HospitalInspections.org

Based on record review and interviews the hospital failed to ensure a system was in place to prevent the theft of the belongings of patients because of their mental status are in need of a safe environment as evidenced by missing personal belongings for 3 of 3 random patients (R8, R9, R11) out of 14 Risk Management reports reviewed. Findings:

Review of the 14 Risk Management Reports submitted by the hospital for the time period of 01/2010 through the present revealed two reports involving the theft of personal belongings involving three patients.

Review of the Risk Management Report dated 01/18/10 at 1025 (am/pm not documented) revealed ....Patient (R8) belongings missing from Nurses Station Lock Box. Inventory search revealed several articles of patient belongings missing. Actions taken: replaced patient' s money as agreeable to patient. Investigation regarding missing valuables in process with authorities. Actions taken to prevent further occurrences: Reported to DON and Administrator " .
Review of the Admission Inventory Sheet of Valuables and Restricted Items form dated 01/10/10 for random patient R8, revealed an inventory of valuables listed as money (6 ones, 3 pennies, 1 Canadian penny, 1 Lady Liberty dime (1944), belt, cigarettes, lighter and medication (Pristiq, Trazodone, Fluphenazine, Zolidem and Benztropine. Further review revealed all items had been returned to the patient.

Review of the Risk Management Report dated 01/19/10 revealed ......"patients' belongings missing from lock box at nursing station. Inventory search revealed several articles of various patient belongings are missing. Patients (R11), (R9), and (R8). Actions taken - reported to DON (Director of Nursing) and Administrator. Investigation per police authorities. Actions taken to prevent further occurrences - Patients reimbursed for missing money and articles. Authorities notified for patients except those requesting authorities not be notified " .

Review of the Admission Inventory Sheet of Valuables and Restricted Items form dated 01/11/10 for random patient R9, revealed an inventory of valuables listed as money (13 ones, 1 ten, 3 fives, 10 twenties, 23 quarters, 1 dime, 1 nickel and 2 pennies) and 1 black wallet (contents not listed). Further review revealed .... "01/25/10 Patient was given check #4217 Capital One Bank for the amount of $232.92".

Review of the Admission Inventory Sheet of Valuables and Restricted Items form dated 01/17/10 for random patient R11, revealed an inventory of items valuables listed as follows: Bell Phone, key, La (Louisiana) Purchase card and a silver and diamond watch. Further review revealed documentation the patient had been reimbursed for the items.

The hospital could not provide a policy for a procedure to ensure patient belongings were kept safe, who has the responsibility for access to those patient belongings, or the process implemented when patient belongings are verified as missing. Review of the "Admission Inventory Sheet of Valuables and Restricted Items" form revealed no documented evidence the inventory was checked before placement into the "locked box in the Nurses station".

In a face to face interview on 03/23/10 at 10:15am S2 RN DON indicated any additional information beyond what had been documented on the Risk Management Report would be in the Administrator's office who is the delegated Risk Management Officer with the responsibility for the investigation of all incidents. Further the DON added she does not know where the Administrator keeps this information within his office.

In a telephone interview on 03/23/10 at 10:30am Administrator S1 indicated he did perform an investigation concerning the theft of patients' belongings in the hospital. Further he indicated he was sick and did not know where the information was located in his office, so it was not possible to direct anyone else on where to look. The Administrator informed the surveyor he was sick and was not coming to the facility today and the surveyors would have to wait until tomorrow. When the surveyor informed the Administrator the team would be exiting today, he gave no response.

The hospital could not provide any additional information at the time of exit to ensure the survey team corrective action had been taken concerning the safety of the patients and/or their belongings in regards to theft.

Based on record review and interview, the hospital failed to ensure the medical record included a description of the patient's behavior prior to each administration of a chemical restraint for 1 of 11 sampled patients (#3). Findings:

Review of Patient #3's medical record revealed the patient was administered Ativan 2 milligrams, Haldol 5 milligrams, and Benadryl 25 milligrams intramuscularly on 3/08/2010 at 11:00 a.m. for increased agitation. Further review revealed no documented evidence describing the behavior exhibited by Patient #3 prior to the administration of a chemical restraint.

Further review revealed Patient #3 was administered Ativan 2 milligrams, Haldol 5 milligrams, and Benadryl 25 milligrams by mouth on 3/07/2010 at 10:20 a.m. and 3/08/2010 at 8:30 a.m. for increased agitation. Further review revealed no documented evidence describing the behavior exhibited by Patient #3 prior to the administration of a chemical restraint.

During a face to face interview on 3/23/2010 at 11:30 a.m., Director of Nursing S2 confirmed the above findings and further indicated there should have been a clear description of the behaviors exhibited by Patient #3 warranting the administration of a chemical restraint.

Review of the hospital policy titled, "Seclusion and/or Restraints" presented by the hospital as their current policy revealed no documented evidence regarding documentation of the patient's behaviors prior to the use of restraints and/or seclusion. Review of the hospital form titled, "Unscheduled Medication Intervention Form" presented by the hospital as their current form revealed in part, "Description of Patient Complaint or Behaviors" with three blank lines for insertion of information.

Based on record review (medical record) and interview the hospital failed to ensure nursing (progress) notes in the medical record were a complete reflection of behavioral progress/decline and implementation of treatment plan measures for 1 of 11 sampled patients (#3). The failure to document incidents of inappropriate sexual behaviors prevents all staff from being aware of potential/actual harmful behaviors and has the potential to affect all patients in the hospital. Findings:

Patient #3:

Review of Patient #3's medical record revealed the patient was admitted to the hospital initially on 2/27/2010 and discharged on 3/11/2010 then re-admitted on 3/14/2010 where he still remained at the time of the survey. Patient #3's diagnoses included Chronic Paranoid Schizophrenia and Dementia. Review of Patient #3's admission history and physical dated 2/28/2010 at 8:00 a.m. revealed in part, "He resides in NH (nursing home) and was throwing trash cans and inappropriately touching female staff. . ." Review of Observation flow sheets for both stays revealed the patient had been identified and observed as being at risk for sexually inappropriate behaviors with the exception of one flow sheet dated 3/21/2010 where there was no check mark identifying the patient as being at risk for sexually inappropriate behaviors.

Review of nursing notes dated 3/03/2010, 3/04/2010, 3/05/2010, 3/07/2010, 3/12/2010, 3/17/2010, and 3/22/2010 did not include descriptive and specific documentation of behavioral issues of Patient #3 and did not reveal documentation of interventions implemented by staff in response to such behaviors.

As documented by RN (Registered Nurse) S16 on 3/03/2010 at 2020 (8:20 p.m.): "threatening other patients. . . patient still sexually inappropriate with females." Further review revealed no documented evidence of what threats Patient #3 made to other patients and/or what sexually inappropriate behaviors were exhibited and to whom the behaviors were exhibited. Review also revealed no documented evidence of interventions implemented by staff.

As documented by RN S16 on 3/04/2010 at 2100 (9:00 p.m.): "patient still door checking. Patient still sexually inappropriate c (with) females. Will monitor." Further review revealed no documented evidence of what sexually inappropriate behaviors were exhibited and to whom the behaviors were exhibited. Review also revealed no documented evidence of interventions implemented by staff.

As documented by RN S20 on 3/05/2010 at 1930 (7:30 p.m.): "frequently becomes aggressive at times c (with) staff and other pts (patients)." Further review revealed no documented evidence of what aggressive behaviors were exhibited and to whom. Review also revealed no documented evidence of interventions implemented by staff.

As documented by RN S2 on 3/07/2010 at 2010 (8:10 p.m.): "attempts to go into other rooms, wanders, . . verbally aggressive at times." Further review revealed no documented evidence of what verbally aggressive behaviors were exhibited and to whom. Further review revealed no documented evidence of interventions implemented by staff.

As documented by RN S16 on 3/12/2010 at 2010 (8:10 p.m.): "Patient still sexually inappropriate (with) staff." Further review revealed no documented evidence of interventions implemented by staff.

As documented by RN S16 on 3/17/2010 at 2015 (8:15 p.m.): "Patient continues to be sexually inappropriate. Patient door checking, will monitor". Further review revealed no documented evidence of what sexually inappropriate behaviors were exhibited and to whom. Further review revealed no documented evidence of interventions implemented by staff.

During a face to face interview on 3/19/2010 at 10:00 a.m., RN S16 indicated she had never witnessed Patient #3 exhibiting sexually inappropriate behavior towards patients; however, he had touched one Mental Health Tech on the behind one time on 3/01/2010 and an occurrence report was made (confirmed with record review). RN S16 indicated Patient #3 was not capable of internal regulation of his behaviors; therefore, the hospital had made sure the patient has an employee located in close proximity to the patient to provide monitoring and redirecting as needed. RN S16 indicated the patient had hit her one time in the past and frequently would strike Mental Health Techs. S16 indicated Patient #3 would take off his diaper at times but never completely disrobe and his penis had never exposed. S16 indicated when Patient #3 would begin to act out, staff would change his environment such as moving him into the TV room or the Activity Room. S16 indicated this would often help his mood to change. S16 further indicated she had never had any complaints from other patients about Patient #3. S16 confirmed her documentation in patient #3's medical record on 3/12/10 and 3/17/10 failed to contain descriptive information of the sexually inappropriate behaviors exhibited by Patient #3 or interventions utilized by staff.

Registered Nurse (RN S20) was scheduled to be interviewed on 3/22/2010 at 10:00 a.m.; however, she failed to show. Attempts were made by the Director of Nursing and the surveyor to reach S20 by telephone after her failure to show for an interview without success. Phone calls by the surveyor without success on 3/22/1010 x 4 attempts beginning at 2:20 p.m. and on 3/23/2010 x 2 attempts beginning at 12:10 p.m.

During a face to face interview on 3/22/1010 at 11:10 a.m., MHT (Mental Health Tech) S19 indicated he recalled Patient #3 making an attempt to follow Patient #8 into her room while calling her by his wife's name on the date of 3/06/2010 (unable to recall the time). #8 indicated Patient #3 was redirected to another area of the hospital before he had a chance to completely enter Patient #8's room. S19 indicated he told RN S20 of the incident. S19 confirmed there was no documentation of the incident in either patient's medical record.

During a face to face interview on 3/23/2010 at 11:30 a.m., Director of Nursing S2 indicated sexually inappropriate behaviors and/or aggressive behaviors should be accurately described in the medical record of the patients to include a description of the behavior, who the behavior was directed towards, any untoward effect of the behavior, and all interventions implemented by staff. S2 reviewed the above listed documentation by nursing staff and indicated it was not descriptive enough to know what had occurred, who was involved, and that safety had been maintained for other patients/staff.

Based on record review and interview the hospital failed to ensure the process in place for high-risk and problem prone area of adverse patient occurrences as evidenced by a)witnessed patient to employee physical contact not being reported (Patient #3); b) incomplete Risk Management (Incident) Reports (#3, #7, #10, R1, R2, R3, R5); and c) a policy and procedure for Risk Management Reports which does not require an investigation of the reported occurrences which resulted in inaccurate statistical data submitted to the Quality Management Department. Findings:

a)witnessed patient to employee abuse not being reported (Patient #3);
Patient #3
Observations on 03/19/10 between 8:40 a.m. and 9:12 a.m. revealed Patient #3 had been redirected by S5MHT on three separate occasions (8:40am, 9:03am and 9:12am) when attempting to enter an area where the medication nurse was giving medications to the other patients. On all 3 occasions S5MHT placed both of his hands around one arm of patient #3 and attempted to physically turn him while verbally telling him he could not enter that area. On all 3 occasions patient #3 swung at S5MHT with his free arm, physically striking him in the head and shoulder area on two occasions.

Review of the 14 submitted Risk Management Reports revealed no documented evidence a Risk Management Report had been initiated concerning the incidents of Patient #3 hitting staff.

In a face to face interview on 03/19/10 at 1:25pm S5MHT confirmed that patient #3 had swung at him 3 times on the morning of 03/19/10 and had struck him on 2 of those occasions. When the surveyor asked if he (S5 MHT ) had completed a Risk Management Report he stated that he had not filled out an incident report or notified the RN or DON.

In a face to face an interview on 03/23/10 at 9:45am S2DON indicated she would expect staff members to fill out an incident report when a patient strikes them. S2DON confirmed that S5 MHT had not reported the incident to her and that a Risk Management Report had not been routed to her desk concerning the incident on 03/19/10.


b) incomplete Risk Management (Incident) Reports
Patient #3 and Patient #7
Review of the Risk Management Report dated 3/06/2010 at 10:10 a.m. revealed Patient #3 had inappropriately touched (Patient #7) on the back while walking down the hallway and also made sexual comments to her. Further review revealed no documented evidence to indicate the name of the MHT involved, the exact location and manner in which patient #7 had been touched, the type of sexual gestures and comments made, the location of staff on duty at the time of the incident, and/or any interviews with staff to investigate the incident. This finding was confirmed by the Director of Nursing (S2).

Review of the Risk Management Report dated 03/06/10 at 1930 (7:30pm) revealed Patient #3 was being re-directed by a MHT (Mental Health Tech) from entering another patient's room, turned to confront the MHT, lost footing and fell to the floor sustaining a laceration to the R (Right) eye. Further review revealed no documented evidence the incident had been documented in the chart or that the physician had been notified as evidenced by blank spaces on the Risk Management Report.

Review of the Risk Management Report dated 03/16/10 at 0420 (4:20am) revealed Patient #3 was in the dayroom watching television when the nurse approached to turn the TV off and was struck by the patient. Further review of the Risk Management Report revealed .... " Assessment Findings: Patient hitting staff. Actions Taken: Patient placed in seclusion. Documented in Medical Record ..... " . The report indicated the patient had seen the physician but there was no documented evidence of the date or time when the physician came to see #3.


Patient #10
Review of the medical record for Patient #10 revealed she had been admitted to the hospital on 03/07/10 for depression.

Review of the Risk Management Report dated 03/10/10 revealed ... "Patient reported that on two mornings, she woke up with panties off, found on bed. Patient denies any memory of any activity occurring because she had been started on ew medication to help her sleep". Further review of the report revealed the investigation by S3, RN Charge Nurse had been documented as follows: "Patient denies any physical injuries or trauma. Patient reported to police, administrator and DON notified. Patient reassured of safety. Actions Taken to Prevent Further Occurrences - Roommate placed in room with patient as part of patient's reassurance. Patient seen by Physician: Yes (No Name of the physician or date/time physician was notified had been documented.)".

In a face to face interview on 03/19/10 at 10:30am S3 RN Charge Nurse verified he was the person completing the Risk Management Report and the Charge Nurse on duty when the patient called her mother who then advised her (Patient #10) to report this to the police. RNS3 indicated the police conducted the investigation and afterwards Patient #10 told him she had no memory of what happened the past two nights and had done this to gain attention. The Charge Nurse verified the conversation with #10 had not been documented nor did he remember which physician he called or the date/time the call had been placed.

Review of the handwritten documentation by Administrator S1dated 03/10/10 concerning the Risk Management Report involving Patient #10 revealed a summary of the events including the charge nurse reporting of the incident, the police interview with #10, and notification of the physicians S13 and S22. Further review revealed no documented evidence an investigation had been performed by the hospital.

In a face to face interview on 03/22/10 at 11:05am MHT S18 indicated she was assigned to the night shift on the women's hall from 03/08/10 through 03/10/10. S18 indicated Patient #10 told her that she had found her panties off and laying on the bed. S3 indicated she told #10 she need to report this to the charge nurse and later checked with the charge nurse to make sure RN S3 had been made aware of the situation. Further, MHT S18 indicated at no time did the charge nurse, police, or anyone from administration ask her about the incident.

In a face to face interview on 03/22/10 at 12:10pm Psychiatrist S13 indicated he was aware of the incident which had been reported by Patient #10; however the patient never brought up the subject during therapy sessions and he felt it would not be beneficial to the patient to discuss it further.

Random Patient R1
Review of the Risk Management Report dated 02/13/10 revealed ..... R1 reported to RN S20 that she had fallen forward while sitting on the toilet, and hit her head on the wall. Further review revealed ...Nurse reported bruise to L (left) forehead. There was no documented evidence an investigation had been performed to determine how the fall had occurred when the R1 had been placed in Acute Close Observation. In addition the date/time the physician had been notified had not been documented as evidenced by a blank in the section titled "Physician Notification" and no date/time in the section titled "Actions Taken".

Random Patient R2
Review of the Risk Management Report dated 02/18/10 revealed ..... R2 was found sitting on bed bleeding per MHT (Mental Health Tech). Laceration noted to back of head. Bleeding from head, laceration noted on R (Right) posterior of head. VS (Vital Signs) and BP (Blood Pressure) 131/84, HR (Heart Rate) 104, R (Respirations) 20 " . Further review revealed no documented evidence an investigation had been performed to determine if the fall had been witnessed or how the patient had fallen or whether the patient had lost consciousness. The date/time the physician had been notified had not been documented as evidenced by the lack of documentation in the section titled " Physician Notification " and in the section titled " Actions Taken " .

Random Patient R3
Review of the Risk Management Report dated 01/21/10 at 2:50pm revealed Random Patient R3 had fallen out of his wheelchair after another random patient pulled at the chair. Further review of the report revealed ... " Assessment: R (Right) arm abrasion. Actions Taken: treated with TAO (Triple Antibiotic Ointment). Actions to Prevent Further Occurrences: Educated to call for help when ambulating. Physician Notification: (no documentation in the space provided). Person seen by Physician: a check in the space N/A (Not Applicable). Orders/Instructions Received: TAO Apply to wound as needed). Further review revealed the incident had not been documented in the Treatment Plan as indicated in the report nor had any further investigation been conducted.

Random Patient R5
Review of the Risk Management Report dated 02/13/10 at 0420 (4:20am) revealed .... " Patient (Random Patient R5) was getting up off floor in room. Patient stated ' I fell getting into the bed ' . Assessment: patient skin assessed - no injuries noted. Patient stated he was all right. Patient encouraged to ask staff for help when needed. Person seen by Physician: Yes " . Further review revealed no documented evidence details of the fall had been investigated to ensure the fall had not included injury to the head or other parts of the body besides the skin. The report had no documented evidence of the name of the physician seen by R5 or the date/time of the exam.

c) a policy and procedure for Risk Management Reports which did not require an investigation of the reported occurrences
Review of Policy NO: 630.1 titled " Risk Management Reports " last revised 02/07 and submitted by the hospital as the one currently in use revealed .... " Policy: The Administrator, Nurse Manager and Medical Director must be notified of any unusual or unexpected incidents which involve a patient in this program ... 4. The completed Risk Management Report will be forwarded to the Medical Director for review .... " . Further review of the policy revealed no documented evidence an investigation of the incident was required as evidenced by the Risk Management Report form with the following information listed: Date of Occurrence; Time of Occurrence; Location; Occurrence Involves (Patient, Employee, Visitor, Other); Type of Occurrence; Description of Occurrence; Charge Nurse Responsibilities (Assessment Findings, Actions Taken, Actions Taken to Prevent Further Occurrences, Documentation of Event in the Medical Record: Yes/No/Not Applicable, Communication of event to ensure awareness between shifts: Change of shift Report/Verbal Report/White Board/Patient Treatment Plan/Other; Notifications as Applicable.

In a face to face an interview on 03/23/10 at 9:45am S2DON indicated she thre Risk Management Report needed to be revised and agreed it did not contain the needed information, especially about investigations. Further the DON indicated changes may have to be made on the responsibility for completion of the forms.