The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

O U MEDICINE 700 NE 13TH STREET OKLAHOMA CITY, OK 73104 July 27, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review and interview, the hospital failed to:

1) Ensure nursing staff performed nursing interventions such as assess for need of PRN (as needed) medications or one to one time according to the plan of care for one out of 20 records reviewed (Patient # 13). See Tag - 0144

2) Ensure the facility completed an investigation of physical restraint on 06/16/18 to include behaviors that lead up to restraint, date, time, location of occurrence with interventions and response of patient for one out of 20 records reviewed (Patient # 13). Tag - 0145
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on record review, observation, and interview, the hospital failed to ensure nursing staff performed nursing interventions such as assess for the need of PRN (as needed) medications or an order for one to one precautions according to the plan of care for one out of 20 records reviewed (Patient # 13)

This failed practice had the likelihood to for patient # 13 to be at risk for unsafe and non-therapeutic outcomes and interventions.

Findings:

A policy titled "Restraints and Seclusion" says a physical restraint is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient's body that he/she cannot easily remove that restricts freedom of movement or normal access to one's body to include immobilization or reduction of the ability of a patient to move his/her arms, legs, body, or head freely is considered a physical restraint.


A policy titled "Restraints and Seclusion" says the plan of care will clearly reflect a loop of assessment, intervention, and evaluation for restraint, seclusion and medications.


Patient # 13

A review of hospital video showed on 06/16/18, Staff M and Patient # 13 having a conversation. Staff M was leaning against the wall and patient # 13 was standing in front of Staff M. Patient # 13 had his/her hands on hips. Then patient # 13 began talking with his/her hands. Staff M walked off but turned back around to face and walk towards patient # 13. At that point, Staff M put patient # 13 into a physical hold for approximately 11-12 seconds and walking patient back up against wall in the hallway of unit. Other nursing staff came to assist and Staff M walked away. Another nurse, who no longer works at facility, walked patient down to the group room. A few minutes later, Staff M walked down to group room and says something to the nurse or patient in the group room. The nurse walks out of the group room. Staff M and the nurse are arguing. After the argument is over, Staff M walks down the hall and the other nurse goes back into the room with the patient.


A review of patients plan of care shows no documentation of assessment, intervention and evaluation for restraint.


On 07/26/18 at 12:15 pm, Staff N stated the charge nurse should have documented incident in the RL Solution; the other nurse should have put in an incident report about his/he interaction with patient.


On 07/26/18 at 3:15 pm, after observation of video Staff I stated yes that is a hold; the correct technique for a hold is two staff on the side or behind patient.


On 07/26/18 at 3:15 pm, Staff I stated whenever an incident happens the nurse who takes care of the patient is liable to make sure he/she documents the event.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review and interview, the hospital failed to ensure patient # 13 was not harassed by Staff M for 1 of 20 (Patient # 13) records reviewed.

This failed practice resulted in the facility not protecting patient # 13 from harassment by Staff M.


Findings:


A policy titled "Protecting Patients from Abuse, Neglect, and Harassment" says OU Medical System ensures, in a timely and thorough manner, objective investigation of all allegations of abuse, neglect or mistreatment...assures that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law.


A review of the policy titled "Protecting Patients from Abuse, Neglect, and Harassment" says that any incidents of abuse, neglect or or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law.


Patient # 13


A review of hospital video showed on 06/16/18 Staff M and Patient # 13 having a conversation. Staff M was leaning against the wall and patient # 13 was standing in front of Staff M. Patient # 13 had his/her hands on hips. Then patient # 13 began talking with his/her hands. Staff M walked off but turned back around to face and walk towards patient # 13. At that point, Staff M put patient # 13 into a physical hold for approximately 11-12 seconds and walking patient back up against wall in the hallway of unit. Other nursing staff came to assist and Staff M walked away. Another nurse, who no longer works at facility, walked patient down to the group room. A few minutes later, Staff M walked down to group room and says something to the nurse or patient in the group room. The nurse walks out of the group room. Staff M and the nurse are arguing. After the argument is over, Staff M walks down the hall and the other nurse goes back into the room with the patient.


The hospital staff notified patient # 13 family. The local police were called to investigate an adverse event of alleged abuse.


On 07/24/18 at 8:30 am, surveyors requested a copy of the investigation for alleged patient abuse. A copy of the investigation was not provided to surveyors.


On 07/26/18 at 2:45 pm, Staff B stated, the investigation itself is not being conducted as a protected patient safety work product, but in conjunction with the Edmond Police Department investigation.


On 07/26/18 at 2:45, Staff B stated, I do not have what you need.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on record review and interview, the hospital failed to ensure a written investigation of alleged abuse, unsafe situation and falls for five of 20 (Patient # 13, 17, 18, 19, 20 and 21) records reviewed.

This failed practice resulted in the facility not completing an investigation regarding an adverse event of alleged abuse, an unsafe situation and falls.


Findings:


A policy titled "Patient Safety Plan 2018" says patient safety committees perform ongoing assessment, using internal and external sources to prevent error occurrence, and to improve patient safety.


A policy titled "Occurrence Reporting" says an occurrence is defined as any event that results in injury or potential injury to a patient, non-patient (visitor, physician, resident, student, or volunteer), or employee...Patient occurrences should be communicated by completing a Patient Notification in RL Solutions (RLS - adverse occurrences involving patients, non-patients and employees).


Alleged Abuse

Patient # 13

A review of hospital video showed on 06/16/18 Staff M and Patient # 13 having a conversation. Staff M was leaning against the wall and patient # 13 was standing in front of Staff M. Patient # 13 had his/her hands on hips. Then patient # 13 began talking with his/her hands. Staff M walked off but turned back around to face and walk towards patient # 13. At that point, Staff M put patient # 13 into a physical hold for approximately 11-12 seconds and walking patient back up against wall in the hallway of unit. Other nursing staff came to assist and Staff M walked away. Another nurse, who no longer works at facility, walked patient down to the group room. A few minutes later, Staff M walked down to group room and says something to the nurse or patient in the group room. The nurse walks out of the group room. Staff M and the nurse are arguing. After the argument is over, Staff M walks down the hall and the other nurse goes back into the room with the patient.

The hospital staff notified patient # 13 family. The local police were called to investigate an adverse event of alleged abuse.

A review of patients medical record for the timeframe of 07/24/18 and 07/25/18 showed no documentation in nursing notes or RL Solution of restraint to include behaviors that lead up to restraint, date, time, location of occurrence with interventions and response of patient.


Reported Event (Per Incident Report)

Patient # - 17 ("Unsafe situation") - the documentation did not give a description of the unsafe situation


Falls (Per Incident Report)

# - 18, 19, 20 & 21 (Falls) - the documentation did not give a description of the falls.

The reported event and falls was listed on a document with no title contained the following categories: incident date, department, general event type and level of risk.

On 07/24/18 at 8:30 am, surveyors requested a copy of incident reports. A detailed timeline of incident reports was not provided to the surveyors.

On 07/24/18 at 8:30 am, surveyors requested a copy of the investigation for alleged patient abuse. A copy of investigation was not provided to surveyors.

On 07/26/18 at 2:45 pm, Staff B stated, the investigation itself is not being conducted as a protected patient safety work product, but in conjunction with the Edmond Police Department investigation.

On 07/26/18 at 2:45, Staff B stated, I do not have what you need.