HospitalInspections.org

Based on review of medical records (MR), Patient Bill of Rights, facility policies and procedures, video footage, Restraint and Seclusion logs, and interviews with staff, it was determined the facility failed to ensure a safe environment free from abuse was provided to the patients.

This had the potential to effect all patients but did affect 4 of 5 records reviewed which included Patient Identifier (PI) # 1, 2, 4, and 5.

Refer to Tag A 144 and A 145 for findings.

Based on review of medical records (MR), policy and procedure, and interviews with staff, it was determined the facility failed to ensure a safe environment was provided to the patients by failing to document patient observations every 15 minutes per the physician order.

This deficient practice affected 3 of 5 MR's reviewed, including Patient Identifier (PI) # 1, PI # 5, PI # 2, and had the potential to affect all patients served by the facility.

Findings include:

Facility Policy: Levels of Observation/ Precautions/ Restrictions
Policy number: ACU-C.024
Review date: 01/21

Policy:

All patients will be routinely observed and monitored in compliance with physician orders and Laurel Oaks' policies, procedures and protocols. Staff members assigned to each patient will provide continuous monitoring, precautions, oversight and intervention to provide for their safety and security...

Procedure:

1. Patients will be observed and observations documented at random intervals not to exceed fifteen (15) minutes, unless a higher frequency of observation is put into place...

2. Levels of Observation/ Supervision Options include:
1) q (every) 15 minute: this is the standard level of observation/ supervision for patients who do not require a special level of observation...

...8. Q 15 Minute Observations

-Minimum level of observation for all patients.
-Staff will observe patient and document on the Patient Observation Record at random intervals not to exceed fifteen minutes ("q [every] 15 minutes").
-Assigned staff will make direct visual contact with patients and confirm they are in no danger or distress...

1. PI # 1 was admitted to the facility on 10/20/21 with a diagnosis of Disruptive Mood Dysregulation Disorder.

Review of the Physician orders dated 10/21/21 revealed an order for q 15 minute (min) observations.

Review of the q 15 min observation form dated 10/24/21 revealed documentation of:

An observation was conducted at 1:08 AM and the next observation was documented at 1:40 AM, which was 32 minutes without a patient observation documented.
An observation was conducted at 8:00 AM and the next observation was documented at 9:28 AM, which was 1 hour and 28 minutes without a patient observation documented.
An observation was conducted at 4:48 PM and the next observation was documented at 5:19 PM, which was 31 minutes without a patient observation documented.

Review of the q 15 min observation form dated 10/29/21 revealed documentation of:

An observation was conducted at 11:11 AM and the next observation was documented at 11:43 AM, which was 32 minutes without a patient observation documented.
An observation was conducted at 8:40 PM and the next observation was documented at 9:24 PM, which was 44 minutes without a patient observation documented.
An observation was conducted at 9:36 PM and the next observation was documented at 10:07 PM, which was 31 minutes without a patient observation documented.

Review of the q 15 min observation form dated 11/4/21 revealed documentation of:

An observation was conducted at 4:00 AM and the next observation was documented at 4:44 AM, which was 44 minutes without a patient observation documented.
An observation was conducted at 7:02 AM and the next observation was documented at 7:39 AM, which was 37 minutes without a patient observation documented.
An observation was conducted at 9:36 PM and the next observation was documented at 10:07 PM, which was 31 minutes without a patient observation documented.

Review of the q 15 min observation form dated 11/6/21 revealed documentation of:

An observation was conducted at 7:44 AM and the next observation was documented at 8:16 AM, which was 32 minutes without a patient observation documented.
An observation was conducted at 6:05 PM and the next observation was documented at 6:46 PM, which was 41 minutes without a patient observation documented.
An observation was conducted at 8:16 PM and the next observation was documented at 9:00 PM, which was 44 minutes without a patient observation documented.

Review of the q 15 min observation form dated 11/7/21 revealed documentation of:

An observation was conducted at 10:40 AM and the next observation was documented at 11:20 AM, which was 40 minutes without a patient observation documented.
An observation was conducted at 12:30 PM and the next observation was documented at 1:12 PM, which was 42 minutes without a patient observation documented.
An observation was conducted at 5:00 PM and the next observation was documented at 5:31 PM, which was 31 minutes without a patient observation documented.
An observation was conducted at 8:00 PM and the next observation was documented at 8:44 PM, which was 44 minutes without a patient observation documented.
An observation was conducted at 9:00 PM and the next observation was documented at 9:32 PM, which was 32 minutes without a patient observation documented.

An interview was conducted on 11/9/21 at 4:46 PM with Employee Identifier (EI) # 3, Chief Nursing Officer, who confirmed there was no documentation of a patient observation on the above dates and times.

2. PI # 5 was admitted to the facility on 10/15/21 with a diagnosis of Unspecified Mood Disorder.

Review of the Physician orders dated 10/15/21 revealed an order for q 15 min observations.

Review of the q 15 min observation form dated 10/24/21 revealed documentation of:

An observation was conducted at 1:05 AM and the next observation was documented at 1:35 AM, which was 30 minutes without a patient observation documented.
An observation was conducted at 4:47 PM and the next observation was documented at 5:18 PM, which was 31 minutes without a patient observation documented.

Review of the q 15 min observation form dated 10/26/21 revealed documentation of:

An observation was conducted at 12:22 AM and the next observation was documented at 1:04 AM, which was 42 minutes without a patient observation documented.

Review of the q 15 min observation form dated 10/27/21 revealed documentation of:

An observation was conducted at 4:53 AM and the next observation was documented at 5:34 AM, which was 41 minutes without a patient observation documented.
An observation was conducted at 6:45 AM and the next observation was documented at 7:20 AM, which was 35 minutes without a patient observation documented.

An interview was conducted on 11/9/21 at 4:40 PM with EI # 3, who confirmed there was no documentation of a patient observation on the above dates and times.



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3. PI # 2 was admitted to the facility on 10/18/21 with a diagnosis of Unspecified Mood Disorder.

Review of the physicians orders dated 10/18/21 revealed the Level of Observation was Q 15 minutes.

Review of the q 15 minute observation form dated 10/29/21 revealed the following:

An observation was conducted at 11:10 AM, and the next observation was documented at 11:43 AM, which was 33 minutes without a patient observation documented.

An observation was conducted at 2:01 PM, and the next observation was documented at 2:31 PM, which was 30 minutes without a patient observation.

An observation was conducted at 8:00 PM, and the next observation was documented at 8:31 PM, which was 31 minutes without a patient observation.

An observation was conducted at 8:45 PM, and the next observation was documented at 9:26 PM, which was 41 minutes without a patient observation.

An observation was conducted at 9:39 PM, and the next observation was documented at 10:10 PM, which was 31 minutes without a patient observation.

Review of the q 15 minute observation form dated 11/3/21 revealed the following:

An observation was conducted at 6:29 AM, and the next observation was documented at 7:00 AM, which was 31 minutes without a patient observation.

Review of the q 15 minute observation form dated 11/4/21 revealed the following:

An observation was conducted at 4:00 AM, and the next observation was documented at 5:01 AM, which was 61 minutes without a patient observation.

An observation was conducted at 2:20 PM, and the next observation was documented at 2:50 PM, which was 30 minutes without a patient observation.

Review of the q 15 minute observation form dated 11/6/21 revealed the following:

An observation was conducted at 8:17 PM, and the next observation was documented at 9:03 PM, which was 46 minutes without a patient observation.

An interview was conducted on 11/9/21 at 4:46 PM with EI # 3, who confirmed staff failed to document the q 15 minute checks as ordered.

Based on review of medical records (MR), Patient Bill of Rights, facility policies and procedures, video footage, Restraint and Seclusion logs, and interviews, it was determined the facility failed to ensure:

1) Patients were safe and free from abuse by staff.

2) Staff followed proper restraint guidelines and documentation.

3) Staff followed facility policy for incident and grievance reporting.

This affected 3 of 5 MR's reviewed, including Patient Identifier (PI) # 2, PI # 4, PI # 5, and had the potential to affect all patients served by the facility.

Findings include:

Facility Policy: Patient Bill of Rights
Policy number: None listed
Revised date: 1/26/16

Laurel Oaks Behavioral Health Center will protect the fundamental human, civil, constitutional and statutory right of patients and will provide considerate and respectful care...

YOU HAVE THE RIGHT:

a. To be free from neglect, exploitation, all forms of abuse (verbal, mental, physical and sexual), harassment and corporal punishments;...

Facility Policy: Identifying, Reporting and Investigating Abuse, Neglect, Mistreatment and Exploitation
Policy number: ADM-B.011

Policy:

Any form of patient abuse, neglect, exploitation, or mistreatment will not be tolerated...

Purpose:

This policy establishes standards for reporting, investigation, and resolving allegations of patient abuse... and other similar incidents in this facility...

Definitions:

1. Physical Abuse means any assault by an employee upon a patient and includes but not limited to hitting, kicking, pinching, slapping, or otherwise striking a patient or using excessive force regardless of whether an injury results...

2. Verbal Abuse means verbal conduct by an employee that demeans a patient or could reasonably be expected to cause shame or ridicule, humiliation, embarrassment or emotional distress. Verbal abuse includes but is not limited to:
a. threatening a patient
b. using abusive, obscene or derogatory language to a patient
c. using profanity directly or indirectly to a patient
d. teasing or taunting a patient in a manner to expose the patient to ridicule...

Standards:

1. It shall be the responsibility of all Laurel Oaks Behavioral Health Center employees to treat all patients with dignity and respect, to ensure that all patients receive appropriate care and treatment, and to provide all patients with protection from abuse and neglect, mistreatment or exploitation.

...Staff receives written agency policy statement on abuse/neglect upon employment.

...2. Investigations of such allegations shall begin immediately upon notification...

3. Abuse, neglect, and similar incidents shall be reported as follows:

a. All allegations and all incidents of suspected abuse, neglect, and similar incidents shall be reported immediately to the CEO (Chief Executive Officer).

Facility Policy: Proper Use of Monitoring of Physical and Chemical Restraints and Seclusions
Policy Number: ACU-A.005
Date Reviewed: 8/20

Policy:

It is the policy of Laurel Oaks Behavioral Health Center to support each resident's right to be free from restraint or seclusion and therefore limit the use of the interventions to emergencies in which there is an imminent risk of a resident physically harming him/herself or others. Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the resident or others from harm. The resident has a right to be free from restraint/ seclusion imposed as a means of coercion, punishment, discipline, or retaliation by staff...

Definition

...Physical Restraints: The application of any manual method that immobilizes or reduces the ability of the resident to move his or her arms, legs, body, or head freely...

3.0 Physician Orders, Consultation, and Evaluation:

3.1 Restraint or seclusion shall be used in emergency situations only and requires an order from a LIP (Licensed Independent Practitioner)/ physician...

4.1 If physical restraint is indicated, at least 2 staff must participate in the physical hold application.

4.1.1. If the physical restraint/ hold is on a child resident, one staff may implement the hold (e.g. Child's Control Position) while a second staff serves as a witness to monitor resident and staff safety for the duration of the hold.

...13.0 Documentation of use of restraint/ seclusion: The use of restraint/ seclusion will be thoroughly documented in the resident's medical record...

Facility Policy: Incident Reporting
Policy number: ACU-A.006
Date revised: 11/20

Policy:

It shall be the policy of this hospital that a Patient Report Form be completed whenever an unexpected occurrence happens with a patient or visitor... The Patient Report Form shall be forwarded to the Risk Manager after documentation of the unexpected occurrence.

Procedure:

A. The staff member who witnesses or observes an unusual incident shall complete the Incident Report before that staff member leaves the shift on which the incident occurred. If no one witnesses an unusual incident, the person who receives the report shall initiate the Incident Report.

B. Staff is to complete the appropriate report...

C. Complete the dates, time, and place of Incident, as well as the status of the person involved.

...IV. Reports Required For:

...G. Patient Neglect/ Abuse

Facility Policy: Grievances: Patients and Family Grievances and the Role of the Patient Advocate
Policy number: ADM-A.017
Review date: 02/19

Policy:

To provide clear and concise explanation of a grievance. A "patient grievance" is a formal or informal written or verbal complaint that is made to the hospital by a patient... regarding the patient's care... abuse or neglect...

All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance... are considered grievances for the purposes of the requirements.

Procedure:

...5. Patient/ Family Grievance Forms are made available to patients to encourage their report of concerns while a patient is in this facility. The staff member receiving a verbal grievance must instruct the patient to fill our the Patient/ Family Grievance Form or assist the patient in completing the form. The form will be immediately given to the Patient Advocate (Monday through Friday), the House Supervisor (evenings, nights, and weekends) or the Administrator-on-Call. The House Supervisor and/or Administrator on Call shall investigate and address the grievance within 24 hours of the grievance being received if possible.

1. An interview was conducted on 11/8/21 at 10:00 AM with Employee Identifier (EI) # 4, Patient Advocate, who confirmed the facility had self reported an occurrence to DHR (Department of Human Resources). The incident occurred on 10/24/21, but was not discovered by EI # 4 until 10/27/21, when she/he read complaint forms retrieved from the patient complaint box. EI # 4 stated a review of video footage on 10/27/21 of the 10/24/21 incident, substantiated the complaint of abuse. The employee in the video, EI # 5, RN (Registered Nurse) was immediately removed from the floor, allowed to write his/her statement, and then terminated. EI # 5 did not work 10/25/21 or 10/26/21 at the facility.

2. On 11/9/21 at 1:00 PM, the surveyors reviewed the facility's video footage of the 10/24/21 occurrence with EI # 1, Director of Risk and Quality.

Review of the video of Day Room 4 revealed at 2:58 PM, there were 10 patients (ages 5 through 12), and one nurse, EI # 5, present in the room. PI # 2 was observed playing with a ball with Unsampled Patient (UP) # 1. At one point, PI # 2 grabbed the ball away from UP # 1. EI # 5 immediately grabbed PI # 2 by the back of the neck, and pushed PI # 2 up against the wall, and pinned her/him there with his/her body. EI # 5's head was moving back and forth as he/she appeared to be yelling at PI # 2. When EI # 5 released PI # 2, PI # 2 turned around and sat down on a nearby chair.

A few minutes later, PI # 4 had his/her feet on one arm of a chair and his/her hands on the other arm of the chair. PI # 4 was performing hip thrusts toward UP # 2. EI # 5 was observed lunging toward PI # 4, grabbing one ankle, and in one motion, pulled PI # 4 all the way to the floor. At this point in the video, all of the children turned toward EI # 5, stopped their activities/ commotions, and sat down. EI # 5 then turned to PI # 5, who was sitting in the floor, walked over to her/him, grabbed PI # 5's chin, and held her/his face upward, while talking close to her/his face.

A few minutes later, EI # 5 left the day room when EI # 6, MHT (Mental Health Technician) appeared.

During the video observation, EI # 1 confirmed the restraint on PI # 2 by EI # 5 was not performed per policy, no order had been obtained for the restraint, and there was no documentation regarding the restraint.

Review of the Restraint and Seclusion logs also confirmed no documentation of a restraint of PI # 2 on 10/24/21.

3. PI # 2 was admitted to the facility on 10/18/21 with a diagnosis of Unspecified Mood Disorder.

Review of the MR revealed no documentation regarding the restraint on 10/24/21.

An interview was conducted on 11/9/21 at 4:46 PM with EI # 1, who confirmed there was no documentation regarding a restraint on 10/24/21.

4. A phone interview was conducted on 11/9/21 at 2:02 PM with EI # 6. The surveyors asked EI # 6 if she/he knew anything about an occurrence that happened around 10/24/21. EI # 6 answered, "Yes." EI # 6 explained that she was relieved by EI # 5, so that she/he could take a break. On EI # 6's return to the Day Room, PI # 1 told her/him that EI # 5 "...had pulled someone out of a chair, grabbed one by the face, and pinned one against the wall." The surveyor asked EI # 6 what action did she/he take regarding the report. EI # 6 stated she/he reported the incidence to a nurse, but stated she/he did not remember the nurse's name because she/he was new. The surveyors asked for a description of the nurse, but was unable to determine the identity of the nurse. Two additional nurses were interviewed by the surveyors, and both stated they were unaware of the incident until it was reported on 10/27/21. EI # 6 failed to complete a Patient Report Form per policy.

5. A phone interview was conducted on 11/9/21 at 2:37 PM with EI # 7, MHT. The surveyors asked if EI # 7 was aware of an occurrence around 10/24/21 to 10/27/21. EI # 7 stated yes that PI # 1 reported to her/him that they were afraid of a nurse. The nurse had grabbed one of the girls by the face and shoved one. EI # 7 stated she/he told the girls they could file a complaint and it would be researched. EI # 7 stated she/he showed them the forms and told them how to fill it out. EI # 7 further stated, "They tried to give me the forms but I told them to put them in the box." EI # 7 failed to report the incident to the CEO per policy, and failed to complete a Patient Report Form, per policy.

An interview was conducted on 11/9/21 at 4:46 PM with EI # 1, who confirmed staff failed to follow the policy for reporting claims of abuse by patients.

Based on review of medical records (MR), policies and procedures, and interviews with staff, it was determined the facility failed to ensure the nursing staff followed physician orders for every 15 minutes per the physician order.

This deficient practice affected 3 of 5 MR's reviewed, including Patient Identifier (PI) # 1, PI # 5, PI # 2, and had the potential to affect all patients served by the facility.

Findings include:

Facility Policy: Levels of Observation/ Precautions/ Restrictions
Policy number: ACU-C.024
Review date: 01/21

Policy:

All patients will be routinely observed and monitored in compliance with physician orders and Laurel Oaks' policies, procedures and protocols. Staff members assigned to each patient will provide continuous monitoring, precautions, oversight and intervention to provide for their safety and security...

Procedure:

1. Patients will be observed and observations documented at random intervals not to exceed fifteen (15) minutes, unless a higher frequency of observation is put into place...

2. Levels of Observation/ Supervision Options include:
1) q (every) 15 minute: this is the standard level of observation/ supervision for patients who do not require a special level of observation...

...8. Q 15 Minute Observations

-Minimum level of observation for all patients.
-Staff will observe patient and document on the Patient Observation Record at random intervals not to exceed fifteen minutes ("q [every] 15 minutes").
-Assigned staff will make direct visual contact with patients and confirm they are in no danger or distress...

1. PI # 1 was admitted to the facility on 10/20/21 with a diagnosis of Disruptive Mood Dysregulation Disorder.

Review of the Physician orders dated 10/21/21 revealed an order for q 15 minute (min) observations.

Review of the q 15 min observation form dated 10/24/21 revealed documentation of:

An observation was conducted at 1:08 AM and the next observation was documented at 1:40 AM, which was 32 minutes without a patient observation documented.
An observation was conducted at 8:00 AM and the next observation was documented at 9:28 AM, which was 1 hour and 28 minutes without a patient observation documented.
An observation was conducted at 4:48 PM and the next observation was documented at 5:19 PM, which was 31 minutes without a patient observation documented.

Review of the q 15 min observation form dated 10/29/21 revealed documentation of:

An observation was conducted at 11:11 AM and the next observation was documented at 11:43 AM, which was 32 minutes without a patient observation documented.
An observation was conducted at 8:40 PM and the next observation was documented at 9:24 PM, which was 44 minutes without a patient observation documented.
An observation was conducted at 9:36 PM and the next observation was documented at 10:07 PM, which was 31 minutes without a patient observation documented.

Review of the q 15 min observation form dated 11/4/21 revealed documentation of:

An observation was conducted at 4:00 AM and the next observation was documented at 4:44 AM, which was 44 minutes without a patient observation documented.
An observation was conducted at 7:02 AM and the next observation was documented at 7:39 AM, which was 37 minutes without a patient observation documented.
An observation was conducted at 9:36 PM and the next observation was documented at 10:07 PM, which was 31 minutes without a patient observation documented.

Review of the q 15 min observation form dated 11/6/21 revealed documentation of:

An observation was conducted at 7:44 AM and the next observation was documented at 8:16 AM, which was 32 minutes without a patient observation documented.
An observation was conducted at 6:05 PM and the next observation was documented at 6:46 PM, which was 41 minutes without a patient observation documented.
An observation was conducted at 8:16 PM and the next observation was documented at 9:00 PM, which was 44 minutes without a patient observation documented.

Review of the q 15 min observation form dated 11/7/21 revealed documentation of:

An observation was conducted at 10:40 AM and the next observation was documented at 11:20 AM, which was 40 minutes without a patient observation documented.
An observation was conducted at 12:30 PM and the next observation was documented at 1:12 PM, which was 42 minutes without a patient observation documented.
An observation was conducted at 5:00 PM and the next observation was documented at 5:31 PM, which was 31 minutes without a patient observation documented.
An observation was conducted at 8:00 PM and the next observation was documented at 8:44 PM, which was 44 minutes without a patient observation documented.
An observation was conducted at 9:00 PM and the next observation was documented at 9:32 PM, which was 32 minutes without a patient observation documented.

An interview was conducted on 11/9/21 at 4:46 PM with Employee Identifier (EI) # 3, Chief Nursing Officer, who confirmed there was no documentation of a patient observation on the above dates and times.

2. PI # 5 was admitted to the facility on 10/15/21 with a diagnosis of Unspecified Mood Disorder.

Review of the Physician orders dated 10/15/21 revealed an order for q 15 min observations.

Review of the q 15 min observation form dated 10/24/21 revealed documentation of:

An observation was conducted at 1:05 AM and the next observation was documented at 1:35 AM, which was 30 minutes without a patient observation documented.
An observation was conducted at 4:47 PM and the next observation was documented at 5:18 PM, which was 31 minutes without a patient observation documented.

Review of the q 15 min observation form dated 10/26/21 revealed documentation of:

An observation was conducted at 12:22 AM and the next observation was documented at 1:04 AM, which was 42 minutes without a patient observation documented.

Review of the q 15 min observation form dated 10/27/21 revealed documentation of:

An observation was conducted at 4:53 AM and the next observation was documented at 5:34 AM, which was 41 minutes without a patient observation documented.
An observation was conducted at 6:45 AM and the next observation was documented at 7:20 AM, which was 35 minutes without a patient observation documented.

An interview was conducted on 11/9/21 at 4:40 PM with EI # 3, who confirmed there was no documentation of a patient observation on the above dates and times.



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3. PI # 2 was admitted to the facility on 10/18/21 with a diagnosis of Unspecified Mood Disorder.

Review of the physicians orders dated 10/18/21 revealed the Level of Observation was Q 15 minutes.

Review of the q 15 minute observation form dated 10/29/21 revealed the following:

An observation was conducted at 11:10 AM, and the next observation was documented at 11:43 AM, which was 33 minutes without a patient observation documented.

An observation was conducted at 2:01 PM, and the next observation was documented at 2:31 PM, which was 30 minutes without a patient observation.

An observation was conducted at 8:00 PM, and the next observation was documented at 8:31 PM, which was 31 minutes without a patient observation.

An observation was conducted at 8:45 PM, and the next observation was documented at 9:26 PM, which was 41 minutes without a patient observation.

An observation was conducted at 9:39 PM, and the next observation was documented at 10:10 PM, which was 31 minutes without a patient observation.

Review of the q 15 minute observation form dated 11/3/21 revealed the following:

An observation was conducted at 6:29 AM, and the next observation was documented at 7:00 AM, which was 31 minutes without a patient observation.

Review of the q 15 minute observation form dated 11/4/21 revealed the following:

An observation was conducted at 4:00 AM, and the next observation was documented at 5:01 AM, which was 61 minutes without a patient observation.

An observation was conducted at 2:20 PM, and the next observation was documented at 2:50 PM, which was 30 minutes without a patient observation.

Review of the q 15 minute observation form dated 11/6/21 revealed the following:

An observation was conducted at 8:17 PM, and the next observation was documented at 9:03 PM, which was 46 minutes without a patient observation.

An interview was conducted on 11/9/21 at 4:46 PM with EI # 3, who confirmed staff failed to document the q 15 minute checks as ordered.