6/16 at 15:45 confirmed above findings that an incident of SP#2 occurred on 02/25/16 at 16:15 and was reported on 02/25/2016 at 19:19 by the Registered Nurse (RN) staff F as follows: Pt. (SP #2)claims she was punched in the head by another pt. (not observed by staff). Pt. reports mild headache, Tylenol given. Head/face was assessed and no visible injuries noted. Psychiatrist was called and notified, no further orders given. Charge Nurse and other team members were also made aware.

Review of the Sampled Patient (SP) #1 physician progress notes dated 02/23/2016 at 08:19 am showed that SP #1 had a history of aggressive behavior and hitting other patient at an ALF (Assisted Living Facility). The notes also report that the patient is a danger to self and others.

Sampled Patient #1 (who was reported as the one who hit SP #2) on the date of the incident his progress notes reported on 02/25/2016 at 16:25 pm, that patient (SP#1) has been restless, angry, loud, difficult to redirect. Pt attempted to hit another pt. He was taken to his room for 20 minutes until he was more in control of his behavior. He is closely monitored by staff.

There were 2 incidents submitted regarding the pt. (SP #1) observed fall and aggression while being aggressive towards staff and fall incident report on 02/27/16. Follow up investigation - pt. fell while being aggressive towards staff at time of incident he was on fall precaution appropriate to his risk factors.

Interview with Risk Manager on 4/6/2016 at 12:30PM regarding SP# 1 revealed he was admitted on [DATE] admitted involuntarily under Baker Act with aggressive behavior hitting staff and was transferred here; pt. was incontinent of bowel and bladder and pt. incoherent mumbling with limited insight. Pt still exhibiting with behavior that is a threat to self or others .
SP #1 behavior continued with aggression towards staff and expresses poor boundaries required multiple intramuscular every day since admission and from time pt. fell , pt. inconsistently accepting oral meds as ordered and for this reason staff giving intramuscular injections; On 2/27/16, at 05:11, during routine q (every 15 minutes rounds pt. was found had voided on his bed and himself, was agitated and not responding to redirection; when staff attempted to move him to be cleaned up, he lunged at staff member lost his balance and fell on his right side; staff helped him to his feet and escorted to the bathroom to clean him up; Upon assessment, the RN (Registered Nurse) noted that pt. complaint of shoulder pain and called the Medical Doctor ( MD ) and ordered to send to emergency room ( ER ); the radiology report confirmed " chronic " Fracture deformity and of distal radius and highly commuted fracture of humeral neck and possible with half shaft medial displacement of the distal fragment.

Interview with Social Worker 1 on 4/6/2016 at 1:00 PM revealed that the patient (SP #1) stands out; attacking patients every day; patient was loud; day to day with him was a challenge.


Interview with RM( Risk Manager) on 4/6/2016 at 12:30PM regarding SP# 1 revealed he was placed close to the nurse's station and close every 15 minute monitoring continues.

Record review of Jackson Health System Clinical Rounds of Behavioral Health Hospital dated 02/20/2016 to 03/3/2016 showed every 15 minute observation of his behavior and location by different staff are noted. (sampled patient #1 was not placed on one to one supervision or with constant supervision)

In an interview questions via e-mail on 04/ 21/2016 at 11:25 with the Chief Nursing Officer (CNO) Behavioral Unit revealed that this physical abuse was not called to the Abuse Hot line; making of the allegation of being hit should have been called. The staff did not call as she (SP #2) was voluntary and there was no evidence of injury or abuse. They believed the allegation was part of delusions. Department of Children's and family (DCF) was not called.

Review of the facility's policy and procedure section Code No. 400 .001; subject: Identification and Assessment of Adult Victims of Abuse showed Policy: It is the policy of (name of facility) that all employees particularly health care professional, identify, assess and report cases where there is cause to suspect abuse, neglect or exploitation of vulnerable adults in accordance with the Adult Protective Service Act, Chapter 415 Florida Statutes.
It is also the responsibility of all employees to identify and assess any adult patient who may be the victim of abuse but who does not fall under the protection of the Adult Protective Service Act. This includes victims of domestic abuse, physical assault and sexual molestation.
Procedure:1. B. In accordance with the Adult Protective Service Act, it is the responsibility of any ( name of facility ) employee to report alleged or suspected abuse to the Department of Children ' s and Family ( DCF's) Abuse Hotline 1-800-96-ABUSE, which is available 24 hours per a day, 7 days a week. The report may be made by any employee directly. This report shall be documented in the patient's medical record reflecting the date the report was made and the name and 3 digit I.D. number of the DCF worker accepting the report."

Review of the facility's policy and procedure Code No. 400.005-Section: 400.00- Care Of The Patient: Subject: Patient's Rights And Responsibilities - showed that The hospital and its governing body support the following rights: receive care in a safe setting.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the nursing staff failed to provide supervision to meet the needs of 2 sampled patients (SP #1 and SP #2).

Findings:

Review of Sampled Patient (SP) #2 medical record showed that she was admitted on [DATE] under Baker Act (BA) and later became voluntary. Review of the progress notes dated 02/25/2016 at 18:50 pm reported that patient (SP#2) states she was hit in head by another patient (was not observed by staff). This writer assessed the head/face and no injury was observed. Tylenol was given. Dr. [named], charge nurse and other team members were notified. This patient is closely monitored by staff. Review of the progress notes dated 02/25/2016 at 19:34 pm reported that patient appears to be doing good, but she got mad in the beginning because another patient apparently hit her in her forehead and her shoulder. She seemed to be okay.

The Nurse Manager of Behavioral Tower (BT)3 on 04/6/2016 at 3:15 PM stated that SP #2 said that another patient hit her. This was reported. Nursing assessment showed no bruising. The other patient was put back in the quiet room after he punched her. Psychiatrist was notified; Tylenol was ordered.

Review of the facility's reporting system on 04/6/16 at 15:45 confirmed above findings that an incident of SP#2 occurred on 02/25/16 at 16:15 and was reported on 02/25/2016 at 19:19 by the Registered Nurse (RN) staff F as follows: Pt. (SP #2)claims she was punched in the head by another pt. (not observed by staff). Pt. reports mild headache, Tylenol given. Head/face was assessed and no visible injuries noted. Psychiatrist was called and notified, no further orders given. Charge Nurse and other team members were also made aware.

Review of the Sampled Patient (SP) #1 physician progress notes dated 02/23/2016 at 08:19 am showed that SP #1 had a history of aggressive behavior and hitting other patient at an ALF (Assisted Living Facility). The notes also report that the patient is a danger to self and others.

Sampled Patient #1 (who was reported as the one who hit SP #2) on the date of the incident his progress notes reported on 02/25/2016 at 16:25 pm, that patient (SP#1) has been restless, angry, loud, difficult to redirect. Pt attempted to hit another pt. He was taken to his room for 20 minutes until he was more in control of his behavior. He is closely monitored by staff.

There were 2 incidents submitted regarding the pt. (SP #1) observed fall and aggression while being aggressive towards staff and fall incident report on 02/27/16. Follow up investigation - pt. fell while being aggressive towards staff at time of incident he was on fall precaution appropriate to his risk factors.


Interview with Risk Manager on 4/6/2016 at 12:30PM regarding SP# 1 revealed he was admitted on [DATE] admitted involuntarily under Baker Act with aggressive behavior hitting staff and was transferred here; pt. was incontinent of bowel and bladder and pt. incoherent mumbling with limited insight. Pt still exhibiting with behavior that is a threat to self or others . SP #1 behavior continued with aggression towards staff and expresses poor boundaries required multiple intramuscular every day since admission and from time pt. fell , pt. inconsistently accepting oral meds (by mouth) as ordered and for this reason staff giving intramuscular injections; On 2/27/16, at 05:11, during routine q (every) 15 minutes rounds pt. was found to had voided on his bed and himself, was agitated and not responding to redirection; when staff attempted to move him to be cleaned up, he lunged at staff member lost his balance and fell on his right side; staff helped him to his feet and escorted to the bathroom to clean him up; Upon assessment, the RN (Registered Nurse) noted that pt. complaint of shoulder pain and called the Medical Doctor ( MD ) and ordered to send to emergency room ( ER ); the radiology report confirmed "chronic" Fracture deformity and of distal radius and highly commuted fracture of humeral neck and possible with half shaft medial displacement of the distal fragment.

Interview with Social Worker 1 on 4/6/2016 at 1:00 PM revealed that the patient (SP #1) stands out; attacking patients every day; patient was loud; day to day with him was a challenge.


Interview with RM ( Risk Manager) on 4/6/2016 at 12:30PM regarding SP# 1 revealed he was placed close to the nurse's station and close every 15 minute monitoring continued.

Record review of Jackson Health System Clinical Rounds of Behavioral Health Hospital dated 02/20/2016 to 03/3/2016 showed every 15 minute observation of his behavior and location by different staff are noted. (sampled patient #1 was not placed on one to one supervision or with constant supervision)