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Based on record reviews and interviews, the hospital failed to ensure that the hospital's grievance process was implemented according to hospital policy as evidenced by having no documented evidence that a grievance submitted verbally by the daughter of Patient #2 was listed on the grievance log, and there was no documented evidence that an investigation had been conducted.
Findings:

Review of the hospital policy titled "Patient Complaint/Grievance process", policy number H-PC 05-007, revised December 2008, and presented as the current policy for the grievance process by S2Behavioral Health (BH) Nurse Manager, revealed that the Governing Board delegated the complaint and grievance process to the Hospital Quality Council who had delegated the responsibility for the complaint and grievance process to S1Chief Executive Officer (CEO). Further review revealed a grievance was defined as a written or verbal complaint about patient care presented by a patient or the patient's representative that could not be resolved on the spot by the staff present. The staff person receiving the complaint logs it on the "Complaint/Grievance Log", calls the Risk Line in the Director of Quality Management office to report the complaint, notifies the House Supervisor and their supervisor who then notifies the Director of Quality Management (who enters the complaint on the "Complaint/Grievance Log"). The grievance is to be documented on the "Patient & (and) Family grievance Report Form" and forwarded to the appropriate departments to promptly investigate. The person initiating the form completes Step 1 of the form, the Department Manager/Supervisor completes Step 2, the Chief Clinical Officer/Chief Operating Officer/Assistant Administrator completes Step 3, and the CEO or designee completes Step 4 of the form.

Review of the "Complaint/Grievance Log" presented by S3Resource Director of Quality Management (QM) revealed grievances for January 2014 through July 2014. A request was made during the entrance conference for the list of grievance from January 2014 through the date of the entrance on 09/08/14.

In an interview on 09/08/14 at 1:05 p.m., S2BH Nurse Manager indicated there had been no grievances related to the Geriatric Behavioral Health Unit for August 2014 and for September as of the date of this interview.

Review of the "Hospital Abuse/Neglect Initial Report" presented by S2BH Nurse Manager revealed the report that was completed by S15Resource Chief Clinical Officer (CCO) on 09/03/14 and sent to DHH (Department of Health and Hospitals) revealed the type of incident was "other" (other choices to select were alleged sexual abuse, alleged physical abuse, alleged neglect). Further review revealed the first employee who became aware of the allegation was S4RN (registered nurse) who was questioned by Patient #2's daughter about her mother's facial bruising and swelling/bruising to the left hand. Further review revealed the following description of the alleged incident: "During the visitation of this patient (Patient #2) on 08/30/14, the daughter was surprised to see that her mother had lip and facial bruising, in addition to bruising/swelling of left hand. According to the daughter, these injuries were (should read not apparent) apparent during her visit on 8/29/14. The daughter's perception is that 1 of 3 things occurred that caused her mother's injuries: 1) mother had altercation with another patient; 2) mother caused injuries to herself; 3) an employee of facility assigned to her mother's care "lost control". Based on internal facility investigation, it has not been determined how injuries occurred. Etiology of injuries not known..." Further review revealed left hand x-ray on 08/30/14 revealed a 2nd metacarpal fracture to the left hand.

Review of Patient #2's medical record revealed she was a 75 year old female admitted on 08/19/14 with an admitting diagnosis of Dementia. Patient #2 was transferred to another psychiatric hospital on 09/05/14. Review of her psychiatric evaluation conducted on 08/20/14 by S16APRN (advanced practice registered nurse) PMHNP (psychiatric mental health nurse practitioner) revealed her diagnosis was Dementia: Alzheimer's Type with Behavioral Disturbance and identified problems were altered thought, increased confusion, and assaultive behavior. Review of documentation in Patient #2's nurses' notes revealed no documented evidence of Patient #2's daughter's complaints voiced to S4RN.

Review of Patient #2's "Progress Notes" revealed an entry on 09/05/14 at 10:25 a.m. by S9LPC (licensed professional counselor) that revealed she had called Patient #2's daughter to update her on her mother's progress. During the call Patient #2's daughter requested the name and phone number of someone in medical records who could assist her to receive her mother's records. Further review revealed that Patient #2's daughter stated she desired to remove her mother from Kindred Hospital, because her mother had not walked in 7 days, and she (daughter) had not been informed of the action plan of the orthopedist in evaluating Patient #2's fractured hand. Further review revealed that Patient #2's daughter stated that instead "she has been accused of beating her mother."

In an interview on 09/10/14 at 10:40 a.m., S9LPC indicated when she called to update Patient #2's daughter on her mother's medication changes on 09/02/14 (medical record has documentation on 09/05/14 and not 09/02/14), she (daughter) became upset, so she (S9LPC) transferred Patient #2's daughter to S15Resource CCO.

In an interview on 09/10/14 at 9:25 a.m., S2BH Nurse Manager confirmed that he had no documentation of the investigation related to Patient #2's daughter's complaints, because he didn't take notes when he met with the staff. He indicated that S15Resource CCO took notes of the interviews with the MHTs (mental health techs) and the nurses. He further indicated that S15Resource CCO was on vacation, but he would try to obtain documentation from her.

In an interview on 09/10/14 at 11:30 a.m., S3Resource Director of QM indicated she was responsible for complaints and grievances but was not at the hospital during the time of the grievance and thus could not comment on it. She confirmed there were no grievances for the Geriatric Behavioral Health Unit for August and up to this date in September. She confirmed no grievance was documented as having been received from Patient #2's daughter.

In an interview on 09/10/14 at 11:50 a.m., S4RN indicated she didn't document Patient #2's complaint as a grievance or complaint, because she didn't consider it a complaint but rather just asking why the staff couldn't keep her mother sedated to keep her from hurting herself. She further indicated that she never saw the discussion as Patient #2's daughter being angry when she (daughter) spoke to her (S4RN).

Review of an e-mail sent to S2BH Nurse Manager from S15Resource CCO on 09/10/14 at 11:20 a.m, presented by S2BH Nurse Manager on 09/11/14 at 10:05 a.m., revealed a list of first names of 7 employees with a date (month and date) and time next to each name. Further review revealed the subject line read as "Staff interviews." There was no documented evidence of documented interviews with staff as part of the investigation of the grievance presented as of the time of exit on 09/11/14 at 4:05 p.m.

Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by:

1) Failing to provide an effective intervention to prevent patient injury during periods of aggression and combativeness for 1 (#2) of 1 patient record reviewed with self-injury from a total sample of 5 patient records (#1 - #5). Patient #2 fractured the 2nd metacarpal of her left hand and had bruising to her scalp, right hip, and right side of her face near her eye caused by her continued slapping and punching the walls and chairs, "banging" her head against the floor, and hitting and scratching her face with no further intervention implemented when one-to-one (1:1) monitoring and placing mattresses on the floor did not prevent Patient #2 from injuring herself;

2) Having electric beds in patient rooms with electrical cords ranging from 34 inches to 83 inches in length that presented a ligature risk; the electrical outlet cover to protect one from tampering with the outlet was not secured closed with screws and could be opened with access to the outlet;

3) Having the toilet plumbing not enclosed to prevent tampering, the covering used to secure the sink plumbing not screwed tightly, and a plastic liner in the garbage can in the bathroom used by patients in seclusion;

4) Having all room entrance doors and doors to patients' bathrooms with hinges with separations that pose a ligature risk;

5) Having all patient bathrooms' toilet plumbing exposed that posed a risk for tampering;

6) Having each patient bed mattress with a vinyl/plastic covering that could be unzipped and provide a means of suffocation;

7) Having a 5 to 6 feet rubber hose hanging from the shower head in the patient shower room that posed a ligature risk.

Findings:

1) Failing to provide an effective intervention to prevent patient injury during periods of aggression and combativeness for Patient #2 that resulted in a fractured 2nd metacarpal of her left hand and bruising to her scalp, right hip, and right side of her face near her eye caused by her continually slapping and punching the walls and chairs, "banging" her head against the floor, and hitting and scratching her face:

Review of Patient #2's medical record revealed she was a 75 year old female admitted on 08/19/14 with an admitting diagnosis of Dementia. Patient #2 was transferred to another psychiatric hospital on 09/05/14. Review of her psychiatric evaluation conducted on 08/20/14 by S16APRN (advanced practice registered nurse) PMHNP (psychiatric mental health nurse practitioner) revealed her diagnosis was Dementia: Alzheimer's Type with Behavioral Disturbance and identified problems were altered thought, increased confusion, and assaultive behavior.

Review of Patient #2's "Physician Admission Orders" dated 08/19/14 at 1:00 a.m. revealed she was to have 1:1 observation. Review of her "Physician Order" revealed an order on 08/25/14 (no documented evidence of the time the order was written) by S12Psychiatrist to have at least 2 mattresses in the room on the floor and the bed removed from the room in the morning. Further review revealed a telephone order received by S4RN (registered nurse) from S12Psychiatrist on 08/30/14 at 3:30 p.m. for an x-ray of Patient #2's left hand due to swelling with a subsequent telephone order received by S4RN from S12Psychiatrist on 08/30/14 at 6:51 p.m. to consult Orthopedics related to fractured left hand. Further review revealed an order written by S12Psychiatrist on 09/02/14 (unable to read the time written) that read as "If the resources are available suggest adding more mattresses to floor if there has been difficulty keeping patient off hard portion of floor."

Review of Patient #2's "Wound Care Photo Documentation 09/02/2014" revealed pictures of a bruise to Patient #2's scalp, a bruise to the right side of her face near the eye, an area of discoloration to the sacrum, and a bruise to the right hip.

Review of Patient #2's computerized "Nurses notes" revealed the following entries:
08/23/14 at 7:20 a.m. by S14RN - patient is kicking, hitting, and spitting on staff; ran head first into another staff member;
08/24/14 at 6:23 a.m. by S17RN - client did not sleep through the night... screaming, spitting at staff and peers... continues to punch, scratch, and bite at 1:1 staff; S12Psychiatrist notified Ativan was not effective;
08/26/14 at 1:47 a.m. by S13RN - abrasions noted to bilateral extremity; large purple bruise noted to right lateral thigh and right lower deltoid;
08/26/14 at 11:50 a.m. by S14RN - spitting on floor and hitting on the chair with her hand, fist, and feet;
08/26/14 at 11:56 a.m. by S14RN - scattered bruises/scratches, most scratches self inflicted to upper and lower extremities and buttock area;
08/26/14 at 9:28 p.m. by S13RN - multiple abrasions to bilateral upper and lower extremities with purplish bruising to right lower deltoid area, right lateral thighs, left upper arm, and coccyx area;
08/30/14 at 7:32 p.m. by S13RN - bruise noted to right and left cheeks, outer area of right eye, and patient's right upper lip;
08/30/14 at 10:46 p.m. by S13RN - multiple bruises to bilateral upper and lower extremities; left hand swollen; quarter-sized bruise noted to the crown of patient's scalp;
09/02/14 at 6:00 p.m. by S14RN - greenish color bruising to right cheek, jaw, lip, eye, and chin; greenish color bruise to left cheek/chin; top of head with red bruise to top of head; right hip with large red bruise; scattered greenish/blue bruises to lower extremities; some scabbed areas as well as bruises to upper extremities;
09/03/14 at 6:16 p.m. by S14RN - while walking back to the day area, the patient jerked her arm away and began "beating her elbow against the wall";
09/04/14 at 12:15 a.m. by S13RN - MHT (mental health tech) reported patient slapping her hand on the side of the chair; patient redirected on several occasions;
09/04/14 at 6:16 a.m. by S13RN - MHT reported patient slapping her hand on her chair; no new bruising noted to her body.
Review of Patient #2's "Nurses notes" revealed no documented evidence of Patient #2 continually slapping and punching the walls, "banging" her head against the floor, and hitting and scratching her face. There was no documented evidence of how Patient #2 obtained the self-inflicted injuries noted above by multiple RNs. There was no documented evidence of interventions implemented to provide a safe environment for Patient #2 when it was determined that medication administration, 1:1 monitoring by staff, and mattresses on the floor were not successful in preventing Patient #2 from inflicting injury to herself.

In an interview on 09/09/14 at 12:50 p.m., S4RN indicated that she couldn't say that she witnessed any activity by Patient #2 that could have resulted in bruises to her scalp, face, and hip.

In a telephone interview on 09/09/14 at 2:55 p.m., S5MHT indicated she was assigned to observe Patient #2 1:1 at least twice. She further indicated that she never witnessed Patient #2 rolling to the floor, but she witnessed her beating the walls and the geri-chair with her hands. She further indicated that when Patient #2 was assigned to another MHT, she (S5MHT) witnessed Patient #2 on the floor, hitting her fist on the walls and floor, and "bobbing her head against the floor."

In a telephone interview on 09/09/14 at 3:10 p.m., S6MHT indicated he was assigned to monitor Patient #2 one-to-one on the day shift (7:00 a.m. to 7:00 p.m.) on 08/29/14 and 08/30/14. He further indicated that Patient #2's hand was bruised on 08/29/14 but not swollen. He indicated that Patient #2 was "banging" her hands on the floor, walls, and geri-chair and had a bruise to her right eye where she had scratched herself. He further indicated that she had been hitting herself all day like she was arguing with someone and punched herself in the face a couple of times. When asked if Patient #2 had punched herself in the right eye, S6MHT answered, "she punched all over and had blood on her teeth... busted her lip." He further indicated that Patient #2 was hitting herself the "whole time she was here." He further indicated that he thought he noticed the "busted lip" on 08/30/14 when he saw dried blood on her teeth, but he knew that he noticed her eye on 08/29/14. S6MHT indicated he told the RN on 08/29/14 about Patient #2 hitting herself, but he didn't report anything about her right eye. He indicated that he did not witness Patient #2 hitting her lip but did witness her scratching her right eye. He further indicated that he saw her "bang her head on the floor", and she had a bruise in the back of her head on top. S6MHT indicated that he reported this information when S2BH (Behavioral Health) Nurse Manager and S15Resource CCO spoke with him.

In a telephone interview on 09/09/14 at 3:25 p.m., S7MHT indicated that she was assigned to observe Patient #2 3 or 4 times and was assigned to Patient #2 on 08/29/14 from 7:00 p.m. to 7:00 a.m. on 08/30/14. She further indicated that there were 2 mattresses on the floor, and Patient #2 would scoot off the mattress onto the floor. She indicated that Patient #2's right eye was bruised when she came to work on 08/29/14. She further indicated that the eye was "blood shot with a bruise next to it", and she had dried blood on her teeth and an abrasion on the outside corner of her lip. She indicated that Patient #2 would "bang her head on the floor." When asked what she did when she witnessed Patient #2 "banging her head", S7MHT answered, "she would hit us and punch the staff, there was nothing to combat it." She indicated that the nurse tried to give Patient #2 medication, but Patient #2 would spit the medication out her mouth. She indicated that she would report Patient #2 banging her head to the nurse, and the nurse could hear Patient #2 from the nursing station, because Patient #2 usually screamed during this behavior. S7MHT indicated that Patient #2 didn't sleep at all the night of 08/29/14 and was combative and aggressive all night.

In an interview on 09/09/14 at 3:40 p.m., S8LCSW (licensed clinical social worker) indicated they have had a "lot of combative patients" recently. She further indicated that when a patient is exhibiting self-injurious behavior, the team is supposed to problem-solve as a group to seek interventions to prevent self-injury. She indicated that she was not aware of the behaviors of banging her head, hitting/punching herself in the face, and hitting the walls and geri-chair arms. S8LCSW indicated these type behaviors was not discussed during the treatment team meeting held on 08/26/14. She indicated that S4RN told her on 08/31/14 about Patient #2's fractured hand. When she asked S4RN how the fracture happened, she indicated that S4RN said the "documentation said she was hitting the chair."

In an interview on 09/10/14 at 10:40 a.m., S9LPC (licensed professional counselor) indicated she knew that Patient #2 was "picking and scratching her arms", but she was never told that Patient #2 was punching her face and scratching her eye. She further indicated they "provided extensive support to reduce self-injury and basically that was the 1:1." She further indicated they tried changing her medications and giving her some space. S9LPC confirmed no other interventions were implemented when the 1:1 and medication changes were not successful in preventing Patient #2 from self-injurious behavior.

In a telephone interview on 09/10/14 at 1:20 p.m., S12Psychiatrist indicated that he could believe that Patient #2 was injuring herself, but no RN documented it in her chart. He further indicated that he didn't find out about the injurious behavior until he received a phone call from a RN saying that Patient #2's daughter noticed that her (Patient #2) hand was swollen. He further indicated that he wasn't told about any bruising at the time of the call. S12Psychiatrist indicated that there seemed "to be a breakdown of information (regarding Patient #2) and how it was traveling." When asked if he was informed that Patient #2 was punching herself and scratching her face, he answered, "No, I would have ordered medications or gotten on the floor with her again." When asked about no changes in interventions made to keep Patient #2 from self-injury when 1:1 and mattresses on the floor wasn't effective, S12Psychiatrist answered, "increasing staff is an administrative issue... do you know how hard it was to get mattresses on the floor?"

In a telephone interview on 09/10/14 at 2:10 p.m., S13RN indicated that she had never been made aware that Patient #2 was punching and scratching her face on her shift. She further indicated that she didn't hear about this behavior until after Patient #2 was noted to have a fractured hand. S13RN indicated that Patient #2 would flail her hands and bite and kick staff, so 1:1 was ordered to provide safety. She further indicated that no other interventions were implemented to provide safety for Patient #2 other than monitoring her.

In a telephone interview on 09/11/14 at 1:50 p.m., S7MHT indicated that punching the wall meant that Patient #2 would slap the wall with the back of her hand in a waving motion. She further indicated that she would bang her head on the floor or the wall , and it was a "hard bang, not a tap." When asked what she would do when Patient #2 would slap the wall or bang her head on the floor or the wall, S7MHT answered, "I would call the nurse." She indicated that the nurse would come and try to get her to stop by telling her to stop. She further indicated that no physical intervention was attempted to stop the behavior. When asked if she had witnessed Patient #2 punch herself in the face, S7MHT indicated that Patient #2 would grab her face and head with both hands and scream and tried to scratch herself. She further indicated that the night of 08/29/14, Patient #2 did not sleep "at all", and she kept trying to tell her to stop slapping the wall, banging her head on the wall and floor, and grabbing her head and face, but it didn't work.

In a telephone interview on 09/11/14 at 2:00 p.m., S6MHT indicated that Patient #2 would either slap the wall with her fist or with an open hand that was not a tap but a punch. He further indicated that "it was like she was fighting somebody." When asked what he would do when she exhibited this behavior, S6MHT indicated that he would talk to her and try to grab her hands before she could hit, but she would hit him. He further indicated the RN would come to the room to see what Patient #2 was doing, but they (RN) do anything to stop it, because I told them that Patient #2 hit me when I tried to stop her. He further indicated that every time he tried to stop her, she would hit him, so "at some point you say if you want to do that... you're going to beat me up in the process."

In a telephone interview on 09/11/14 at 2:15 p.m., S4RN indicated Patient #2 would hit her open palm of her hand on the arm of the geri-chair when in the day room, and she (S4RN) would tell the MHT to stop her. She further indicated that she never witnessed Patient #2 banging her hands and head when Patient #2 was in her room.

In an interview on 09/11/14 at 2:20 p.m., S14RN indicated Patient #2 hit her fist or open palm hard against the arm of the geri-chair and kick her legs against the chair. She further indicated she would talk to Patient #2 and try to divert her attention at these times.

In an interview on 09/11/14 at 2:40 p.m., S2BH Nurse Manager indicated he saw Patient #2 in the day room attempting to hit or bang her arm against the arm of the geri-chair, and the RN would try to stop her or give her medication. He further indicated that he never witnessed any of the above-mentioned behaviors while Patient #2 was in her room. S2BH Nurse Manager, after reviewing the documentation in Patient #2's medical record and being informed of information gathered during interviews with staff, indicated that "it sounds like the MHTs weren't articulating clearly (to the RNs) what they observed, or whether they did and the nurses were nonchalant, I would hold them both responsible."

2) Having electric beds in patient rooms with electrical cords ranging from 34 inches to 83 inches in length that presented a ligature risk and having the electrical outlet cover (used to protect one from tampering with the outlet) not secured with screws to prevent access to the outlet:

Observation on 09/10/14 at 10:10 a.m. revealed the covers to the electrical outlets used to plug the electrical beds in Rooms "a", "b", "c", "d", "e", and "f" were able to be lifted to plug/unplug the electrical cord of the bed. The screws that could be used to secure the cover to the wall were missing. Further review revealed the length of the electrical cords from the bed to the wall outlet were long enough to pose a ligature risk.
Room "a" had a 55 inch cord on the bed near the door and a 50 inch cord on the bed near the window.
Room "b" had a 43 inch cord on the bed near the door and a 39 inch cord on the bed near the window.
Room "c" had only one bed in the room with a 63 inch cord on the bed.
Room "d" had a 66 inch cord on the bed near the door and a 60 inch cord on the bed near the window.
Room "e" had a 64 inch cord on the bed near the door and a 34 inch cord on the bed near the window.
Room "f" had a 46 inch cord on the bed near the door and an 83 inch cord on the bed near the window.

In an interview on 09/10/14 at 10:10 a.m. during the above observation, S2BH Nurse Manager confirmed that the electrical cords from the bed to the wall outlet could pose a ligature risk for patients. He indicated that the hospital does admit patients with suicide ideations and who may be placed on suicide precautions.

3) Having the toilet plumbing not enclosed to prevent tampering, the covering used to secure the sink plumbing not screwed tightly, and a plastic liner in the garbage can in the bathroom used by patients in seclusion:
Observation of the bathroom used by patients in seclusion 09/08/14 at 9:57 a.m. with S2BH Nurse Manager present revealed the toilet plumbing was not enclosed to prevent tampering, the cover used to secure the sink plumbing from tampering was loose and able to be pulled away from the wall, and the garbage can was lined with a plastic liner.

In an interview on 09/08/14 at 9:57 a.m., S2BH Nurse Manager indicated that the bathroom was used by staff when a patient was not in seclusion, and the plastic liner would be removed if a patient was in seclusion. He confirmed the absence of a cover to the toilet plumbing and unsecured cover over the sink plumbing.

4) Having all room entrance doors and doors to patients' bathrooms with hinges with separations that pose a ligature risk:
Observation of the patient rooms and bathrooms within the patient rooms on 09/08/14 at 10:05 a.m. revealed all the doors had hinges with wide spaces between each hinge that presented a risk for ligature.

In an interview on 09/08/14 at 10:05 a.m., S2BH Nurse Manager indicated that patients were allowed in their rooms and bathrooms unattended by staff if they were not on 1:1 or visual contact observation levels. He confirmed that the hinges were a ligature risk.

5) Having all patient bathrooms' toilet plumbing exposed that posed a risk for tampering:
Observation of the patient bathrooms in Rooms "a", "b", "c", "d", "e", and "f" on 09/08/14 at 10:05 a.m. revealed the toilet plumbing was not covered leaving it exposed and a risk for tampering. This observation was confirmed by S2BH Nurse Manager who was present during the observation.

6) Having each patient bed mattress with a vinyl/plastic covering that could be unzipped and provide a means of suffocation:
Observation of the patient Rooms "a", "b", "c", "d", "e", and "f" on 09/08/14 at 10:05 a.m. revealed each room had a vinyl/plastic covering on the mattress that could be unzipped around the entire circumference of the mattress that would present a risk for suffocation. This observation was confirmed by S2BH Nurse Manager who was present at the time of the observation.

7) Having a 5 to 6 feet rubber hose hanging from the shower head in the patient shower room that posed a ligature risk:
Observation of the shower room on the Geriatric Behavioral Health Unit on 09/08/14 at 10:20 a.m. revealed a 5 to 6 feet rubber hose was hanging from the shower head that provided a ligature risk.

In an interview on 09/08/14 at 10:20 a.m., S2BH Nurse Manager indicated that staff stood outside the closed door while patients were in the shower. He confirmed that the long rubber hose was a ligature risk.

Based on record reviews and interviews, the hospital failed to ensure that each patient was free from all forms of neglect (a form of abuse) as evidenced by failure to provide an effective intervention to prevent patient injury during periods of aggression and combativeness for 1 (#2) of 1 patient record reviewed with self-injury from a total sample of 5 patient records (#1 - #5) as evidenced by Patient #2 fractured the 2nd metacarpal of her left hand and had bruising to her scalp, right hip, and right side of her face near her eye caused by her continued slapping and punching the walls and chairs, "banging" her head against the floor, and hitting and scratching her face with no further intervention implemented when one-to-one (1:1) monitoring and placing mattresses on the floor did not prevent Patient #2 from injuring herself.
Findings:

Review of the "Hospital Abuse/Neglect Initial Report" presented by S2BH (Behavioral Health) Nurse Manager revealed the report that was completed by S15Resource Chief Clinical Officer (CCO) on 09/03/14 and sent to DHH (Department of Health and Hospitals) revealed the type of incident was "other" (other choices to select were alleged sexual abuse, alleged physical abuse, alleged neglect). Further review revealed the first employee who became aware of the allegation was S4RN (registered nurse) who was questioned by Patient #2's daughter about her mother's facial bruising and swelling/bruising to the left hand. Further review revealed the following description of the alleged incident: "During the visitation of this patient (Patient #2) on 08/30/14, the daughter was surprised to see that her mother had lip and facial bruising, in addition to bruising/swelling of left hand. According to the daughter, these injuries were (should read not apparent) apparent during her visit on 8/29/14. The daughter's perception is that 1 of 3 things occurred that caused her mother's injuries: 1) mother had altercation with another patient; 2) mother caused injuries to herself; 3) an employee of facility assigned to her mother's care "lost control". Based on internal facility investigation, it has not been determined how injuries occurred. Etiology of injuries not known..." Further review revealed left hand x-ray on 08/30/14 revealed a 2nd metacarpal fracture to the left hand.

Review of Patient #2's medical record revealed she was a 75 year old female admitted on 08/19/14 with an admitting diagnosis of Dementia. Patient #2 was transferred to another psychiatric hospital on 09/05/14. Review of her psychiatric evaluation conducted on 08/20/14 by S16APRN (advanced practice registered nurse) PMHNP (psychiatric mental health nurse practitioner) revealed her diagnosis was Dementia: Alzheimer's Type with Behavioral Disturbance and identified problems were altered thought, increased confusion, and assaultive behavior.

Review of Patient #2's "Physician Admission Orders" dated 08/19/14 at 1:00 a.m. revealed she was to have 1:1 observation. Review of her "Physician Order" revealed an order on 08/25/14 (no documented evidence of the time the order was written) by S12Psychiatrist to have at least 2 mattresses in the room on the floor and the bed removed from the room in the morning. Further review revealed a telephone order received by S4RN (registered nurse) from S12Psychiatrist on 08/30/14 at 3:30 p.m. for an x-ray of Patient #2's left hand due to swelling with a subsequent telephone order received by S4RN from S12Psychiatrist on 08/30/14 at 6:51 p.m. to consult Orthopedics related to fractured left hand. Further review revealed an order written by S12Psychiatrist on 09/02/14 (unable to read the time written) that read as "If the resources are available suggest adding more mattresses to floor if there has been difficulty keeping patient off hard portion of floor."

Review of Patient #2's "Wound Care Photo Documentation 09/02/2014" revealed pictures of a bruise to Patient #2's scalp, a bruise to the right side of her face near the eye, an area of discoloration to the sacrum, and a bruise to the right hip.

Review of Patient #2's computerized "Nurses notes" revealed the following entries:
08/23/14 at 7:20 a.m. by S14RN - patient is kicking, hitting, and spitting on staff; ran head first into another staff member;
08/24/14 at 6:23 a.m. by S17RN - client did not sleep through the night... screaming, spitting at staff and peers... continues to punch, scratch, and bite at 1:1 staff; S12Psychiatrist notified Ativan was not effective;
08/26/14 at 1:47 a.m. by S13RN - abrasions noted to bilateral extremity; large purple bruise noted to right lateral thigh and right lower deltoid;
08/26/14 at 11:50 a.m. by S14RN - spitting on floor and hitting on the chair with her hand, fist, and feet;
08/26/14 at 11:56 a.m. by S14RN - scattered bruises/scratches, most scratches self inflicted to upper and lower extremities and buttock area;
08/26/14 at 9:28 p.m. by S13RN - multiple abrasions to bilateral upper and lower extremities with purplish bruising to right lower deltoid area, right lateral thighs, left upper arm, and coccyx area;
08/30/14 at 7:32 p.m. by S13RN - bruise noted to right and left cheeks, outer area of right eye, and patient's right upper lip;
08/30/14 at 10:46 p.m. by S13RN - multiple bruises to bilateral upper and lower extremities; left hand swollen; quarter-sized bruise noted to the crown of patient's scalp;
09/02/14 at 6:00 p.m. by S14RN - greenish color bruising to right cheek, jaw, lip, eye, and chin; greenish color bruise to left cheek/chin; top of head with red bruise to top of head; right hip with large red bruise; scattered greenish/blue bruises to lower extremities; some scabbed areas as well as bruises to upper extremities;
09/03/14 at 6:16 p.m. by S14RN - while walking back to the day area, the patient jerked her arm away and began "beating her elbow against the wall";
09/04/14 at 12:15 a.m. by S13RN - MHT (mental health tech) reported patient slapping her hand on the side of the chair; patient redirected on several occasions;
09/04/14 at 6:16 a.m. by S13RN - MHT reported patient slapping her hand on her chair; no new bruising noted to her body.

Review of Patient #2's "Nurses notes" revealed no documented evidence of Patient #2 continually slapping and punching the walls, "banging" her head against the floor, and hitting and scratching her face. There was no documented evidence of how Patient #2 obtained the self-inflicted injuries noted above by multiple RNs. There was no documented evidence of interventions implemented to provide a safe environment for Patient #2 when it was determined that medication administration, 1:1 monitoring by staff, and mattresses on the floor were not successful in preventing Patient #2 from inflicting injury to herself.

In an interview on 09/09/14 at 12:50 p.m., S4RN indicated that she couldn't say that she witnessed any activity by Patient #2 that could have resulted in bruises to her scalp, face, and hip.

In a telephone interview on 09/09/14 at 2:55 p.m., S5MHT indicated she was assigned to observe Patient #2 1:1 at least twice. She further indicated that she never witnessed Patient #2 rolling to the floor, but she witnessed her beating the walls and the geri-chair with her hands. She further indicated that when Patient #2 was assigned to another MHT, she (S5MHT) witnessed Patient #2 on the floor, hitting her fist on the walls and floor, and "bobbing her head against the floor."

In a telephone interview on 09/09/14 at 3:10 p.m., S6MHT indicated he was assigned to monitor Patient #2 one-to-one on the day shift (7:00 a.m. to 7:00 p.m.) on 08/29/14 and 08/30/14. He further indicated that Patient #2's hand was bruised on 08/29/14 but not swollen. He indicated that Patient #2 was "banging" her hands on the floor, walls, and geri-chair and had a bruise to her right eye where she had scratched herself. He further indicated that she had been hitting herself all day like she was arguing with someone and punched herself in the face a couple of times. When asked if Patient #2 had punched herself in the right eye, S6MHT answered, "she punched all over and had blood on her teeth... busted her lip." He further indicated that Patient #2 was hitting herself the "whole time she was here." He further indicated that he thought he noticed the "busted lip" on 08/30/14 when he saw dried blood on her teeth, but he knew that he noticed her eye on 08/29/14. S6MHT indicated he told the RN on 08/29/14 about Patient #2 hitting herself, but he didn't report anything about her right eye. He indicated that he did not witness Patient #2 hitting her lip but did witness her scratching her right eye. He further indicated that he saw her "bang her head on the floor", and she had a bruise in the back of her head on top. S6MHT indicated that he reported this information when S2BH (Behavioral Health) Nurse Manager and S15Resource CCO spoke with him.

In a telephone interview on 09/09/14 at 3:25 p.m., S7MHT indicated that she was assigned to observe Patient #2 3 or 4 times and was assigned to Patient #2 on 08/29/14 from 7:00 p.m. to 7:00 a.m. on 08/30/14. She further indicated that there were 2 mattresses on the floor, and Patient #2 would scoot off the mattress onto the floor. She indicated that Patient #2's right eye was bruised when she came to work on 08/29/14. She further indicated that the eye was "blood shot with a bruise next to it", and she had dried blood on her teeth and an abrasion on the outside corner of her lip. She indicated that Patient #2 would "bang her head on the floor." When asked what she did when she witnessed Patient #2 "banging her head", S7MHT answered, "she would hit us and punch the staff, there was nothing to combat it." She indicated that the nurse tried to give Patient #2 medication, but Patient #2 would spit the medication out her mouth. She indicated that she would report Patient #2 banging her head to the nurse, and the nurse could hear Patient #2 from the nursing station, because Patient #2 usually screamed during this behavior. S7MHT indicated that Patient #2 didn't sleep at all the night of 08/29/14 and was combative and aggressive all night.

In an interview on 09/09/14 at 3:40 p.m., S8LCSW (licensed clinical social worker) indicated they have had a "lot of combative patients" recently. She further indicated that when a patient is exhibiting self-injurious behavior, the team is supposed to problem-solve as a group to seek interventions to prevent self-injury. She indicated that she was not aware of the behaviors of banging her head, hitting/punching herself in the face, and hitting the walls and geri-chair arms. S8LCSW indicated these type behaviors was not discussed during the treatment team meeting held on 08/26/14. She indicated that S4RN told her on 08/31/14 about Patient #2's fractured hand. When she asked S4RN how the fracture happened, she indicated that S4RN said the "documentation said she was hitting the chair."

In an interview on 09/10/14 at 10:35 a.m., S2BH Nurse Manager indicated that Patient #2 was neglected due to failed attempts to prevent her from injuring herself.

In an interview on 09/10/14 at 10:40 a.m., S9LPC (licensed professional counselor) indicated she knew that Patient #2 was "picking and scratching her arms", but she was never told that Patient #2 was punching her face and scratching her eye. She further indicated they "provided extensive support to reduce self-injury and basically that was the 1:1." She further indicated that tried changing her medications and giving her some space. S9LPC confirmed no other interventions were implemented when the 1:1 and medication changes were not successful in preventing Patient #2 from self-injurious behavior.

In a telephone interview on 09/10/14 at 1:20 p.m., S12Psychiatrist indicated that he could believe that Patient #2 was injuring herself, but no RN documented it in her chart. He further indicated that he didn't find out about the injurious behavior until he received a phone call from a RN saying that Patient #2's daughter noticed that her (Patient #2) hand was swollen. He further indicated that he wasn't told about any bruising at the time of the call. S12Psychiatrist indicated that there seemed "to be a breakdown of information (regarding Patient #2) and how it was traveling." When asked if he was informed that Patient #2 was punching herself and scratching her face, he answered, "No, I would have ordered medications or gotten on the floor with her again." When asked about no changes in interventions made to keep Patient #2 from self-injury when 1:1 and mattresses on the floor wasn't effective, S12Psychiatrist answered, "increasing staff is an administrative issue... do you know how hard it was to get mattresses on the floor?"

In a telephone interview on 09/10/14 at 2:10 p.m., S13RN indicated that she had never been made aware that Patient #2 was punching and scratching her face on her shift. She further indicated that she didn't hear about this behavior until after Patient #2 was noted to have a fractured hand. S13RN indicated that Patient #2 would flail her hands and bite and kick staff, so 1:1 was ordered to provide safety. She further indicated that no other interventions were implemented to provide safety for Patient #2 other than monitoring her.

In a telephone interview on 09/11/14 at 1:50 p.m., S7MHT indicated that punching the wall meant that Patient #2 would slap the wall with the back of her hand in a waving motion. She further indicated that she would bang her head on the floor or the wall , and it was a "hard bang, not a tap." When asked what she would do when Patient #2 would slap the wall or bang her head on the floor or the wall, S7MHT answered, "I would call the nurse." She indicated that the nurse would come and try to get her to stop by telling her to stop. She further indicated that no physical intervention was attempted to stop the behavior. When asked if she had witnessed Patient #2 punch herself in the face, S7MHT indicated that Patient #2 would grab her face and head with both hands and scream and tried to scratch herself. She further indicated that the night of 08/29/14, Patient #2 did not sleep "at all", and she kept trying to tell her to stop slapping the wall, banging her head on the wall and floor, and grabbing her head and face, but it didn't work.

In a telephone interview on 09/11/14 at 2:00 p.m., S6MHT indicated that Patient #2 would either slap the wall with her fist or with an open hand that was not a tap but a punch. He further indicated that "it was like she was fighting somebody." When asked what he would do when she exhibited this behavior, S6MHT indicated that he would talk to her and try to grab her hands before she could hit, but she would hit him. He further indicated the RN would come to the room to see what Patient #2 was doing, but they (RN) do anything to stop it, because I told them that Patient #2 hit me when I tried to stop her. He further indicated that every time he tried to stop her, she would hit him, so "at some point you say if you want to do that... you're going to beat me up in the process."

In a telephone interview on 09/11/14 at 2:15 p.m., S4RN indicated Patient #2 would hit her open palm of her hand on the arm of the geri-chair when in the day room, and she (S4RN) would tell the MHT to stop her. She further indicated that she never witnessed Patient #2 banging her hands and head when Patient #2 was in her room.

In an interview on 09/11/14 at 2:20 p.m., S14RN indicated Patient #2 hit her fist or open palm hard against the arm of the geri-chair and kick her legs against the chair. She further indicated she would talk to Patient #2 and try to divert her attention at these times.

In an interview on 09/11/14 at 2:40 p.m., S2BH Nurse Manager indicated he saw Patient #2 in the day room attempting to hit or bang her arm against the arm of the geri-chair, and the RN would try to stop her or give her medication. He further indicated that he never witnessed any of the above-mentioned behaviors while Patient #2 was in her room. S2BH Nurse Manager, after reviewing the documentation in Patient #2's medical record and being informed of information gathered during interviews with staff, indicated that "it sounds like the MHTs weren't clearly articulating clearly (to the RNs) what they observed, or whether they did and the nurses were nonchalant, I would hold them both responsible."

Based on record reviews and interviews, the hospital failed to ensure that a physician order was obtained for continued use of seclusion for the management of violent or self-destructive behavior beyond 4 hours for adults 18 years of age or older. The RN (registered nurse) failed to obtain a physician order for continuing seclusion for Patient #2 after 4 hours had elapsed for 1 (#2) of 1 patient record reviewed for restraint/seclusion orders from a total sample of 5 patient records (#1 - #5).
Findings:

Review of the hospital policy titled "Seclusion And Restraint Application", policy number BH 0220 and presented by S2BH (behavioral Health) Nurse Manager as the current restraint/seclusion policy, revealed that a physician's order for restraint/seclusion used to control patient behavior may not exceed 4 hours and must be renewed no leas than every 4 hours.

Review of Patient #2's medical record revealed she was a 75 year old female admitted on 08/19/14 with an admitting diagnosis of Dementia. Patient #2 was transferred to another psychiatric hospital on 09/05/14. Review of her psychiatric evaluation conducted on 08/20/14 by S16APRN (advanced practice registered nurse) PMHNP (psychiatric mental health nurse practitioner) revealed her diagnosis was Dementia: Alzheimer's Type with Behavioral Disturbance and identified problems were altered thought, increased confusion, and assaultive behavior.

Review of Patient #2's "Behavioral Health Restraint and/or Seclusion Nursing Assessment & (and) Physician Order" revealed that S4RN (registered nurse) obtained a telephone order from S12Psychiatrist on 08/21/14 at 3:45 p.m. for seclusion, a therapeutic hold, and a chemical restraint of Zyprexa 10 mg (milligrams) intramuscularly for Patient #2 secondary to Patient #2 attempting to strike, punch, and bite staff. Further review revealed Patient #2 was released from seclusion on 08/21/14 at 9:45 p.m. (6 hours after seclusion was initiated) by S10RN. There was no documented evidence that a physician's order was obtained to continue Patient #2's seclusion after 4 hours.

In an interview on 09/09/14 at 12:50 p.m., S4RN confirmed that she initiated Patient #2's seclusion and restraint on 08/21/14 at 3:45 p.m. She indicated that Patient #2 remained in seclusion when she reported to S10RN at the end of her (S4RN) shift at 7:00 p.m.

In an interview on 09/10/14 at 12:30 p.m., S10RN indicated that she knew another order was needed to continue seclusion, but since Patient #2 was in the seclusion room with the door open, she assumed no order was needed. She confirmed that Patient #2 was not allowed to leave the seclusion room until 9:45 p.m..

In a telephone order on 09/10/14 at 1:20 p.m., S12Psychiatrist confirmed that he did not give another order to continue Patient #2's seclusion beyond 4 hours. He indicated that another order was needed, since she remained in seclusion.

Based on record reviews and interviews, the hospital failed to ensure that a physician or other licensed independent practitioner saw a patient face-to-face within 1 hour after initiation of seclusion when seclusion was used for the management of violent or self-destructive behavior for 1 (#2) of 1 patient record reviewed for the face-to-face assessment by a physician within 1 hour of initiation of seclusion from a total sample of 5 patient records (#1 - #5). Patient #2 failed to have documented evidence of a face-to-face assessment by a physician or other licensed independent practitioner within 1 hour after initiation of seclusion on 08/21/14. Findings:

Review of the hospital policy titled "Seclusion And Restraint Application", policy number BH 0220 and presented by S2BH (Behavioral Health) Nurse Manager as the current restraint/seclusion policy, revealed that the physician or an appropriately trained registered nurse or physician's assistant shall perform a face-to-face assessment of the patient's physical and psychological status within 1 hour of initiation of the restraint. Further review revealed no documented evidence that the policy addressed the need for an assessment by the physician within 1 hour after initiation of seclusion.

Review of Patient #2's medical record revealed she was a 75 year old female admitted on 08/19/14 with an admitting diagnosis of Dementia. Patient #2 was transferred to another psychiatric hospital on 09/05/14. Review of her psychiatric evaluation conducted on 08/20/14 by S16APRN (advanced practice registered nurse) PMHNP (psychiatric mental health nurse practitioner) revealed her diagnosis was Dementia: Alzheimer's Type with Behavioral Disturbance and identified problems were altered thought, increased confusion, and assaultive behavior.

Review of Patient #2's "Behavioral Health Restraint and/or Seclusion Nursing Assessment & (and) Physician Order" revealed that S4RN (registered nurse) obtained a telephone order from S12Psychiatrist on 08/21/14 at 3:45 p.m. for seclusion, a therapeutic hold, and a chemical restraint of Zyprexa 10 mg (milligrams) intramuscularly for Patient #2 secondary to Patient #2 attempting to strike, punch, and bite staff. Further review revealed Patient #2 was released from seclusion on 08/21/14 at 9:45 p.m. (6 hours after seclusion was initiated) by S10RN. Further review revealed no documented evidence that a face-to-face assessment was conducted by a physician or other licensed independent practitioner within 1 hour after initiation of seclusion and restraint as evidenced by the section on the order form for the documentation of the assessment being blank. Review of RN personnel files revealed no RN had been trained and determined to be competent to conduct the face-to-face assessment of patients within one hour of initiation of restraint and seclusion.

In an interview on 09/09/14 at 12:50 p.m., S4RN indicated that she did not remember seeing S12Psychiatrist on the unit on 08/21/14 to perform the face-to-face assessment after she initiated the seclusion and restraint of Patient #2.

In a telephone interview on 09/10/14 at 1:20 p.m., S12Psychiatrist confirmed that he did not conduct a face-to-face assessment of Patient #2 on 08/21/14 within 1 hour after her seclusion and restraint was initiated.

Based on record reviews and interviews, the hospital failed to ensure that the hospital's visitation policies were implemented regarding clinical restrictions and the reasons for the restriction or limitation for 1 (#2) of 1 patient record reviewed with visitation restrictions from a total of 5 (#1 - #5) sampled records. Patient #2 was restricted from visitation by her daughter with no documented evidence that the restriction was based on professional clinical judgment, and there was no documented evidence in Patient #2's medical record of the reason for the restriction.
Findings:

Review of the hospital policy titled "Patient Visitation Rights", policy number H-PC-03-005, effective February 2012 and presented as a current policy by S2BH (Behavioral Health) Nurse Manager, revealed that a patient has the right to choose visits and a right to deny visitors during hospitalization. Further review revealed that these rights include any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights as well as the reasons for the clinical restriction or limitation. Further review revealed that reasonable restrictions may include limiting patient visitation rights based on professional clinical judgment of factors that would interfere with the care, safety and well-being of the patient and/or the care of other patients. Further review revealed that the hospital may deny access to a visitor(s) if that individual(s) has been found to threaten the medical care, safety and well-being of a patient in any manner.

Review of the hospital policy titled "Visitor Regulation", policy number BH 0285 and presented as a current policy for the Geriatric Behavioral Health Unit by S2BH Nurse Manager, revealed that specific visitors are at times restricted by the attending physician to protect the patient or others from harm, intimidation, or harassment. Patients are informed of this possible restriction upon admission. The reason for restrictions is recorded in the appropriate patient care record.

Review of the "Hospital Abuse/Neglect Initial Report" completed by S2BH Nurse Manager on 09/04/14 revealed that the type of incident was "Alleged Physical Abuse" of Patient #2 by her daughter. The description of the alleged incident was as follows: "S5MHT (mental health tech) @ (at) 0623 (6:23 a.m.) on 9/4 by text message made this writer aware that she had witnessed (Patient #2's daughter's name), daughter of Patient #2, a 75 year old Caucasian female then an inpatient at Kindred Hospital New Orleans Geriatric Behavioral Unit, slap the left cheek of Patient #2 with enough force to be audible. The slapping of Patient #2 by (daughter's name) was apparently in response to Patient #2 slapping her daughter during her assisting with ADLs (activities of daily living). S11MHT, an MHT assisting S5MHT with (Patient #2's daughter's name) in performing ADLs, also witnessed (daughter's name) slap the left cheek of her mother, Patient #2. On phone interview with S11MHT @ 1055 (10:55 a.m.) on 9/4/2014, she stated that she did witness the event described above."

Review of Patient #2's medical record revealed she was a 75 year old female admitted on 08/19/14 with an admitting diagnosis of Dementia. Patient #2 was transferred to another psychiatric hospital on 09/05/14. Review of her psychiatric evaluation conducted on 08/20/14 by S16APRN (advanced practice registered nurse) PMHNP (psychiatric mental health nurse practitioner) revealed her diagnosis was Dementia: Alzheimer's Type with Behavioral Disturbance and identified problems were altered thought, increased confusion, and assaultive behavior.

Review of the physician's order section of Patient #2's medical record revealed a "Memorandum" addressed to the Nursing Supervisors and Nursing Staff from S1CEO (Chief Executive Officer) that was dated 09/04/14 regarding "Limited Visitation Privileges for Patient #2 0 6th Floor". Further review revealed that Patient #2's daughter "is restricted from visiting her mother until further notice. Visitation from other family members has not been restricted." Further review revealed the memo was to be attached to the front of Patient #2's chart and a copy of the memo sent to the House Supervisor, Chief Clinical Officer, CEO File, and security. There was no documented evidence in the memo of the reason for limited visitation privileges as required by hospital policy. There was no documented evidence in the medical record that the limitation of visitation privileges was based on professional clinical judgment as required by hospital policy as evidenced by no documented evidence of discussion with S12Psychiatrist who was the attending physician of Patient #2.

In an interview on 09/09/14 at 1:35 p.m., S1CEO indicated that S2BH Nurse Manager had informed him that 2 of the MHTs had reported that Patient #2's daughter had slapped her mother, and they had told Patient #2's daughter that she needed to report to the nurse that she had slapped Patient #2. He further indicated that he when he spoke with Patient #2's daughter by phone, she confirmed that she had not reported to the nurse that she had slapped her mother. He further indicated that she denied slapping her mother and said that she was holding her mother's chin in order to hold her head still while the MHTs were trying to change her diaper. S1CEO indicated that he asked Patient #2's daughter if she thought her action could have been perceived as slapping her or aggressive, and Patient #2's daughter said no. S1CEO indicated he was guided by the hospital's legal department to restrict Patient #2's daughter's visiting privileges.

In a telephone interview on 09/10/14 at 1:20 p.m., S12Psychiatrist indicated that he heard "third hand about Patient #2's daughter slapping her." He further indicated that his plan was to allow visitation in the day room only, so the staff could be present during visitation. He indicated that he found out the an administrative decision was made to ban Patient #2's daughter from the unit. He confirmed that no one in administration conferred with him about the decision, and there was no documentation in Patient #2's record of the reason that Patient #2's visitation privileges had been restricted.

Based on record reviews and interviews, the hospital failed to ensure that the RN (registered nurse) supervised and evaluated the nursing care of each patient as evidenced by:

1) Failing to develop an effective system of communication of patient behaviors between the RNs and MHTs (mental health techs) so effective interventions to prevent patient injury during periods of aggression and combativeness could be implemented for 1 (#2) of 1 patient record reviewed with self-injury from a total sample of 5 patient records (#1 - #5). This failed communication system and ineffective interventions to prevent patient self-injury contributed to Patient #2 fracturing the 2nd metacarpal of her left hand and bruising her scalp, right hip, and right side of her face near her eye caused by her continued slapping and punching the walls and chairs, "banging" her head against the floor, and hitting and scratching her face with no further intervention implemented when one-to-one (1:1) monitoring and placing mattresses on the floor did not prevent Patient #2 from injuring herself;

2) Failing to implement the hospital's policy that required a patient being transferred to the Intensive Care Unit (ICU) to be discharged and the re-admitted upon the patient's return to the Geriatric Behavioral Health Unit (BH) for 1 (#3) of 1 patient record reviewed who was transferred to ICU from a total sample of 5 patient records. Patient #3 was an inpatient on the Geriatric Behavioral Health Unit during the time of the survey, was transferred to ICU and upon her return to the Geriatric Behavioral Health Unit failed to have an admission nursing assessment conducted as required by hospital policy. Findings:

1) Failing to develop an effective system of communication of patient behaviors between the RNs and MHTs (mental health techs) so effective interventions to prevent patient injury during periods of aggression and combativeness could be implemented:
Review of the hospital policy titled "Assessment/Re-Assessment - Interdisciplinary Patient", policy number H-PC 04-009 PRO" and presented as the current policy for nursing assessment by S2BH Nurse Manager, revealed that patients are re-evaluated by a licensed nurse at a minimum every 12 hours based on level of care and patient care needs. Further review revealed that an RN directs the nursing care of every patient through delegation and supervision to other nursing and non-nursing personnel. Patient re-assessment is used to evaluate the patient's response to care, treatment, and services and to respond to a significant change in status and/or diagnosis or condition. All nursing assessments and re-assessments are to be recorded in the patient's medical record by a licensed nurse.

Review of Patient #2's medical record revealed she was a 75 year old female admitted on 08/19/14 with an admitting diagnosis of Dementia. Patient #2 was transferred to another psychiatric hospital on 09/05/14. Review of her psychiatric evaluation conducted on 08/20/14 by S16APRN (advanced practice registered nurse) PMHNP (psychiatric mental health nurse practitioner) revealed her diagnosis was Dementia: Alzheimer's Type with Behavioral Disturbance and identified problems were altered thought, increased confusion, and assaultive behavior.

Review of Patient #2's "Physician Admission Orders" dated 08/19/14 at 1:00 a.m. revealed she was to have 1:1 observation. Review of her "Physician Order" revealed an order on 08/25/14 (no documented evidence of the time the order was written) by S12Psychiatrist to have at least 2 mattresses in the room on the floor and the bed removed from the room in the morning. Further review revealed a telephone order received by S4RN (registered nurse) from S12Psychiatrist on 08/30/14 at 3:30 p.m. for an x-ray of Patient #2's left hand due to swelling with a subsequent telephone order received by S4RN from S12Psychiatrist on 08/30/14 at 6:51 p.m. to consult Orthopedics related to fractured left hand. Further review revealed an order written by S12Psychiatrist on 09/02/14 (unable to read the time written) that read as "If the resources are available suggest adding more mattresses to floor if there has been difficulty keeping patient off hard portion of floor."

Review of Patient #2's "Wound Care Photo Documentation 09/02/2014" revealed pictures of a bruise to Patient #2's scalp, a bruise to the right side of her face near the eye, an area of discoloration to the sacrum, and a bruise to the right hip.

Review of Patient #2's computerized "Nurses notes" revealed the following entries:
08/23/14 at 7:20 a.m. by S14RN - patient is kicking, hitting, and spitting on staff; ran head first into another staff member;
08/24/14 at 6:23 a.m. by S17RN - client did not sleep through the night... screaming, spitting at staff and peers... continues to punch, scratch, and bite at 1:1 staff; S12Psychiatrist notified Ativan was not effective;
08/26/14 at 1:47 a.m. by S13RN - abrasions noted to bilateral extremity; large purple bruise noted to right lateral thigh and right lower deltoid;
08/26/14 at 11:50 a.m. by S14RN - spitting on floor and hitting on the chair with her hand, fist, and feet;
08/26/14 at 11:56 a.m. by S14RN - scattered bruises/scratches, most scratches self inflicted to upper and lower extremities and buttock area;
08/26/14 at 9:28 p.m. by S13RN - multiple abrasions to bilateral upper and lower extremities with purplish bruising to right lower deltoid area, right lateral thighs, left upper arm, and coccyx area;
08/30/14 at 7:32 p.m. by S13RN - bruise noted to right and left cheeks, outer area of right eye, and patient's right upper lip;
08/30/14 at 10:46 p.m. by S13RN - multiple bruises to bilateral upper and lower extremities; left hand swollen; quarter-sized bruise noted to the crown of patient's scalp;
09/02/14 at 6:00 p.m. by S14RN - greenish color bruising to right cheek, jaw, lip, eye, and chin; greenish color bruise to left cheek/chin; top of head with red bruise to top of head; right hip with large red bruise; scattered greenish/blue bruises to lower extremities; some scabbed areas as well as bruises to upper extremities;
09/03/14 at 6:16 p.m. by S14RN - while walking back to the day area, the patient jerked her arm away and began "beating her elbow against the wall";
09/04/14 at 12:15 a.m. by S13RN - MHT (mental health tech) reported patient slapping her hand on the side of the chair; patient redirected on several occasions;
09/04/14 at 6:16 a.m. by S13RN - MHT reported patient slapping her hand on her chair; no new bruising noted to her body.
Review of Patient #2's "Nurses notes" revealed no documented evidence of Patient #2 continually slapping and punching the walls, "banging" her head against the floor, and hitting and scratching her face. There was no documented evidence of how Patient #2 obtained the self-inflicted injuries noted above by multiple RNs. There was no documented evidence of interventions implemented to provide a safe environment for Patient #2 when it was determined that medication administration, 1:1 monitoring by staff, and mattresses on the floor were not successful in preventing Patient #2 from inflicting injury to herself.

In an interview on 09/09/14 at 12:50 p.m., S4RN indicated that she couldn't say that she witnessed any activity by Patient #2 that could have resulted in bruises to her scalp, face, and hip.

In a telephone interview on 09/09/14 at 2:55 p.m., S5MHT indicated she was assigned to observe Patient #2 1:1 at least twice. She further indicated that she never witnessed Patient #2 rolling to the floor, but she witnessed her beating the walls and the geri-chair with her hands. She further indicated that when Patient #2 was assigned to another MHT, she (S5MHT) witnessed Patient #2 on the floor, hitting her fist on the walls and floor, and "bobbing her head against the floor."

In a telephone interview on 09/09/14 at 3:10 p.m., S6MHT indicated he was assigned to monitor Patient #2 one-to-one on the day shift (7:00 a.m. to 7:00 p.m.) on 08/29/14 and 08/30/14. He further indicated that Patient #2's hand was bruised on 08/29/14 but not swollen. He indicated that Patient #2 was "banging" her hands on the floor, walls, and geri-chair and had a bruise to her right eye where she had scratched herself. He further indicated that she had been hitting herself all day like she was arguing with someone and punched herself in the face a couple of times. When asked if Patient #2 had punched herself in the right eye, S6MHT answered, "she punched all over and had blood on her teeth... busted her lip." He further indicated that Patient #2 was hitting herself the "whole time she was here." He further indicated that he thought he noticed the "busted lip" on 08/30/14 when he saw dried blood on her teeth, but he knew that he noticed her eye on 08/29/14. S6MHT indicated he told the RN on 08/29/14 about Patient #2 hitting herself, but he didn't report anything about her right eye. He indicated that he did not witness Patient #2 hitting her lip but did witness her scratching her right eye. He further indicated that he saw her "bang her head on the floor", and she had a bruise in the back of her head on top. S6MHT indicated that he reported this information when S2BH (Behavioral Health) Nurse Manager and S15Resource CCO spoke with him.

In a telephone interview on 09/09/14 at 3:25 p.m., S7MHT indicated that she was assigned to observe Patient #2 3 or 4 times and was assigned to Patient #2 on 08/29/14 from 7:00 p.m. to 7:00 a.m. on 08/30/14. She further indicated that there were 2 mattresses on the floor, and Patient #2 would scoot off the mattress onto the floor. She indicated that Patient #2's right eye was bruised when she came to work on 08/29/14. She further indicated that the eye was "blood shot with a bruise next to it", and she had dried blood on her teeth and an abrasion on the outside corner of her lip. She indicated that Patient #2 would "bang her head on the floor." When asked what she did when she witnessed Patient #2 "banging her head", S7MHT answered, "she would hit us and punch the staff, there was nothing to combat it." She indicated that the nurse tried to give Patient #2 medication, but Patient #2 would spit the medication out her mouth. She indicated that she would report Patient #2 banging her head to the nurse, and the nurse could hear Patient #2 from the nursing station, because Patient #2 usually screamed during this behavior. S7MHT indicated that Patient #2 didn't sleep at all the night of 08/29/14 and was combative and aggressive all night.

In an interview on 09/09/14 at 3:40 p.m., S8LCSW (licensed clinical social worker) indicated they have had a "lot of combative patients" recently. She further indicated that when a patient is exhibiting self-injurious behavior, the team is supposed to problem-solve as a group to seek interventions to prevent self-injury. She indicated that she was not aware of the behaviors of banging her head, hitting/punching herself in the face, and hitting the walls and geri-chair arms. S8LCSW indicated these type behaviors was not discussed during the treatment team meeting held on 08/26/14. She indicated that S4RN told her on 08/31/14 about Patient #2's fractured hand. When she asked S4RN how the fracture happened, she indicated that S4RN said the "documentation said she was hitting the chair."

In an interview on 09/10/14 at 10:40 a.m., S9LPC (licensed professional counselor) indicated she knew that Patient #2 was "picking and scratching her arms", but she was never told that Patient #2 was punching her face and scratching her eye. She further indicated they "provided extensive support to reduce self-injury and basically that was the 1:1." She further indicated they tried changing her medications and giving her some space. S9LPC confirmed no other interventions were implemented when the 1:1 and medication changes were not successful in preventing Patient #2 from self-injurious behavior.

In a telephone interview on 09/10/14 at 1:20 p.m., S12Psychiatrist indicated that he could believe that Patient #2 was injuring herself, but no RN documented it in her chart. He further indicated that he didn't find out about the injurious behavior until he received a phone call from an RN saying that Patient #2's daughter noticed that her (Patient #2) hand was swollen. He further indicated that he wasn't told about any bruising at the time of the call. S12Psychiatrist indicated that there seemed "to be a breakdown of information (regarding Patient #2) and how it was traveling." When asked if he was informed that Patient #2 was punching herself and scratching her face, he answered, "No, I would have ordered medications or gotten on the floor with her again." When asked about no changes in interventions made to keep Patient #2 from self-injury when 1:1 and mattresses on the floor wasn't effective, S12Psychiatrist answered, "increasing staff is an administrative issue... do you know how hard it was to get mattresses on the floor?"

In a telephone interview on 09/10/14 at 2:10 p.m., S13RN indicated that she had never been made aware that Patient #2 was punching and scratching her face on her shift. She further indicated that she didn't hear about this behavior until after Patient #2 was noted to have a fractured hand. S13RN indicated that Patient #2 would flail her hands and bite and kick staff, so 1:1 was ordered to provide safety. She further indicated that no other interventions were implemented to provide safety for Patient #2 other than monitoring her.

In a telephone interview on 09/11/14 at 1:50 p.m., S7MHT indicated that punching the wall meant that Patient #2 would slap the wall with the back of her hand in a waving motion. She further indicated that she would bang her head on the floor or the wall , and it was a "hard bang, not a tap." When asked what she would do when Patient #2 would slap the wall or bang her head on the floor or the wall, S7MHT answered, "I would call the nurse." She indicated that the nurse would come and try to get her to stop by telling her to stop. She further indicated that no physical intervention was attempted to stop the behavior. When asked if she had witnessed Patient #2 punch herself in the face, S7MHT indicated that Patient #2 would grab her face and head with both hands and scream and tried to scratch herself. She further indicated that the night of 08/29/14, Patient #2 did not sleep "at all", and she kept trying to tell her to stop slapping the wall, banging her head on the wall and floor, and grabbing her head and face, but it didn't work.

In a telephone interview on 09/11/14 at 2:00 p.m., S6MHT indicated that Patient #2 would either slap the wall with her fist or with an open hand that was not a tap but a punch. He further indicated that "it was like she was fighting somebody." When asked what he would do when she exhibited this behavior, S6MHT indicated that he would talk to her and try to grab her hands before she could hit, but she would hit him. He further indicated the RN would come to the room to see what Patient #2 was doing, but they (RN) do anything to stop it, because I told them that Patient #2 hit me when I tried to stop her. He further indicated that every time he tried to stop her, she would hit him, so "at some point you say if you want to do that... you're going to beat me up in the process."

In a telephone interview on 09/11/14 at 2:15 p.m., S4RN indicated Patient #2 would hit her open palm of her hand on the arm of the geri-chair when in the day room, and she (S4RN) would tell the MHT to stop her. She further indicated that she never witnessed Patient #2 banging her hands and head when Patient #2 was in her room.

In an interview on 09/11/14 at 2:20 p.m., S14RN indicated Patient #2 hit her fist or open palm hard against the arm of the geri-chair and kick her legs against the chair. She further indicated she would talk to Patient #2 and try to divert her attention at these times.

In an interview on 09/11/14 at 2:40 p.m., S2BH Nurse Manager indicated he saw Patient #2 in the day room attempting to hit or bang her arm against the arm of the geri-chair, and the RN would try to stop her or give her medication. He further indicated that he never witnessed any of the above-mentioned behaviors while Patient #2 was in her room. S2BH Nurse Manager, after reviewing the documentation in Patient #2's medical record and being informed of information gathered during interviews with staff, indicated that "it sounds like the MHTs weren't articulating clearly (to the RNs) what they observed, or whether they did and the nurses were nonchalant, I would hold them both responsible."

2)Failing to implement the hospital's policy that required a patient being transferred to the ICU to be discharged and then re-admitted upon the patient's return to the Geriatric Behavioral Health Unit:
Review of the hospital policy titled "Transfer Of Patient To Other Services", policy number BH 0270 and presented as a current policy by S2BH Nurse Manager, revealed if a decision is made to move the patient to a medical bed, the patient must be discharged from the Geriatric Behavioral Health Unit. Once the medical condition is improved, readmission to the Geriatric Behavioral Health Unit can be initiated if the patient's symptoms are still present. Discharge and readmission must occur.

Review of Patient #3's medical record revealed she was an 86 year old female admitted to the Geriatric Behavioral Health Unit on 08/28/14 with an admitting diagnosis of Dementia With Behavior Disturbance. Further review revealed Patient #3 was transferred to ICU on 09/02/14 with no documented evidence of a physician's order to transfer Patient #3 to ICU. Patient #3 was not discharged from the Geriatric Behavioral Health Unit and admitted to the LTAC (long term acute care hospital) ICU.

Review of Patient #3's "Physician Order" revealed an order dated 09/05/14 at 12:20 p.m. to transfer her to "Geri Psych". Further review revealed an order on 09/05/14 at 4:03 p.m. to continue all medications, diet, activity, and discontinue telemetry monitoring. There was no documented evidence that Patient #3 was re-admitted to Geriatric Behavioral Health Unit and had a new nursing admission assessment conducted as required by hospital policy.

In an interview on 09/11/14 at 12:50 p.m., S2BH Nurse Manager confirmed that Patient #3 did not have a physician's order documented for her transfer to ICU, and she was not discharged from and re-admitted to the Geriatric Behavioral Health Unit as required by hospital policy.

Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failing to develop a nursing care plan for patients' medical problems for 2 (#3, #4) of 3 current inpatients's care plans reviewed from a total of 4 (#1, #3, #4, #5) inpatients in the sample of 5 patients.
Findings:

Review of the hospital policy titled "Treatment Plan - Initial, Master And Review", policy number BH 0275 and presented as a current policy by S2Behavioral Health (BH) Nurse Manager, revealed a preliminary treatment plan is developed as soon as possible after initial contact and/or during the first 24 hours of admission and will address the patient's presenting and immediate needs. Further review revealed that objectives and interventions pertaining to problems and goals may change during treatment.

Patient #3
Review of Patient #3's medical record revealed she was a 76 year old female admitted on 08/25/14 with an admitting diagnosis of Major Depressive Episode Recurrent. Review of her physician orders revealed wound care orders for the left shoulder wound, a consult for evaluation related to a seizure, and a consult related to Bradycardia and Hypertension (while in the Intensive Care Unit).

Review of Patient #3's "Master Problem List" revealed diagnoses were Dementia Mixed Type With Disturbance of Mood/Behavioral Disturbance, Status Post Shoulder Surgery (staples in place), Chronic Atrial Fibrillation, Hypertension, and Incontinence. Further review revealed the problem identified was Altered Thought Process. There was no documented evidence that Patient #3's nursing care plan included interventions for the wound to the left shoulder and seizure-like symptoms exhibited on 09/02/14 and for Bradycardia and Hypertension upon her transfer to the Geriatric Behavioral Health Unit from the Intensive Care Unit.

Patient #4
Review of Patient #4's medical record revealed she was an 85 year old female admitted on 09/06/14 with an admitting diagnosis of Psychosis. Review of her physician orders revealed she orders for a Combivent Inhaler 14.7 grams/200 daily and Advair Diskus Inhaler 500-50 micrograms/dose daily.

Review of Patient #4's "Master Problem List" revealed her diagnoses were Psychosis Rule Out Dementia With Disturbance Of Mood, Hypertension, Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease, and Hypercholesterolemia. Her identified problem was Altered Thought Process. There was no documented evidence that Patient #4's nursing care plan included interventions and goals related to COPD for which she was receiving respiratory inhalers.

In an interview on 09/11/14 at 12:50 p.m., S2BH Nurse Manager confirmed that Patients #3's and #4's nursing care plans did not include nursing interventions and goals related to their medical diagnoses. He further indicated that he has had a problem with getting the nurses to include medical problems when developing patient care plans.

Based on record reviews and interviews, the hospital failed to ensure that drugs and biologicals were administered in accordance with the orders of the physician and hospital policy for 2 (#1, #2) of 5 patient records reviewed for medication administration from a total of 5 sampled patients. The RNs failed to ensure patient behaviors were assessed and documented prior to administering prn (as needed) medications ordered for aggressive or combative behavior, medications were administered as ordered, prn medication orders had an indication for use, and medications ordered to be given "now" were administered with the same time constraints as medications ordered "stat". The hospital's medication administration policy did not address the time interval to be met for medications ordered to be given "now".
Findings:

Review of the hospital policy titled "Administration of Medications", policy number H-MM 05-001 PRO and presented as a current policy by S2BH (Behavioral Health) Nurse Manager, revealed that one of the 7 "R's" of administering medications to be followed was the right reason. Further review revealed that "stat" was defined as the designation for an actual emergency or life threatening situation where an immediate response is required, and stat medication orders were to be given priority attention. All other activity is suspended until the stat request is completed. Review of all medication administration policies presented by S2BH Nurse Manager revealed no documented evidence of the requirements of a complete medication order that included an indication for use and what time interval of administration was expected for medications ordered to be given "now" by the physician.

Patient #1
Review of Patient #1's medical record revealed she was a 76 year old female admitted on 08/25/14 with an admitting diagnosis of Major Depressive Episode Recurrent. Review of her "Physician Order" revealed an order dated 08/28/14 at 8:00 p.m. for Tums 2 tablets by mouth prn not to exceed 8 tablets in 24 hours; please give 2 tablets tonight if awake; if sleeping give 2 tablets by mouth in the morning. Further review revealed S10RN did not review the order for Tums until 08/29/14 at 12:10 a.m. (4 hours and 10 minutes after the order had been written by the physician. There was no documented evidence of the indication for use for Tums, and there was no clarification order obtained by the RN. Further review revealed a physician's order written on 09/02/14 at 8:00 p.m. for Trazadone 50 mg (milligrams) by mouth every night at bedtime. Further review revealed the nurse did not review the order for Trazadone until 09/03/14 at 10:15 a.m. (14 hours and 15 minutes after the order had been written by the physician).

Review of Patient #1's MARs (medication administration record) presented by S2BH Nurse Manager revealed no documented evidence that Tums was administered to Patient #1 at bedtime on 08/28/14 or in the morning of 08/29/14. Further review revealed the first time Trazadone was administered was on 09/03/14 at 9:15 p.m. (25 hours and 15 minutes after it was initially ordered.

In an interview on 09/08/14 at 11:35 a.m., S2BH Nurse Manager confirmed the physician order for Tums did not include an indication for use. He further that the administration of Tums should have been documented on the MAR if it was given, and Tums was not documented as administered.

In an interview on 09/09/14 at 9:40 a.m., S2BH Nurse Manager indicated that Patient #1 was documented as awake at 10:49 p.m. on 09/02/14 when she was ordered to receive Trazadone at bedtime.

Patient #2
Review of Patient #2's medical record revealed she was a 75 year old female admitted on 08/19/14 with an admitting diagnosis of Dementia. Patient #2 was transferred to another psychiatric hospital on 09/05/14. Review of her psychiatric evaluation conducted on 08/20/14 by S16APRN (advanced practice registered nurse) PMHNP (psychiatric mental health nurse practitioner) revealed her diagnosis was Dementia: Alzheimer's Type with Behavioral Disturbance and identified problems were altered thought, increased confusion, and assaultive behavior.

Review of Patient #2's "Physician Order" revealed the following medications were ordered by telephone by S12Psychiatrist:
08/19/14 at 7:20 a.m. Haldol 5 mg IM (intramuscular) for increased agitation and aggression;
08/19/14 at 3:50 p.m. Zyprexa Zydis 15 mg p.o. (by mouth) times 1 now;
08/20/14 at 4:30 p.m. Zyprexa 10 mg IM times 1 now;
08/21/14 at 8:00 p.m. Zyprexa Zydis 10 mg at bedtime with no route of administration ordered; Zyprexa Zydis 5 mg in the morning with no route of administration ordered; Zyprexa 10 mg IM every 24 hours prn with no indication for use ordered;
08/24/14 at 4:20 a.m. Ativan 1 mg IM times 1 State for increased agitation.

Review of Patient #2's MARs and nurses' notes presented by S2BH Nurse Manager revealed the following related to the above ordered medications:
08/19/14 Haldol was administered at 8:01 a.m. (41 minutes after it was ordered) with no documented evidence of the behaviors exhibited by Patient #2 to warrant the medication;
08/19/14 Zyprexa Zydis 15 mg p.o. was administered at 5:30 p.m. (1 hour and 40 minutes after it was ordered to be given "now") with no documented evidence of the behaviors exhibited by Patient #2;
08/20/14 Zyprexa 10 mg IM was administered at 7:00 p.m. (2 hours and 30 minutes after it was ordered to be given "now") with no documented evidence of patient behaviors;
08/24/14 Ativan 1 mg IM was administered at 4:33 a.m. with no documented evidence of Patient #2's behaviors that warranted the use of prn medication.

In an interview on 09/09/14 at 9:40 a.m., S2BH Nurse Manager indicated that sometimes there may be a delay in administering medications if medication is needed after pharmacy hours, because the nursing supervisor may need to get the medication out the night locker.

In an interview on 09/11/14 at 12:50 p.m., S2BH Nurse Manager confirmed that the RNs did not document the behaviors that Patient #2 was exhibiting prior to her receiving prn medications. He could not explain why there such a delay in the time the medication was ordered and the time that medication was administered.