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STRATEGIC BEHAVORIAL CENTER-GARNER 3200 WATERFIELD DRIVE GARNER, NC 27529 March 23, 2017
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on policy and procedure review, grievance log review, and staff interviews, the hospital failed to provide a written response to a grievance for 1 of 2 grievances reviewed (#3).

The findings include:

Review of the facility policy on 03/21/2017 titled, "Patient Grievance/Complaint" with revision date of 05/09/2016, revealed "...3. A written response will be provided to the patient within three working days of the initial meeting of the Patient Advocate and the patient. The response will include: Name of the facility contact person. The steps taken on behalf of the patient to investigate the grievance. The results of the grievance process. The date of the completion....When the issue or concern is not resolved at this stage, the Director of Risk Management is responsible for facilitating the Grievance Process as follows: ....Step 3: Within five (5) working days of the Safety-Grievance Comittee Meeting, a response will be provided to the patient or his/her parent/guardian with a written or verabl notice of determiniation regarding the committee's decision communicated in a manner with language the patient and his/her parent/guardian understands...."

Review of open medical record of Patient #3 on 03/21/2017 revealed a 9 year old male admitted on petition of IVC (involuntary committment) on 02/16/2017 for agressive/assaultive behavior and threw chair at teacher in school.

Review of an internal investigation dated 02/24/2017 revealed (Patient #3) reported to (family) that staff has been 'mean,' 'putting me against the wall and 'hitting me.' (Patient #3) mentioned 2 specific staff members...."

Interview on 03/21/2017 at 1515 with (quality compliance risk) revealed the investigation was completed. Further interview revealed a letter regarding outcome has not been sent to (family) of patient.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, electronic mail review and staff interview, nursing staff failed to assess a human bite after a patient altercation; failed to notify the physician of the bite; failed to complete an incident report regarding the incident; and failed to take action to replace a patient's broken eye glasses for 1 of 10 sampled medical records reviewed (#2).

The findings include:

Review of the "Assessment of Patient" policy reviewed/revised May 2016 revealed " ... VIII. Utilization of Staff and Staffing A. 1. Staffing, both in numbers and competency, will be sufficient at all times to ensure that: a. A registered nurse defines, directs, supervises, and evaluates, prescribes, delegates, and coordinates the nursing care of each patient. ... c. Assessment and meeting of patient care needs occurs on admission, during stay, on transfer and at discharge. ..."

Review of a "Nursing Assessment" policy reviewed/revised May 2016 revealed "...Reassessment: ... 2. The RN (registered nurse) reassesses additionally in the following circumstances: ... (a) Change in patient condition (b) Physical complaint ... 3. Assessment documentation is written on the Progress Notes at the time of the assessment."

Review of an "Incident Reporting" policy reviewed/revised May 24, 2016 revealed "... Definition: Incidents - Any unusual or unexpected occurrence that results in injury or potential injury to patients ... and any event that results in damage or loss of hospital property, patient property ... Procedure: A. Employees who witness or are aware of an incident are responsible for completing an Incident Report at the time they become aware of the incident or as soon as the situation is under control. B. An Incident Report must be completed anytime there is a potential injury (regardless of severity) to residents, employees or visitors. ... C. Incident Reports must be completed to include the following information: a. description of the event b. actions taken on behalf of the client c. clients' condition following the event ..."

Closed medical record review of Patient #2 revealed a 7 year-old male that was admitted on [DATE] with oppositional defiant disorder and attention deficit hyperactivity disorder. Review of an admission nursing assessment recorded on 03/03/2017 at 2200 revealed the patient was wearing eye glasses upon arrival. Review of the "Observation Sheets" from March 03 through March 17, 2017 recorded by Mental Health Technicians revealed no documentation of a patient to patient altercation and no documentation regarding a human bite or broken eye glasses. Review of nursing notes from March 03 through March 17, 2017 revealed no documentation of a patient to patient altercation and no documentation or assessment regarding a human bite or broken eye glasses. Review of a nursing note dated 03/18/2017 at 1430 documented by LPN #1 revealed " ... Patient had a visit with Father and Grandmother this morning, this nurse was asked to go speak to family. This nurse spoke to Grandmother and Father who stated they were upset that patient told them that he was bitten by peer and glasses broken. This nurse researched and wasn't able to fine anything. Patient had no evidence of bruising or bite marks to the skin. A small scratch like area was noted at the site. DON (Director of Nursing) was notified of the situation. ..." Review of Therapist #2's Case Management Note dated 03/20/2017 at 1012 revealed "Therapist spoke with (patient's legal guardian, DSS); (Legal guardian) responded to therapist that she had not yet read her e-mail in response to (patient's) glasses and bite. Therapist let (legal guardian) know they were aware of the altercation between (Patient #2) and his roommate; the nurse had looked at the bite immediately after it happened and his glasses were broken and therapist had them, to give back to her. (Legal guardian) confirmed that she will be coming to pick (Patient #2) up this afternoon around 2:00pm to discuss discharge." Review revealed the patient was discharged on [DATE].

Review of an electronic mail dated 03/18/2017 at 1219 from Patient #1's legal guardian (DSS) to Therapist #2 revealed "...(Patient #1's) father has informed me that (Patient #1) has a bite mark and his glasses have been broken by another client in the hospital. Do you all have any record of how the bite mark and the breaking of his glasses occurred? His dad said that he asked the staff member that was there today and they said there were no incident reports detailing the occurrences...." Review of another electronic mail dated 03/20/2017 at 0846 from Therapist #2 to the patient's legal guardian revealed "... Yes; I will provide you with a letter for the school at discharge today and yes; we are aware of the situation that occurred. (Patient #2) had an altercation with his roommate, who was new, at the time. The roommate messed up (Patient #2's) bed, so (Patient #2) went after him and the roommate then bit his arm and his glasses were broken in the process. Nursing staff looked at his arm and examined it immediately after it happened and I have his glasses in my desk. Will see you this afternoon."

Telephone interview on 03/21/2017 at 1440 with LPN #1 revealed Patient #2 had a family visit on 03/15/2017 and she was called to speak with the family. The nurse stated she was told that Patient #2's roommate had bit him on the arm and broken his eye glasses. The nurse stated she looked at the patient's arm and saw a small superficial scratch. The nurse stated she did not see any puncture marks or bruising on the patient's arm. LPN #1 stated she tried to find out what happened and no one knew. The nurse stated she was unable to find the patient's broken eye glasses. Interview revealed a family member told her that the incident with the roommate happened on 03/15/2017 and that the patient told the nurse about it. Interview with the nurse revealed that Patient #2 wore his eye glasses most of the time when she had seen him. She stated she was never able to find the patient's eye glasses. The nurse stated she did not complete an incident report but had reported the incident to the Director of Nursing.

Interview on 03/22/2017 at 1330 with Therapist #2 revealed she knew Patient #2 and was present on the unit during an altercation between Patient #2 and his roommate. The therapist stated the roommate had just been admitted on the day that the incident happened (03/15/2017). The staff member stated the roommate pulled the sheets off Patient #2's bed and they got into an altercation. The therapist stated the roommate bit Patient #2's wrist and broke his eye glasses. The staff member stated the "arm of the glasses was twisted off." Interview revealed the therapist told a male nurse what happened and went into the room to assess the bite. The therapist was not able to remember if Patient #2's skin was broken. The therapist stated she took the broken eye glasses and put them in a bag in her drawer. Interview revealed the therapist notified Patient #2's legal guardian (DSS) on 03/20/2017.

Interview on 03/22/2017 at 1430 with the Director of Nursing (DON) revealed LPN #1 had notified her that Patient #2 had been bitten by his roommate on 03/15/2017. Interview revealed she had talked with the patient's family on 03/18/2017 when the family reported the altercation with the roommate. Interview with the DON revealed the registered nurse who was working at the time of the incident no longer worked at the hospital. Interview revealed the DON had attempted to contact the nurse for interview and he was not able to be reached. Interview with the DON revealed she was unable to find any nursing assessment of Patient #2 after he was bitten by his roommate on 03/15/2017. Interview revealed there was no documentation of an altercation between Patient #2 and his roommate, no evidence that the physician was notified of a human bite, no record of treatment provided and no incident report written. The DON stated the nurse should have documented an incident report, assessed and documented the patient after the bite and notified the physician and legal guardian. The DON stated the therapist should have notified the legal guardian about the broken eye glasses and made provisions to get replacement eye glasses.

NC 233 and NC 881