HospitalInspections.org

482.13 Patient Rights

A hospital must protect and promote each patient's rights.

This CONDITION is not met as evidenced by;

Based on medical record review, staff interviews, employee education, observation and review of the investigation of the physical assault of Patient 2 by Patient 1, the facility failed to ensure the right of Patient 2 to receive care in a safe setting. Please refer to A144.

Per review medical record reviews of Patients 1, 2 and 10, Patient 1 physically assaulted Patient 2 while he/she laid defenseless in bed in a room the two patients shared. Safeguards such as a process to ensure pairings between patients included consideration of mental status issues was not in place. Per interview with Staff A on 11/15/10 at 1:28 PM, Patient 1 was transferred to a semi-private room with Patient 2 primarily because both required isolation for C Difficile. A system to monitor Patients 1 and 10 included bed alarms. It was learned through interview on 11/15/10 with Staff H, one of the nursing supervisors, that both Patient 1 and 10 knew how to disarm the bed alarms and nothing further was implemented. Please see A144.

Per review of physician progress notes written in regard to Patient 1 from 11/05/10-11/11/10, the patient was described as belligerent, hard to manage, paranoid, psychotic, delirious, confused, agitated and demanding regarding requests for more pain medication. Per interview with Staff E, the physician on 11/17/10 between 1:17 PM-2:03 PM, he/she did not consider making a referral to a psychiatrist when the patient was known to have a history of substance abuse. Please see A144.

Per interviews with Staff A and Staff E on 11/17/10, neither was aware of whether or not the facility had a psychiatrist available if a referral to one was made. Staff A is the director of quality management and Staff E is one of the facility's medical directors and Patient 1's attending physician. Per interview with Staff C, the facility administrator, on 11/17/10 at 4:25 PM revealed currently there is one psychiatrist and one psychologist credentialed. Per medical staff bylaws review, both are required to complete a consultation request within 48 hours of receipt. Please see A144.

This deficiency substantiates the allegation contained in complaint OH00058328.

Based on medical record reviews, staff interview, observation, review of education provided to staff relating to managing patient behavior and investigation of an incident which occurred on 11/12/10 between 1:15 AM and 1:25 AM, the hospital failed to ensure Patient 2's right to receive care in a safe setting. This also includes Patient 10, who eloped from the hospital on 11/02/10.

Findings include:

Per review on 11/15/10 of the investigation conducted by facility management of the patient to patient physical assault which occurred on 11/12/10 between 1:15 AM-1:25 AM, it was determined that Patient 1 caused a life threatening facial injury/head injury to Patient 2. Per statements obtained from staff on duty at the time of the incident, Patient 2 had been bathed by Staff J between 1:00 AM-1:15 AM as it was noted Patient 2 was diaphoretic and needed to have the bedding changed. At this time, Patient 2 shared a semi-private room with Patient 1. Per the investigation, Patient 1 was observed outside the room between 1:20 AM and 1:25 AM with an unknown object in his/her hand and stated, "This guy hit me." Patient 1 was then observed to run down the hall to an exit from this 7th floor. When Staff J saw that Patient 1 ran down the hall, she/he saw the door to the semi-private room was closed and went in to discover, "Patient 2 covered with blood." Staff J called for help and hit the code blue button. Per Staff K's written statement, upon entering the room shared by Patient 1 and 2, she found Patient 2 with a bloodied face and a laceration on the side of her/his face. Staff K noticed Patient 2's tracheostomy cannula was out and blood was all over the chest. She/He checked for a pulse and called a code blue. Resting on top of Patient 2's chest was a pulse oximetry unit, a trapeze pole and a telephone receiver. Staff K instructed his/her co-worker to call the police and the medical house officer. Then the code team arrived and Staff K initiated cardiopulmonary resuscitation. A respiratory therapist placed the tracheostomy cannula back in the neck opening and Patient 2 was placed on the ventilator he/she had previously been weaned from. Per investigation timelines, Patient 2 was transferred to the host hospital intensive care unit at 2:20 AM from where he/she was life lighted to a trauma 1 hospital at 6:30 AM. Per interview with Staff A on 11/16/10 at 1:28 PM, Patient 2 expired sometime between 11/14/10 and 11/16/10 at the trauma 1 hospital.

Per medical record review on 11/15/10, Patient 2 was admitted to the facility on 09/29/10 with diagnoses including acute respiratory failure, status post left middle cerebral artery extensive stroke with symptoms of complete right hemiparesis and aphasia, stenting of the right common iliac artery, deep vein thrombosis of the left lower extremity and pneumonia. The patient had a tracheostomy and had been on mechanical ventilation with recent weaning. Patient 2 received tube feedings through a percutaneous gastrostomy tube. Anticoagulation was ordered daily per laboratory results and due to attempts by Patient 2 to dislodge the tracheostomy and indwelling bladder catheter, a mitt on the left hand had been in use since 10/02/10 and was on at the time of the incident. Patient 2 was bed bound and dependent on staff for all activities of daily living.

Per medical record review on 11/15/10 , in the history and physical (H & P) report written on 11/05/10 by Staff E, Patient 1 was admitted to this facility from the host acute hospital on 11/04/10 at 7:00 PM. Diagnoses of this 41 year old included rhabdomyolysis resulting in acute renal failure, encephalopathy possibly secondary to drug overdose, change of mental status, pneumonia on two intravenous antibiotics, anxiety, hypertension, hypothyroidism, congestive heart failure, clostridium difficile, mood disorder and psychosis. The plan for the stay in this facility was to manage the renal failure, keep on telemetry, administer intravenous antibiotics for the pneumonia, pain control with fentanyl, control of anxiety with ativan and depakote, blood pressure control with hydralazine and norvasc, physical and occupational therapies and a high caloric nutrition to be provided. This patient was 6 feet tall and weighed 276 pounds. Per this H & P, Patient 1 was released from prison three weeks prior to the 10/10/10 admission to the host hospital. Patient 1's history included a three year incarceration for heroin abuse and larceny. This report described Patient 1 as awake, very confused with periods of agitation. (Patient 1) swings at people at times. (Patient 1) complains of pain in his/her back and leg. Per interview with Staff A on 11/15/10 at 1:28 PM, Patient 1 had a 1:1 sitter at all times on this date.

Per progress notes written by Staff E, on 11/06/10 at 4:56 PM, Patient 1 was described as awake and alert, needs a sitter as he/she is very agitated at times and behavior is absurd at times. She/He is demanding more pain medications and is anxious. (Patient 1) is known to be a substance abuser in the past. Depakote was increased from 250 milligrams twice daily to 500 milligrams twice daily and seroquel 50 milligrams every 8 hours was ordered. Fentanyl .025 micrograms intravenous every 4 hours as needed was ordered for pain.

Per progress notes written by Staff E on 11/07/10 at 4:41 PM, Patient 1 was described as awake and alert. He/She is very belligerent and very difficult to manage, but mental state is improving every day. Per interview with Staff F on 11/17/10 at 10:15 AM, Patient 1 was in a semi-private room with a 1:1 sitter until 1:00 PM when moved to a private room across from the nurses station.

Per progress notes written by Staff E on 11/08/10 at 3:23 PM, the patient is a lot more awake, but still belligerent and difficult to manage. Is walking around. Trazadone 50 milligrams was ordered for sleep.
Per interview with Staff A on 11/15/10 at 1:28 PM, Patient 1 remained in the private room across from the nurse's station on this date.

Per progress notes written by Staff E on 11/09/10 at 1:55 PM, Patient 1 is more awake, but is still belligerent and difficult to control. Intravenous fentanyl was discontinued and percocet tablet one every 4 hours as needed was ordered for pain. A small blister on the right foot was noted to be open. Patient 1 remained in the private room across from the nurse's station per interview with Staff A on 11/15/10 at 1:28 PM.

Per progress notes written by Staff E on 11/10/10 at 4:11 PM, Patient 1 is looking great now and is walking around and mental state is improving. (Patient 1) wants more pain medication though. Percocet was increased to two tablets every 6 hours as needed. Per interview with Staff A on 11/15/10, Patient 1 remained in the private room across from the nurse's station on this date.

Per progress notes written by Staff E on 11/11/10 at 1:43 PM, patient looks a lot better, walking around with a limp. Antibiotics are finished. For his/her psychosis and delirium, she/he is continued on depakote, trazadone and seroquel. That seems to be helping him/her a lot and it takes the edge off. Also needs occasional percocet. Per interview with Staff A on 11/15/10 at 1:28 PM, Patient 1 was moved to a semi-private room with Patient 2 at 5:23 PM on 11/11/10. Approximately eight hours later, Patient 1 physically attacked Patient 2.

Per interview with Staff E on 11/17/10 from 1:17 PM-2:03 PM in the presence of Staff A, Staff E stated he/she had not considered a psychiatric consultation as (Staff E) is a medical director in a nursing home and has experience managing psychiatric patients and medications. Staff E also stated there is an issue with availability of psychiatrists for consultation at this long term acute care hospital. Per interview with Staff C, the hospital administrator on 11/17/10 at 4:20 PM, stated there is a psychiatrist available for consultation and a psychologist, who are required by hospital bylaws to complete a consultation within 48 hours of referral. Staff E stated in the interview on 11/17/10 between 1:17 PM-2:03 PM that Patient 1 was not in pain but was addicted. Staff E also stated it would not have been in Patient 1's best interest to stop the pain medications during this hospitalization. When Staff E was asked if Patient 1's discharge plan had been to transfer to a facility for detoxification, Staff E stated he/she had not mentioned it to facility staff but was considering that option. Per review of the discharge plan for Patient 1 written by the interdisciplinary team, the plan was to transfer to a skilled nursing facility. Staff E also stated that to his/her knowledge, Patient 1 did not display aggressive or violent behavior during this hospitalization so when made aware of the incident involving the assault of Patient 2 by Patient 1, she/he was completely surprised.

Per interview with Staff G on 11/17/10 between 10:40 AM-11:12 AM, this physical therapy assistant felt "intimidated" by Patient 1 on 11/07/10 when working with him/her in the room. Staff G stated she/he had to awaken Patient 1 on 11/07/10 when entering the room to deliver physical therapy. "(Patient 1) woke up and was agitated initially. (Patient 1) had a bad attitude." Per interview, when Staff G asked Staff F, the sitter with Patient 1 on 11/07/10, if someone needs to watch Patient 1 at all times, Staff F responded, "Yes. (Patient 1) had become combative at an earlier point." Staff G indicated Staff F left the room for approximately 10 minutes and during Staff F's absence, Staff G kept his/her distance from Patient 1 and stood further away, didn't turn her/his back to the patient. Patient 1's behavior was described as "erratic, up and down." Staff G stated that while he/she was working with Patient 1 another nursing assistant entered the room to tell Patient 1 it was not time yet for a pain medication Patient 1 had requested. When the nursing assistant left the room, Staff G stated Patient 1 told her/him the aide was getting on his/her nerves. Then Patient 1 persisted by asking Staff G three times to get her/his pain medication as he/she was "in a lot of pain." Staff G also stated Patient 1 asked where he/she lived and told Staff G he/she smelled good. Per Staff G, this was reported to Staff I, the physical therapist who indicated Staff G could provide therapy in the rehabilitation gym in the future. When Staff I was interviewed on 11/18/10 at 11:24 AM, she/he recalled a conversation with Staff G about Patient 1 but stated Staff G did not reveal all the information to Staff I as had been shared with the surveyor. Per review of facility staff handbook information provided to each staff member upon hire, when a staff member has a "gut feeling" which includes feeling uncomfortable with or frightened by a patient or if a patient displays provacative behavior toward staff to call for backup support. Per interview with Staff I, since Staff G did not say the patient was abusive or lashing out, she/he did not feel it necessary to report this to his/her supervisor. In fact, Staff I told the surveyor Patient 1's behavior described by Staff G would be associated with drug addiction and encephalopathy.

Per physical therapy notes through 11/10/10, Patient 1's gait was unsteady and he/she was not safe to walk without someone right with her/him. Staff I stated a walker was recommended on 11/08/10 and Patient 1 told her/him "Maybe tomorrow." On 11/09/10, Patient 1 refused physical therapy. Per nursing notes, from 11/08/10-11/12/10 Patient 1 had an alarm on his/her bed to alert staff when up in the room as he/she was at high risk for falling. When Staff H was assisting the surveyor to review Patient 1's computerized medical record on 11/15/10 and the surveyor asked why the staff had not been alerted when the alarm went off when Patient 1 was out of bed on 11/12/10 between 1:15 AM-1:25 AM, her response was, "(Patient 1) knew how to disarm the alarm." Per interview with Staff A on 11/17/10 at 11:13 AM, she had not been notified by nursing staff that bed alarms were so easily disarmed by patients. On 11/17/10 at 11:50 AM, the surveyor, while accompanied by Staff A and Staff D, the nurse manager, entered Patient 10's room. Staff H had commented on 11/16/10 that Patient 10 also knew how to disarm the alarm on her/his bed. The surveyor asked Patient 10 to tell her/him about the alarm and Patient 10 stated it beeps at night when she/he tries to get out of bed. When asked if there is anything he/she can do to stop the beeping, Patient 10 got up from the chair, walked to the bed and stated, "I take the batteries out and put them on the window sill." After this observation, Staff A obtained permission from the administrator to order other types of safety devices to alert staff when a patient is out of bed and in the case of Patient 10, when exiting the room.

Per medical record review on 11/16/10, Patient 10 was noted to have eloped from the facility on 11/02/10 after being noted to be missing at 6:15 PM. Per interview with Staff A on 11/17/10 at 11:45 AM, Patient 10 liked to wear street clothes and shoes and walked out of the facility and made it home without being discovered. The facility implemented a missing patient procedure at 6:36 PM when a search of all the rooms in the facility did not locate Patient 10. It was determined at 9:50 PM the patient was at home when a family notified the facility of a telephone call received by Patient 10 telling them he/she was home and wasn't returning to the facility. Per interview with Staff A on 11/17/10, Patient 10 had a peripheral intravenous central catheter in place and was receiving intravenous antibiotics for septic arthritis with incision and drainage of the left shoulder with methicillin resistant staphylococcus aureus. The patient had a history of a cerebrovascular accident and subsequent chronic dementia. Patient 10 returned to the hospital on 11/03/10 at 11:30 AM where she/he remains as of 11/18/10 with no injury reported.

This deficiency substantiates the allegation contained in complaint OH00058328.