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Based on interviews and documentation review, the Hospital (Hospital #2) admitted a patient (Patient #1) against their Admission Policy that resulted in inability to manage Patient #1's behaviors.


Findings included:

Medical record documentation indicated that Patient #1's medical history was significant for severe mental retardation (mentality of a 5-7 year old), mood disorder, seizure disorder (last seizure 5/12/10), hypothyroidism, fetal alcohol syndrome, cocaine exposure in utero, and acute respiratory failure (1997). Patient #1 had a history of temper tantrums, episodes of unpredictable explosions, physical aggression, and outbursts when limitations were set. Patient #1 was diagnosed with intermittent explosive disorder and required residential care. On 9/2/09 Patient #1 was admitted to Hospital #1 (a chronic care pediatric hospital). Patient #1 did well behavior-wise until around 10/17/09 when Patient #1 began exhibiting aggressive behavior. Medication was administered and strategies were developed to help Patient #1 manage/control behaviors. Initially the interventions were effective but their effectiveness decreased over time. In February, 2010 Patient #1 was referred to Hospital #2 (a pediatric hospital/school with structured programs).

Review of the Admissions Policy for Hospital #2, effective 4/10, indicated that applicants with secondary mental health issues, including but not limited to disruptive behavior (such as physical aggression toward self or other) were considered to have service needs that could not effectively and safely be managed at Hospital #2 and were excluded from further consideration.

Interviews with members of Hospital #2's Admission Committee were conducted as follows: the Chief Executive Officer (CEO) was interviewed on 1/5/11 at 12:25 P.M.; the Case Manager was interviewed intermittently throughout the survey; the Clinical Director was interviewed intermittently throughout the survey; the Staff Psychologist was interviewed on 1/13/11 at 9:00 A.M.; the Director of Admissions was interviewed on 1/13/11 at 10:20 A.M., and the Director of Nursing was interviewed on 1/13/11 at 10:45 A.M.

The interviews indicated that: Patient #1 needed a more structured environment and needed rehabilitation therapies both of which Hospital #2 was able to provide. Several meetings were held with staff from Hospital #1, Patient #1, and outside agencies overseeing Patient #1. Documentation provided by Hospital #1 was reviewed by members of the Admissions Committee prior to Patient #1's admission. Information presented by Hospital #1's staff indicated that Patient #1's behaviors were low in intensity. An agreement was made for the outside agency to fund 1:1 coverage for Patient #1 12 hours a day which would be provided by persons identified as Observer/Caregivers hired through the school system. The treatment team from Hospital #1 agreed to provide education to staff at Hospital #2 regarding Patient #1's behavior management The Staff Psychologist from Hospital #2 developed a behavior plan for Patient #1.

Documentation provided by Hospital #1 indicated that both staff and the Observer/Caregivers were educated regarding Patient #1's behavior plan as well as managing aggressive behaviors.

Review of incident reports related to Patient #1 from admission to 12/27/10, indicated that there were approximately 59 incidents most of which were directed toward staff. Review of the incidents indicated that several staff members were repeatedly targeted. There were no injuries related to the incidents.

Documentation and medical record review indicated that during the period of 9/8/10 to 9/21/10 Patient #1 was episodically physically aggressive toward another patient (Patient #3). Patient #3 was not not injured but had to be moved to another unit and in 12/10 there were 2 incidents with another patient (Patient #2).

Review of Incident Reports and medical record documentation for Patient #2 and Patient #3 were reviewed and indicated the following:

9/8/10: Patient #1 was seated at the table for dinner with Patient #3 (both resided on the same unit; dining room located on the unit). Patient #1 picked up the juice bottle (used to serve all patients at the table) and drank directly from it. Patient #3 told Patient #1 not to drink from the bottle. Patient #1 slapped Patient #3's face. There were no injuries.

9/13/10 and 9/14/10: nursing documentation indicated that Patient #3 was frequently targeted by peer (identified as Patient #1) mainly with verbal and occasional attempted at physical assaults. the events took place in the classroom and on the unit.

9/14/10: Patient #3 was passing by Patient #1 in the dining room on the unit when Patient #1 struck Patient #3 open-handed on the back claiming Patient #3 yelled at Patient #1. There were no injuries.

The follow-up risk management report indicated that possibly separating Patient #1 and Patient #3.

9/20/10: Patient #3 continued to be targeted by Patient #1 on the unit. Patient #1 saw Patient #3 on the walkway and yelled at Patient #3. Patient #1 then tried to and slightly rammed Patient #3's motorized wheelchair with Patient #1's motorized wheelchair. There were no injuries or damage to equipment.

9/21/10: Patient #1 went up to Patient #3 in the dining room and hit Patient #3 in the mouth. There were no injuries. At approximately 4:00 P.M. Patient #3 was transferred to another unit.

The Case Manager said there were no altercations between Patient #1 and Patient #3 in the classroom setting and after the transfer there were no further altercations.

12/12/10: Patient #1 entered the television room located on the unit, hit Patient #2 in the stomach and grabbed the remote control from Patient #2. There were no injuries.

12/27/10: Patient #1 ran after Patient #2 and hit Patient #2 on the arm. There were no injuries. Patient #2 was brought to the bedroom and Patient #1 attempted to go after Patient #1 again but was redirected.

Review of documentation indicated that discharge planning was initiated around 7/20/10 however; Patient #1 was not discharged until 1/4/11 due to the involvement of several agencies in the process.

Based on documentation review, the Hospital failed to assess if less restrictive devices were effective for 1 of 2 applicable patients (Patient #1).

Findings included:

Hospital #2's Pre-Admission Screening, dated 2/17/10, indicated that Patient #1 previously used a net bed because Patient #1 was unsteady, needed assist for transfers, and attempted to get up by self. The Screening also indicated that the net bed was used for physical aggression.

Hospital #2's Policy/Procedure titled Restraints, Adaptive, Supportive, Protective, and Safety Devices, effective 7/08, indicated that a netted bed was considered a device intended to compensate for a specific physical deficit or to prevent injuries. These devices were used when all other least restrictive interventions have failed.

Review of medical record documentation, dated 6/9/10 to 1/411, indicated that Patient #1 was placed in a netted bed upon admission and remained in the bed until discharge. There was no documented evidence that other least restrictive interventions were attempted at any point through Patient #1's hospitalization.

Hospital #2 identified one other patient who used a netted bed (Patient #10). Review of documentation indicated that Patient #10 was appropriately assessed.

Based on interview and documentation review Hospital #2 failed to ensure that: 1) NA #2 immediately reported Patient #1's alleged abuse to Charge Nurse #1; 2) verbal reports of an incident between Patient #1 and NA #1 was properly investigated; 3) Patient #1 was properly assessed after it was reported that Patient #1 had fallen, and 4) Patient #1's reported fall was properly documented by nursing staff.

Findings included:

Please refer to Standard A-0084 and A-0278 regarding information about Patient #1 and about the incident.

1) Nurse Aide #2 was interviewed on 1/13/11 at 3:25 P.M. with Surveyor #2 present and a union representative present for part of the interview. Nurse Aide #2 said he/she was escorting a patient to the bathroom when the following was observed: NA #1 was holding Patient #1's arm and walking down the corridor toward the shower/bathroom with the Observer/Caregiver in attendance. Patient #1 was telling NA #1 not to touch him/her. NA #2 was in the corridor outside the shower/bathroom and the Observer/Caregiver was at the threshold of the door to the shower/bathroom when the shower/bathroom door slammed. NA #1 was observed lunging at Patient #1 who then fell to the floor. NA #1, with fists up, asked Patient #1 if he/she wanted some more.

NA #2 reported being very upset but did not immediately report the incident because the patient needed immediate toileting. NA #2 toileted and put the patient to bed then put the roommate to bed. NA #2 then went to Patient #1's room where Patient #1 was observed reporting to Charge Nurse #1 about being pushed down. NA #2 told Charge Nurse #1 the incident was witnessed. NA #2 asked the Observer/Caregiver if he/she had witnessed the incident to which the Observer/Caregiver replied yes.

Nurse Aide #2 did not immediately report the alleged abuse to Charge Nurse #1.

2) Charge Nurse #1 was interviewed on 1/13/11 at 9:40 A.M. with Surveyor #2 and a union representative present. Charge Nurse #1 said the Observer/Caregiver reported that Patient #1 went after NA #1 who defended him/herself. Charge Nurse #1 reported going to check on Patient #1 and asked if he/she was okay. Charge Nurse #1 said Patient #1 reported being mad, wanted boxes to pack for discharge, and made no reference to the incident. Charge Nurse #1 said NA #1 then came and reported Patient #1 became aggressive and fell as NA #1 tried to get away. Charge Nurse #1 said shortly after, NA #2 reported that NA #1 was trying to help bring Patient #1 to the bedroom, Patient #1 turned and punched NA #1, and as NA #1 was trying to get away Patient #1 fell.

Charge Nurse #1 said the incident was reported to the Nursing Supervisor and an incident report was completed.

Charge Nurse #1 said he/she did not ask anyone to detail the incident when it was reported.

3) Please refer to #2.

Review of the shift note and Flowsheet documentation, dated 12/6/10, indicated that Patient #1 became assaultive with staff and crisis intervention techniques were used. There was no indication Patient #1 was assessed for injuries related to the incident/fall.

Charge Nurse #1 said Patient #1 was not assessed for injuries due to agitation.

4) Please refer to #2.

Review of the shift note and Flowsheet documentation, dated 12/6/10, indicated that Patient #1 became assaultive with staff and crisis intervention techniques were used. There was no documentation regarding Patient #1's reported fall.

Review of the Incident Report, dated 12/6/10, indicated that Patient #1's reported fall was not documented.

Based on interviews and documentation review Hospital #2 failed to ensure that an adverse patient event was properly analyzed for one of one applicable patients (Patient #1).

Findings included:

The following was reported to the Department of Public Health: Patient #1, a pediatric patient, was being escorted down the corridor to the bathroom. Patient #1 was yelling at staff to shut up, and then slammed the bathroom door hitting a staff member,NA #1, on the head. NA #1 allegedly reacted by punching Patient #1 on both arms causing Patient #1 to fall to the floor. NA #1 allegedly threatened Patient #1 asking Patient #1 if Patient #1 wanted more. The incident was witnessed by another nurse aide (NA #2) and a person (Observer/Caregiver) who was providing 1:1 supervision for Patient #1. NA #2 reported the incident to the charge nurse (Charge Nurse #1) who reported it to the nursing supervisor (Supervisor #1). The report given to Supervisor #1 did not include the alleged actions of NA #1. Approximately 6 days later NA #2 contacted the Patient Advocate to make sure the incident of 12/6/10 was being acted upon. The next day administration was notified of the NA #2's report. NA #1 was placed on administrative leave pending the outcome of the investigation and Charge Nurse #1 was placed on administrative leave because the incident was not reported to the appropriate authorities in a timely manner.

The Report was also sent to another outside agency who had oversite of Patient. The local police and District Attorney's office were notified.

Documentation provided by Hospital #2 indicated that the Observer/Caregiver and NA #2 were interviewed however; Charge Nurse #1, NA #1, and Patient #1 (who was considered alert and oriented) had not been interviewed.

Charge Nurse #1 and NA #1 confirmed they had not been interviewed prior to being placed on administrative leave.

The Chief Operating Officer (COO) was interviewed on 1/4/11 at 11:00 A.M. an investigation was started however; the investigation was stopped because the local police told them to stop the investigation. The COO confirmed Patient #1 had not been interviewed.

Hospital #2 did not analyze the circumstances surrounding the incident as they related to Hospital systems (such as accuracy of the incident reporting and documentation and failure to properly assess Patient #1 post-fall) to determine if there were opportunities for improvement.

Based on interviews and documentation review, Hospital #2 failed to ensure that staff were re-educated regarding abuse reporting.

Findings included:

Please refer to Standard A-0287 for information regarding the incident.

Review of documentation provided by Hospital #2 indicated that although failure to report abuse in a timely manner was identified as deficient practice; Hospital #2 did not re-educate staff regarding abuse reporting as it pertained to the incident.