HospitalInspections.org

Based on document review and interview, the facility failed to provide Registered Nurse (RN) coverage on 5 of 14 days and failed to evaluate the care of 1 of 10 patients reviewed by not documenting events including physical safety and aggression toward a peer (Patient P6).
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The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the nursing services were being supervised by a registered nurse.

Based on document review and interview, the facility failed to ensure the physical safety of others and prevent physical injury of 1 of 10 patients reviewed (Patient P1).

Findings include:

1. Facility policy titled, Brightwell Behavioral Health Patient Rights and Responsibilities, no approval date listed, document given to patients upon admission to facility, indicated patients have the right to protection from harm and to be free from physical abuse.

2. Review of facility incident reports indicated multiple incident reports made and reviewed between 11/1/23 through 11/6/23, describing P1 being physically aggressive as follows:
a. 11/1/23 at 3:50 PM, indicated P1 attacked staff by hitting, grabbing and pouring water on staff. The provider was notified and an order for Geodon was received. Director of Nursing (DON) recommendations were to attempt redirection, de-escalation, and therapeutic communication.
b. 11/1/23 at 4:00 PM, indicated P1 attacked staff and had increased aggression, pushed nurse. Writer of incident report indicated P1 would not redirect. The provider was notified. DON recommendations were to redirect, de-escalate, and use therapeutic communication.
c. 11/2/23 at 12:10 PM, indicated P1 screamed "Fuck you bitch!" then poured a cup of juice over the MHT's head. The provider was notified and an order for Ativan was received. DON recommendations were to attempt redirection, de-escalation and therapeutic communications. Recommended to remember CPI training.
d. 11/2/23 at 12:25 PM, indicated P1 was agitated, staff attempted to redirect, P1 was aggressive and hit staff multiple times, threw a drink at a staff member, then smashed the cup against a nurse. Staff remained unable to direct. The provider was notified. DON recommendations were redirection, de-escalation, and therapeutic communication. Recommended hold per CPI training.
e. 11/2/23 at 12:45 PM, indicated P1 was banging on window, enough to knock the glass from the door. The provider was notified. DON recommendations were to attempt redirection, de-escalation and therapeutic communication. Recommendations indicated to implement hold per CPI training.
f. 11/5/23 at 10:30 PM, indicated P1 was yelling out and kicking staff. Provider notified, order for Geodon received. DON recommendations were to attempt redirection, de-escalation and therapeutic communication.
g. 11/6/23 at 9:00 PM, indicated P1 was pushed and fell on the right shoulder. DON review indicated there was video footage of the altercation. Per DON review of video footage, at 10:47:15 PM, P1 was being aggressive and punched P6 from behind. At 10:58:30 PM, P6 shoved P1, causing an unplanned descent to the floor resulting in right shoulder injury. The provider was notified. DON recommendations were to keep the patients apart and to monitor for behaviors.
h. 11/6/23 at 9:45 PM, indicated P1 was yelling, hitting, physically aggressive. An injection of Geodon 10 mg was given at 9:45 PM, IM.

3. Review of medical records (MR) for P1 indicated physician orders as follows:
a. 11/2/23 at 12:11 PM, Ativan 1 milligram (mg), intramuscular (IM), 1 dose, ordered for aggression.
b. 11/3/23 at 12:14 PM, Seroquel 25mg, by mouth (PO), 1 dose now, ordered for agitation/aggression.
c. 11/3/23 at 6:40 PM, Geodon 10mg, IM, 1 dose now, ordered for aggression.
d. 11/4/23 at 7:22 am, Seroquel 25mg, PO, two times per day (BID), ordered for mood.
e. 11/4/23 at 7:22 am, Depakote 125 mg, PO, three times per day (TID), ordered for mood.
f. 11/4/23 at 5:10 PM, Seroquel 25mg, PO, 1 dose now, ordered for mood.
g. 11/5/23 at 9:00 PM, Geodon 10mg, IM, 1 dose, ordered for physical aggression.
h. 11/6/23 at 12:41 PM, Seroquel increased to 50mg, and Depakote increased to 250mg for aggression and mood.
i. 11/6/23 at 3:45 PM, Ativan 1mg, IM, 1 dose now ordered for aggression.
j. 11/6/23 at 9:00 PM, Geodon 10mg, IM, 1 dose now ordered for aggression.
k. The MR lacked documentation of action taken after 10:47 pm for physical aggression on 11/6/23 and prior to event with injury at 10:58 pm on 11/6/23.
l. 11/7/23 at 12:30 PM, line of sight (level of observation), ordered for arm fracture.
m. The patient was on 15 minute checks until the change on 11/7/23.

4. Review of patient P6's MR indicated facility admission from 11/3/23 through 11/20/23, for Dementia with Behavioral Disturbances, physical and verbal aggression. MR nurses notes lacked any indication of an altercation with P1. The patient was on 15 minute checks.

5. In interview on 11/27/23, at approximately 3:30 PM, via phone call, N4 (Mental Health Technician [MHT]), verified he/she remembered the altercation between P1 and P6. N4 described P1 as being aggressive daily by fighting with staff and other patients. N4 verified P1 was in P6's face being aggressive, they were separated, then P1 charged toward another patient who was in the direction of P6. N4 verified staff saw this happen, but could not get to P1 fast enough. P6 shoved P1. P1 had an unplanned descent to the floor, and remained aggressive toward staff while on the floor.

6. In interview on 11/27/23, at approximately 9:00 PM, via phone call, N5 (RN), verified he/she remembered the altercation between P1 and P6. N5 described P1 as being very aggressive and demanding as the time of the altercation. N5 verified P1 had been poking his/her finger in P6's face. N5 verified P6 shoved P1, causing P1 to fall back and slide down the wall to the floor. N5 described P1 as having having aggressive behaviors on and off during facility stay. N5 verified P1 would scream at staff and other patients.

Based on document review and interview, the facility failed to ensure Crisis Prevention Intervention (CPI) training in 1 of 5 personnel files reviewed.

Findings include:

1. Preventing Violence Acknowledgement, signed by N1 (Director of Nurses, Registered Nurse [DON, RN]) on 8/9/23, indicated he/she was to complete CPI training within 90 days of hire date (8/9/23).

2. Note provided by administrative staff, A3 (Human Resources Manger [HRM]), indicated per policy CPI training should have been completed by N1 (DON, RN) by 11/9/23.

3. In interview on 11/27/23, at approximately 3:00 PM, A3 (HRM), verified that all documents received for personnel file review were current and accurate.

Based on document review and interview, the facility failed to provide Registered Nurse (RN) coverage on 5 of 14 days.

Findings include:

1. Facility policy titled, Staffing-Nursing, policy number LD 12, issued 4/1/19, indicated the availability of a registered nurse 24 hours a day.

2. Review of the Staffing Pattern Worksheet (SPW) indicated:
a. No RN coverage on 11/4/23, night shift.
b. RN coverage for only half a shift on 4 night shifts: 11/2/23, 11/3/23, 11/5/23 and 11/11/23.

3. N1 (Director of Nursing, Registered Nurse [DON, RN]) verified the staffing pattern worksheet (SPW) and the lack of RN coverage on the shifts listed above. N1 verified the facility operates on 12 hour shifts, day shift and night shift. N1 verified on SPW when 0.5 is seen in RN box, it indicated that a RN was only onsite for half of the shift, that there was no RN coverage in the facility for a period of time on the dates listed above.

Based on document review and interview nursing staff failed to evaluate the care of 1 of 10 patients reviewed by not documenting events including physical safety and aggression toward a peer (Patient P6).

Findings include:

1. Review of patient P6's Medical Record (MR) indicated facility admission from 11/3/23 through 11/20/23, for Dementia with Behavioral Disturbances, physical and verbal aggression. MR nurses notes lacked any indication of an altercation with P1 on 11/6/23.

2. Incident report for P6 indicated on 11/6/23 at 9:00 PM, P6 shoved another patient and caused this patient to slip and fall with injury to his/her shoulder.

3. In interview on 11/27/23, at approximately 3:50 PM, N1 (Director of Nursing, Registered Nurse [DON, RN]), indicated it was the nurses preference as to what they document in the medical record.