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NORTH SHORE MEDICAL CENTER 1100 NW 95TH ST MIAMI, FL 33150 April 27, 2016
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and the hospital policy review, hospital staff failed to follow the hospital Risk Management program related to grievances and incident/event reporting for 1 of 10 patient records reviewed, Patient #1, as evidenced by staff failing to identify a potentially unsafe volatile situation as a reportable incident involving Patient #1.

The findings include:

Review of the March 2016 Grievance Log revealed an entry dated 03/14/16 by the Risk Manager (RM) related to an incident that occurred on 02/02/16 with Patient #1 and involving Patient #2.

Patient #1 was admitted to a semiprivate telemetry bed on 2/1/16 and had a cardiac procedure done on 2/2/16. Review of the Nursing Notes dated 2/2/16 at 11:34 a.m. documents Patient #1 returned back to the room.

Review of the Nursing Notes for Patient #2 revealed she was admitted on [DATE] from the Emergency Department (ED). in the ED Patient #2 was placed under an involuntary admission as she was assaultive to the ED staff and was ordered a one to one sitter. Further review of the Nursing Notes dated 2/2/16 at 5:21 p.m. Patient #2 was transferred to the telemetry unit due to a medical condition requiring monitoring from the Behavioral Unit into the bed next to Patient #1.

Further review of the Nursing Notes for Patient #1 and Patient #2 did not reveal any documentation of any incident occurring on 2/2/16.

On 4/26/16 at 12:00 p.m. an interview was conducted with the RM inquiring about what the incident was and what investigation was done related to the incident. The RM stated when Patient #2 arrived into the same room with Patient #1, Patient #2 exhibited aggressive physical and verbally racial behavior towards Patient #1. She stated she was advised Patient #2 had a fork and walked up to Patient #1's spouse who stopped Patient #2; security was called and they were separated. She stated Patient #2 was not exhibiting any behaviors when first admitted to the room but soon became agitated. She stated they would have moved Patient #2 out of the room but Patient #1 ended up discharge home. An inquiry was made to the RM if it was appropriate to cohort a patient admitted from the Behavior Unit without a one to one sitter to which she replied it would have been reviewed by the physician and he would determine if a sitter was necessary. Review of the physician orders for Patient #2 revealed an order for a continuous sitter dated 2/2/16 at 3:21 p.m. Further review of the Physician orders revealed an order to discontinue the sitter dated 2/2/16 at 3:46 p.m.

A request was made to the RM to provide the investigation and follow up to the incident. The RM was unable to produce any documentation of an investigation or follow up however stated they had a meeting on 3/14/16 with the Director of Risk Management, interim Chief Nursing Officer, Nurse Director of the 2nd floor telemetry unit, Patient Liaison and Director of Security. The RM stated she was not aware of the incident that occurred on 2/2/16 until 3/14/16 when Patient #1's spouse came to the hospital requesting to have a copy of the incident report that was written on 2/2/16 related to the incident. The RM stated an incident report is an internal document and cannot be given out. She further stated there was not an incident report submitted related to the incident on 2/2/16, so when it came to light on 3/14/16 she wrote it up in the Incident Log. She stated referrals were made to the hospital Patient Liaison and the Director of Security on 3/14/16. The RM stated she had the Director of Security fill out an incident report and submit it on 3/14/16 as that was the first time the Director of Security had heard of this incident also.

On 4/26/16 at approximately 12:10 p.m. in the presence of the RM, an interview was conducted with the Patient Liaison who stated on 3/14/16 he met with Patient #1's spouse. The spouse came to the hospital requesting the incident report however, the Patient Liaison stated he was not aware of any incidents occurring. He stated that is when he got the RM and Director of Security involved. He stated Patient #1's spouse stated there was a discussion with the former Chief Nursing Officer (CNO) around the time of the incident but the CNO has since left the hospital so he explained to the spouse that is probably why there was no follow up or resolution to the incident. The Patient Liaison stated the incident should have been reported to the Director of Security and the RM and he could not explain why it was not. During the interview with the Patient Liaison in the presence of the RM, the RM stated the Director of Security, on 3/14/16, spoke with the 2 Security Officers that responded to the call on 2/2/16 related to Patient #1 and Patient #2 and had them complete an incident report.

On 4/26/16 at 1:17 p.m. an interview was conducted with the Registered Nurse Unit Manager of the telemetry unit. She stated she was informed of the incident the following day by the former CNO. She stated she was told by the former CNO that Patient #1's spouse called the former CNO on 2/3/16 and was told Patient #1 was coming back to the hospital with a medical issue. She was not sure if the former CNO met with Patient #1 during the readmission. She stated an incident report would have been done by who was present at the time of the incident. She confirmed that she did not do any follow up to ensure an incident report was completed.

On 4/26/16 at 1:25 p.m. an interview was conducted with the Security Supervisor who was one of the officers who responded to the security call on 2/2/16. He stated he recalls they received a call at Control Central that a patient was being loud and boisterous so he and another Security Officer responded to the call. He stated Patient #2 was making racial slurs against Patient #2 so they intervened. He stated they were there for about 45 minutes and it was determined that instead of moving the patients apart, Patient #1 was going to be discharged . An inquiry was made to the Security Supervisor if he completed an incident report after the incident happened to which he confirmed he did not and could not explain why he did not.
On 4/26/16 at 2:49 p.m. another interview was conducted with the Patient Liaison, in the presence of the RM, who stated Patient #1 was readmitted on [DATE] for an unknown reason. He stated Patient #1's spouse met with him and told him all about what transpired the night before and Patient #1's spouse said they felt threatened and were in fear for their safety. The Patient Liaison stated the spouse said there was a discussion with the CNO who told Patient #1's spouse he was looking into it. An inquiry was made to the Patient Liaison if he completed an incident report or did any follow up to see if there was an ongoing investigation to which he confirmed he did not follow up on the incident and did not get involved again until 3/14/16 when Patient #1's spouse came back to the hospital requesting a copy of the incident report and that was when he got the RM involved. The Patient Liaison stated he did not have any contact with them after that. The RM stated during the interview with the Patient Liaison at this time that she has had no further contact with Patient #1 or Patient #1's spouse since their discussion on 3/14/16 when she told the spouse that incident reports were internal documents.
On 4/26/16 on the Medical Telemetry Unit, staff interviews were conducted inquiring what they considered to be a reportable incident. The interviews were conducted in the presence of the RM, Administrative Director of Nursing and Clinical Services and the RN Unit Manager of the medical telemetry unit. At 3:42 p.m. an RN did mention verbal abuse would be reportable. The following interviews were conducted with various staff members, all of which did not recite that verbal abuse or aggressive physical behavior was a reportable incident. At 3:45 p.m. interview with a Patient Care Assistant; at 3:48 p.m. an interview with the RN responsible for bed control; at 3:52 p.m. an interview with the unit secretary; at 3:55 p.m., and 3 interviews with monitor technicians in the telemetry room.
On 4/26/16 on the Surgical Telemetry Unit the following interviews were conducted all of which did not recite that verbal abuse or aggressive physical behavior was a reportable incident. At 3:58 p.m. interview with the Unit Secretary; at 4:02 p.m. interview with a RN; at 4:04 p.m. interview with a housekeeper.
On 4/26/16 at 4:12 p.m. and 4:15 p.m. interviews were conducted with 2 Security Officers outside of the Emergency Department. They could not recite verbal abuse or aggressive physical behavior was a reportable incident.
On 4/27/16 at 9:53 a.m. an interview was conducted with the Registered Nurse (RN) from the telemetry unit who stated she responded to the patient's room and discovered there was a commotion going on between Patient #2 yelling racial slurs and waving a fork at Patient #1 so security was called. When security arrived she left the room as Patient #1 was not on her assignment. An inquiry was made if she completed an incident report related to what she observed on that day to which she responded she did not fill out an incident report.
On 4/27/16 at 9:55 a.m. an additional interview was conducted with the RN Unit Manager of the Medical Telemetry unit who reiterated she found out about the incident the following day from the former CNO who was the administrator on call that day and he would have notified the Nursing Supervisor of the incident. She again confirmed she did not follow up to see if an incident report had been completed.
On 4/27/16 at 10:15 a.m. an interview was conducted with the Interim Security Director who stated he first learned of the incident when Patient #1's spouse came to him on March 14 and asked for a copy of the report. He stated that is when he found out a report had never been done so he asked the Security Supervisor who responded to the call on 2/2/16 to write up a report. He stated the Security Supervisor told him the incident had slipped his mind that is why he did not fill out a report. He stated he talked to his staff via an informal brief meeting on March 14 advising them they need to complete a report for all incidents. He stated in this case there was no report as it slipped the Security Supervisors mind but one should have been done.
On 4/27/16 at 11:30 a.m. the personnel records of all the employees who were interviewed on 4/26/16 were reviewed with the Director of Human Resources and Education Coordinator in the presence of the RM. All employees had documentation of up to date in-servicing on Risk Management and Incident/Event Reporting. The RM stated during the review she acknowledged the staff interviewed could not articulate what would be a reportable incident and stated they have some re-education to do.
On 4/27/16 at 3:48 p.m. an interview was conducted with the day shift RN Nursing Supervisor, in the presence of the RM, who was involved in the bed assignment on 2/2/16 for Patient #2. She stated there initially was an order for a sitter for Patient #2 then the physician did an evaluation and determined the patient no longer needed to be under an involuntary admission while on the medical unit. The Behavioral Unit nursing note dated 2/2/16 at 10:24 a.m. was reviewed in the presence of the RN Nursing Supervisor documenting Patient #2 was placed under an involuntary admission as she was assaultive to ED staff. Further review of the physician telephone order, not a face to face written order, dated 2/2/16 at 3:46 p.m., states to discontinue the one to one sitter. Further review of Patient #2's clinical record in the presence of the RN Nursing Supervisor revealed Patient #2 arrived to the medical telemetry unit on 2/2/16 at 5:21 p.m. with the patient to patient altercation initiated by Patient #2 against Patient #1 occurring approximately a half hour after the transfer of Patient #2, without a sitter, to the same room as Patient #1. A request was made to the RM for the investigation and follow up of this incident on 2/2/16 that was brought to her attention on 3/14/16 and any corrective measures that could have been put in place to prevent any similar incidences to which she confirmed there has been no follow up of the incident or with the staff involved since 3/14/16. The RM and RN Nursing Supervisor stated when Patient #2 was admitted from the Behavioral Unit she had received medication to calm her down. When she initially arrived to the telemetry unit she was not exhibiting any behaviors however it looks like the medication was wearing off. The RM and RN Nursing Supervisor acknowledged there was a failure to question or reassess the potential need for a sitter to maintain a safe environment for other patients, visitors and staff.
The RM acknowledged that 2 RNs, 2 Security Officers, RN Nursing Supervisor, RN Telemetry Unit Manager and CNO all failed to follow hospital protocol and policy related to the reporting and documenting of a reportable incident.
Review of the hospital policy titled Event Reporting states in part, 'Reportable event means an event that is not consistent with the routine operation of the Hospital or the routine care of a patient or patients. The potential for accident, injury, illness or property damage commonly referred to as a Near Miss is sufficient for an event to be considered a reportable event.... Any Hospital Staff Member who witnesses, discovers or has direct involvement in and/or knowledge of a reportable event must complete an Event Report. More than one individual may complete a report concerning the same issue.'