HospitalInspections.org

Based on interviews, observations, and record review, the facility staff failed to follow their policy when conducting patient observation rounds (15 minute checks) in 7 of 10 (Patient #1, 2, 3, 4, 6, 7 & 8) medical records reviewed, in completing nursing assessments every 12 hours in 8 of 10 medical records (Patient #'s 1, 2, 3, 4, 5, 6, 7 & 8) and that Columbia Suicide Screening (CSSRS) assessments were completed as per policy in 7 of 10 (Patient #'s 1, 3, 4, 5, 6, 7 & 8) medical records reviewed out of total universe of 10 open and closed records.

Findings:

Facility staff failed to conduct and document patient observation rounds as ordered and documented. See Tag A-0398.

Facility staff failed to conduct and document nursing assessments as ordered. See Tag A-0398.

Facility staff failed to conduct and document CSSRS assessments as ordered. See Tag A-0398.

Based on record review and interview the facility failed to ensure that it's policy was being followed for room placement of a patient who was hypersexual in 1 of 10 (Patient #2) open and closed medical records reviewed out of a total universe of 11.

Findings include:

The facility policy titled "Sexual Aggression and Victimization Prevention and Precautions" last revised 9/10/2021 was reviewed. This document revealed "To provide a plan for the Prevention of Sexual Behavior including Aggression and the Potential for Victimization by identifying early warning signs of sexual behavior, monitoring the patient with a suspected potential for sexual aggression/victimization, and implementing intervention steps to minimize the risk of sexual behavior...ACTION STEPS 1. EARLY IDENTIFICATION: Intake/Admission staff assess patients for: Potential for Sexual Aggression: History of sexually aggressive behavior including criminal sexual history, sexual abuse/assault, psychosis with sexual preoccupation or promiscuity. Current risks for sexual behavior/aggression such as sexually inappropriate verbalization, provocative behavior or gestures...2. Roommate Assignments: The following factors are considered when determining roommate assignments: A: Sexual history...B. OBSERVATION: Nursing staff: Assess patient risk factors for Sexual Aggression/Victimization and places patient on SAO (sexually acting out)-Aggression or SAO-Victim Precautions."

Patient #2 was an inpatient at the facility from 10/24/2022 - 11/9/2022. On the physician to physician phone call for acceptance to the unit the receiving physician documented "hypersexual" on intake form and had an admission diagnosis of "Psychosis & Hypersexual". The "Initial Nursing Treatment Plan" dated 10/24/2022 under "Inappropriate Sexual Behavior" documented "None". Patient #2 was placed in a room with another patient (Patient #1). During his stay Patient #2 did have an allegation of sexual aggression towards a female lab technician which was investigated as per facility policy and frequently tried to have female staff go into his room with him alone. An investigation was conducted by the facility into the allegations of Patient #2 towards the lab technician. The investigation revealed that the lab technician did not follow facility policy and entered Patient #2's room alone to obtain a blood sample knowing that they were to wait for facility staff to go with them.

Patient #2 was an inpatient at the facility from 10/24/2022 - 11/9/2022. On the "High Risk Notification Alert" completed on the physician to physician phone call for acceptance to the unit the receiving physician documented "Hypersexual" on intake form and had an admission diagnosis of "Psychosis & Hypersexual." The "Initial Nursing Treatment Plan" dated 10/24/2022 under "Inappropriate Sexual Behavior" documented "None." Patient #2 was placed in a room in with another patient (Patient #1).

On 11/2/2022 there was an allegation from staff of "Sexual inappropriate contact between patients." Patient #2 was placed in a private room as per facility policy and the facility began conducting an investigation. As per facility investigation "No one observed any interactions, but staff have suspicions." The facility conducted a full investigation including interviews with both patients, staff and physicians. Patient #1 was alert and oriented with no hallucinations or delusions and had an "appropriate" thought process and denied any inappropriate behavior. As per facility investigation they were unable to prove if anything inappropriate occurred and both parties denied the allegation.

An interview was conducted on 11/21/2022 at 4:00 PM with the Director of Performance Improvement D and Chief Operating Officer (COO) C. After discussing Patient #2's medical record with history of being hypersexual and asked the expectation of staff placing him in a room COO C stated "Yes. You are right, in hindsight he probably should have been placed in his own room."

Based on interviews, observations, and record review, the facility staff failed to follow their policy when conducting patient observation rounds (15 minute checks) in 7 of 10 (Patient #1, 2, 3, 4, 6, 7 & 8) medical records reviewed, in completing nursing assessments every 12 hours in 8 of 10 medical records (Patient #'s 1, 2, 3, 4, 5, 6, 7 & 8) and that Columbia Suicide Screening (CSSRS) assessments were completed as per policy in 7 of 10 (Patient #'s 1, 3, 4, 5, 6, 7 & 8) medical records reviewed out of total universe of 10 open and closed records.

Findings include:

A review of the facility policy #11022954, titled "Patient Observation Rounds/Level of Observation", last reviewed on 1/13/2022 revealed: "Procedure. 5. Levels of observation: 1. Q (every) 15-minute observations: staff assigned to complete patient observation rounds will: a. Review and update patient observation forms...d. Observe each patient a minimum of every 15 minutes and according to precaution level, and document observation on the patient observation form...K. Making sure that the patient has moved from his/her previous sleeping position. Visually observe patients when behind closed doors/curtains by knocking on bedroom and bathroom doors. Announce that they are stepping into the room for rounds. Open the door/curtain and visually observe the safety of the patient. During nighttime use flashlights to allow visualization of the patient...Hand off assigned patient observation rounds to another staff member before leaving the patient treatment area (meals, breaks, emergencies)."

A review of the facility policy #11382347, titled "Assessing and Managing Suicide Risk-Columbia" last revised on 3/14/2022 was reviewed. This document revealed "Heightened Observations: 1. All patients will be monitored at least every 15 minutes..."

An interview was conducted on 11/21/2022 at 4:00 PM with Director of Performance and Improvement D and Chief Operating Officer (COO) C. When asked for a facility policy for the completion of the nursing assessments being completed on all inpatients COO C stated "We don't have one."

A review of the facility policy #11382347, titled "Assessing and Managing Suicide Risk-Columbia" last revised on 3/14/2022 was reviewed. This document revealed "Assessment and Re-Assessment Suicide Screening - Intake Assessment: 1. Intake/Admitting Staff will assess all patients presenting for admission that identify specific patient characteristics that may increase or decrease the risk of suicide...Assessment of Risk: 1. The admission RN (Registered Nurse) on the unit will review and sign off on the intake suicide risk assessment indicating that they have reviewed it during the time they complete their nursing assessment and will document the actions taken/precautions implemented which are applicable to the unit...Reassessment of Risk: 1. Reassessment of suicidality will occur every waking shift for any patient on suicide precautions or who exhibits a sudden or significant change in mental status...2. All other patients will be screened using a screening tool at least daily in acute settings by Nursing and/or Social Work/Therapy staff...Pre Discharge Suicide Assessment: 1. Prior to discharge, and RN and/or Therapist who has received training and competency evaluation by the facility will perform an assessment of the patient's level of suicidality...This assessment is to be documented on the day of discharge Suicide Reassessment Form."

Examples of missing (blank) 15 minute checks:

A review of Patient #'1's medical record on 11/21/2022 at 11:00 AM revealed that Patient #1 was admitted to the facility for suicidal ideation's on 10/22/2022. "Observation Record Inpatient" dated 10/30/2022 for Patient #2 documented that no checks were completed from 5:15 PM until 6:00 PM (45 minutes later). On the following dates there were no completed checks for the entire date: 11/8/2022, 11/5/2022, 11/4/2022, 11/3/2022, 11/2/2022, 10/26/2022 & 10/24/2022.

A review of Patient #2's medical record on 11/21/2022 at 10:30 AM revealed Patient #2 was admitted to the facility for Psychosis and Hypersexual behavior on 10/24/2022. "Observation Record Inpatient" dated 11/5/2022 for Patient #2 documented that no checks were completed from 7:30 AM until 8:45 AM (75 minutes later).

A review of Patient #'3's medical record on 11/21/2022 at 11:15 AM revealed that Patient #3 was admitted on 10/19/2022 to the facility for Disorganized Schizophrenia with unstable psychosis. "Observation Record Inpatient" dated 11/16/2022 documented that from 1:15 AM until 2:15 AM (60 minutes) Patient #3 was "Asleep" in the bathroom. On 11/14/2022 there was no completed checks from 7:15 AM until 8: 00 AM (45 minutes), on 11/8/2022 there are no completed checks from 7:45 AM until 12:00 PM on 11/9/2022 and on 11/5/2022 there were no completed checks from 7:30 AM until 8:45 AM (75 minutes).

A review of Patient #4's medical record on 11/17/2022 at 12:00 PM revealed that Patient #4 was admitted on 9/20/2022 under court order with diagnosis of Bipolar Schizophrenia. "Observation Record Inpatient" dated 11/14/2022 had no completed checks from 7:15 AM until 8:00 AM (45 minutes) and on 11/4/2022 no checks from 5:00 PM until 6:00 PM (60 minutes).

A review of Patient #6's medical record on 11/21/2022 at 1:00 PM revealed that Patient #6 was admitted on 11/16/2022 after an attempted suicide. "Observation Record Inpatient" dated 11/19/2022 had no completed checks from 2:15 PM until 3:30 PM (75 minutes) and on 11/17/2022 no completed checks from 4:00 PM until 5:15 (75 minutes).

A review of Patient #7's medical record on 11/21/2022 at 12:30 PM revealed that Patient #7 was admitted on 11/1/2022 with suicidality with a specific plan. "Observation Record Inpatient" dated 11/19/2022 had no completed checks."

Review of Patient #8's medical record on 11/21/2022 at 2:00 PM revealed that Patient #8 was admitted on 11/7/2022 with increased anxiety, depression and suicidal ideation's. "Observation Record Inpatient" dated 11/11/2022 had no completed checks from 11:30 AM until 12:00 PM (30 minutes) and from 5:30 PM until 6:00 PM (30 minutes). On 11/10/2022 there was no completed checks from 5:00 PM until 7:15 PM (135 minutes).

On interview with Director of Performance Improvement D and COO C on 11/21/2022 at 3:00 PM when asked for completed 15 minute checks for the above patients, dates and times COO C stated "We have looked for them and all I can say is we don't have those to provide you. They should be there and they aren't."

Examples of incomplete (blank or not signed by nurse completing) nursing assessments:

A review of Patient #1's medical record on 11/21/2022 at 11:00 AM revealed Patient #1 was admitted to the facility for suicidal ideation's on 10/22/2022. "Daily Nursing Assessment Progress Note" dated 11/11/2022 (day shift), 11/10/2022 (night shift), 11/4/2022 (both day and night shift), 11/3/2022 (night shift), 11/2/2022 (night shift), 10/28/2022 (night shift) & 10/24/2022 (night shift) had blank "Behavioral" and "Medical" assessments.

A review of Patient #2's medical record on 11/21/2022 at 10:30 AM revealed Patient #2 was admitted to the facility for Psychosis and Hypersexual behavior on 10/24/2022. "Daily Nursing Assessment Progress Note" dated 10/29/2022 & 11/2/2022 under "Medical Assessment" for night shift was left blank. On 11/8/2022 & 11/9/2022 the "Behavioral" and "Medical" assessments night shift was blank.

A review of Patient #'3's medical record on 11/21/2022 at 11:15 AM revealed that Patient #3 was admitted on 10/19/2022 to the facility for Disorganized Schizophrenia with unstable psychosis. "Daily Nursing Assessment Progress Note" dated 11/12/2022 & 11/11/2022 under "Medical Assessment" for night shift was left blank.

A review of Patient #4's medical record on 11/17/2022 at 12:00 PM revealed that Patient #4 was admitted on 9/20/2022 under court order with diagnosis of Bipolar Schizophrenia. "Daily Nursing Assessment Progress Note" dated 11/1/2022 there was no signature of nurse completing "Behavioral" and "Medical" assessments for day shift.

A review of Patient #5's medical record on 11/21/2022 at 12:15 PM revealed that Patient #5 was admitted on 11/2/2022 for Catatonic Schizophrenia. "Daily Nursing Assessment Progress Note" dated 11/15/2022 & 11/6/2022 had no completed "Behavioral" and "Medical" assessments for night shift. On 11/12/2022 there was no completed "Behavioral" assessment for day shift.

A review of Patient #6's medical record on 11/21/2022 at 1:00 PM revealed that Patient #6 was admitted on 11/16/2022 after an attempted suicide. "Daily Nursing Assessment Progress Note" dated 11/20/2022 had no completed "Behavioral" and "Medical" assessments for day shift.

A review of Patient #7's medical record on 11/21/2022 at 12:30 PM revealed that Patient #7 was admitted on 11/1/2022 with suicidality with a specific plan. "Daily Nursing Assessment Progress Note" dated 11/19/2022, 11/5/2022, 11/4/2022, 11/3/2022 & 11/1/2022 had no completed "Behavioral" and "Medical" assessments for night shift. On 11/14/2022, 11/11/2022 & 11/7/2022, the "Behavioral" and "Medical" assessments completed on day shift did not have a signature of the nurses completing them.

A review of Patient #8's medical record on 11/21/2022 at 2:00 PM revealed that Patient #8 was admitted on 11/7/2022 with increased anxiety, depression and suicidal ideation's. "Daily Nursing Assessment Progress Note" dated 11/19/2022, 11/14/2022 & 11/9/2022 had no completed "Behavioral" and "Medical" assessments for night shifts. On 11/18/2022, 11/16/2022, 11/12/2022, 11/11/2022 & 11/8/2022 the "Behavioral" and "Medical" assessments completed on day shift did not have a signature of the nurses completing them. On 11/13/2022 the "Behavioral" and "Medical assessments on day and night shift did not have a signature of the nurses completing them.

On interview with Director of Performance Improvement D and COO C on 11/21/2022 at 3:00 PM when asked for completed daily nursing assessments for the above patients, dates and times COO C stated "We have looked for them and all I can say is we don't have those to provide you. They should be there and they aren't."

Examples of incomplete (blank) Columbia Suicide Screening Risk (CSSRS) assessments:

A review of Patient #1's medical record on 11/21/2022 at 11:00 AM revealed that on admission 10/22/2022 the admission CSSRS assessment was blank. On 11/4/2022 the CSSRS assessment was not completed on day or night shifts and on 11/2/2022 there was no completed CSSRS assessment on night shift.

A review of Patient #'3's medical record on 11/21/2022 at 11:15 AM revealed that Patient #3 was admitted on 10/19/2022 to the facility for Disorganized Schizophrenia with unstable psychosis. On 11/12/2022 & 11/11/2022 on the night shift there were no completed CSSRS assessments.

A review of Patient #4's medical record on 11/17/2022 at 12:00 PM revealed that Patient #4 was admitted on 9/20/2022 under court order with diagnosis of Bipolar Schizophrenia. "Daily Nursing Assessment Progress Note" dated 11/4/2022 there was no completed CSSRS on night shift.

A review of Patient #5's medical record on 11/21/2022 at 12:00 PM revealed that Patient #5 was admitted on 11/2/2022 for Catatonic Schizophrenia. There was no documented complete CSSRS assessment for day of admission. Review of "Daily Nursing Assessment Progress Note" dated 11/15/2022 & 11/6/2022 had no completed CSSRS assessments for night shifts.

A review of Patient #6's medical record on 11/21/2022 at 1:00 PM revealed that Patient #6 was admitted on 11/16/2022 after an attempted suicide. On 11/20/2022 there were no completed CSSRS assessments for day shift.

A review of Patient #7's medical record on 11/21/2022 at 12:30 PM revealed that Patient #7 was admitted on 11/1/2022 with suicidality with a specific plan. On 11/19/2022 & 11/5/2022 there were no completed CSSRS assessments for night shifts.

Review of Patient #8's medical record on 11/21/2022 at 2:00 PM revealed that Patient #8 was admitted on 11/7/2022 with increased anxiety, depression and suicidal ideation's. On 11/19/2022, 11/14/2022 & 11/9/2022 there were no completed CSSRS for night shift.

On interview with Director of Performance Improvement D and COO C on 11/21/2022 at 3:00 PM when asked for completed CSSRS for the above patients, dates and times COO C stated "We have looked for them and all I can say is we don't have those to provide you. They should be there and they aren't."