HospitalInspections.org

Based on document reviews, medical record review, and staff interviews, it was determined the facility failed their policies and procedures for zone monitoring and by not notifying the provider of a change of condition for four (4) out of ten (10) patients, Patient #1, 2, 3, and 4. This failure has the potential to negatively affect all patients receiving care from the facility.

Findings include:

The policy was reviewed titled "Unit Zone Monitoring" effective 4/5/24. The policy states, in part, "Policy Statement: Non-Suicidal Zone Monitor observations are utilized to enhance observation of patients within a specific area of the unit. Purpose of Policy: To provide unit safety, patient support, and monitor patient behaviors across all areas of the unit. Procedures: ... 4. Zone Monitor Assignment ...c. Zone Monitors will provide general observation and interaction with patients in their assigned areas. d. Zone Monitor is to be walking throughout the zone, monitoring patients, patient interactions, as well as interacting with patients ...g. Zone Monitors will assist with support calls in their area and aid in their neighboring zone until additional support arrives to relieve them. Once relieved, Zone Monitor will return to the assigned area."

An observation of the videos was conducted on 11/18/24. Video #1 dated 11/11/24, start time at 7:42:36 p.m. At 7:46:15 p.m. Staff #9 (assigned to Zone 1 watcher per assignment) was sitting watching the hallway, then moved away from the zone into the nurse's station to get hygiene supplies for a Patient. At 7:46:52 p.m. Patients alert staff about an incident in Staff #9's zone.

An interview was conducted on November 19, 2024, at 7:42 a.m., with Staff #7. Staff #7 stated, "I was in Zone 2. [Patient #1] was walking towards me saying you're dead, pointing [their] finger at me. I was talking to [them] when [Patient #4] came up and put [Patient #1] in a chokehold. I separated them and [they] walked away. About fifteen (15) to twenty (20) minutes later I heard yelling and found [Patient #1] on the floor. [Patient #4] was kicking [them] in the gut. I pulled Patient #4 away. As soon as we got hold of [Patient #4], [they] stopped and walked away. [Staff #13] was there. [Staff #6] was the first nurse down there. I don't remember who was in Zone 2. The second time, I was really surprised that [Patient #4] did that. In the zone, you don't walk away from the zone. We monitor two (2) zones, and we switch zones watching every hour."

A phone interview was conducted with Staff #9 on 11/19/24 at Staff #9 states, "I briefly remember, another Patient was agitated, making noise, I was getting shower stuff for another patient, one of the staff asked me for the shower stuff for a Patient, this Patient was on one on one (1:1). In some circumstances we leave the zone, we aren't supposed to; I don't remember if another staff member was at the nursing station. Afterwards, nobody talked to me about the incident on 11/11/24, no nurse manager, nobody at all."

Failure to notify the provider:

A review of the policy titled "Incident Reporting and Review" effective date 08/26/24. The policy states, in part, "...Procedure: 1. Reporting Patient Incidents: The Charge Nurse must assure that the attending provider or designee has been notified, family contacts have been made, Progress Notes completed, and the Incident Report form is accurately completed and signed ... 4. Rules to Remember: All sections of the report must be completed ...Do not place the report in the patient ' s medical record. Document a complete description of the incident in the progress notes. Do not use a co-patient name or patient medical record number in the patient's chart."

A medical record review was conducted for Patient #1. The patient was admitted to the facility on 10/09/2022. A "Behavior Note" 11/11/24 at 9:24 a.m. states, "[Patient #1] was in the breakfast line with peer. [Patient #1] was "in his peer space". [Patient #1] allegedly would not leave peer alone and was pushing them in line. [Patient #1] was struck by a peer in the face, and they quickly separated. De-escalated by staff. Patients remained separated until after breakfast. No injuries on physical assessment. Slight redness on [Patient #1]'s cheek."

A review of a document titled "Addendum Status Completed" 11/11/24 at 5:40 p.m. states, "[Patient #1] and this same peer had another altercation this evening around 1600 [4:00 p.m.] They were both between the quiet room and the day area talking back and forth. Allegedly [Patient #1] had provoked [his/her] peer repeatedly all day and had threatened [him/her]. [Patient #1] had been having altercations with staff and had threatened staff all day as well. This peer struck [Patient #1] in the day room. No injuries present on either patient. Physical assessment WNL (with normal limits). Patients separated and deescalated successfully."

May it be noted, there was no documentation in the medical record a provider was notified after the above incidents.

A medical record was reviewed for Patient #2. Patient #2 was admitted on 08/24/24 to George (G) two (2) then transferred to Nancy (N) one (1) on 09/15/24. Patient #2's ninth (9th) admission to the facility, eloped from [other facility], with history of violence and diagnoses: Bipolar II disorder/Autistic disorder/ borderline personality disorder.

A "Behavior Note" 11/11/24 at 7:09 p.m. states, in part, "At approximately 1600 (4:00 p.m.) this patient was standing in quiet room talking to two (2) [states gender] peers [states gender] peer #1, [states gender] peer #2, staff observed these patients talking for approximately 10 (ten) minutes, then a [gender] health service worker (HSW) observed this patient strike [states gender] peer #1, [states gender] peer #1 was observed stumbling backwards, and exited from quiet room. Where another [states gender] peer [states gender] peer #4 that was sitting in day area struck the [gender] peer #1. This patient came out of quiet room and began yelling at staff telling them about [states gender] peer #1 'get this [expletive] person off this unit, they aren't safe, and I will [expletive] them up' this patient was asked to step away from the situation, staff attempted to verbally de-escalate but this patient continued being verbally aggressive and threatening. No injuries were observed, on-call provider notified."

May it be noted, there was no documentation in the medical record which provider was contacted, or if a response was received.

A medical record review was conducted for Patient #3. The Patient was transferred to the facility on 11/08/24 after a probable cause for being a harm to themself and/or others, rambling speech, and aggressive behaviors. The Patient was diagnosed with Bipolar Disorder (with psychotic features) and admitted to the facility on unit Nancy One (N1).

On 11/11/24 at 8:38 a.m., a "Behavior Note" by Staff #3 states, "[Patient #3] was in the breakfast line with peer. Peer was in '[his/her] space'. This peer in particular has been in multiple altercations in the past couple of days. Peer allegedly would not leave [Patient #3] alone, and was pushing [him/her] in line. [Patient #3] struck peer in the face and they were quickly separated. De-escalated by staff. Patients remain separated until after breakfast."

On 11/11/24 at 5:31 p.m., a "Behavior Note" by Staff #3 states, "[Patient #3] and the same peer had another altercation this evening around 1600 (4:00 p.m.). They were both between the quiet room and the day area talking back and forth. Allegedly [his/her] peer had provoked [him/her] repeatedly all day and had threatened [him/her]. This particular peer had been having altercations with staff and had threatened staff all day as well. [Patient #3] struck this peer in the day room. No injuries present on either patient. Physical assessment WNL. Patient separated and de-escalated successfully."

May it be noted, there is no documentation in the Patient's medical record that the provider was notified of the above incidents.

A medical record review was completed on 11/18/24, for Patient #4. Patient #4 was admitted on September 18, 2024, as a probable forensic cause (PFC) commitment. The Patient has a diagnosis of Intellectual Disability Disorder (IDD) and Attention Deficient Hyperactivity Disorder (ADHD). Patient #4 was admitted to the (Nancy) N-1 unit.

A video review was completed on 11/9/24, of an incident that took place with Patient #4 and Patient #1, on November 11, 2024, at 7:43 p.m. on the N1 unit. The video revealed that the Patient entered the right side of the day area, where Patient #1 was standing. Patient #4 immediately came up behind the Patient #1 and got the patient in a choke hold. Staff #3 and Staff #7 were able to separate the two (2) patients.

A video review was completed on 11/19/24, of the hallway in the N1 unit for the day of November 11, 2024. The video showed that at 7:48 p.m. on November 11, 2024, three minutes after the initial altercation with Patient #1. Patient #1 was walking down the hall, when Patient #4 approached the patient and was hitting the patient. Patient #1 went down to the floor and Patient #4 began stomping on them. Patient #4 was stopped when staff arrived and escorted back down the hall.

May it be noted, there is no documentation in the Patient's medical record of the above incidents.

An interview was conducted with Staff #8 on 11/19/24 at 8:25 a.m. Staff #8 states, in part, "I was on call on 11/11/24. I was told [Patient #1] was attacked by another patient, other peer had [Patient #1] in a choke hold, then the Patient was kicked and stomped on. I came to the unit and saw [Patient #1]...This was the only call I received regarding this patient that day. [Patient #4] immediately was put on two to 1 (2:1) did not ask me about moving [him/her] out of the unit."

An interview was conducted with Staff #2 on 11/19/24 at 9:50 a.m. Regarding notification of the provider for incidents on 11/11/24 involving Patient #1, Patient #2, and Patient #4, Staff #2 states, "I know I talked to the provider three (3) or four (4) times that day. After the 4:00 p.m. incident with [Patient #1] and [Patient #2], I called the provider and left a message. I don't remember who the zone watchers were at shift change, but I do know there wasn't any more assigned after the incident with [Patient #1] around 8:00 p.m."

An interview was conducted with Staff #3 on 11/19/24 at 10:13 a.m. Regarding notification of the provider for incidents on 11/11/24 involving Patient #1 and Patient #3, Staff #2 states, "I don't remember how I contacted the provider or what they said. I would continue to call if the provider didn't call back if it was urgent. I wouldn't consider either incident that day urgent. I don't send text messages to the provider; I would call them directly or leave a message."

An interview was conducted with Staff #12 on 11/19/24 at 9:33 a.m. Regarding notification of providers, Staff #12 states, "There would be no way of knowing if the provider is notified unless it would be on the NCC log, the switchboard log, or documented by nursing."

An interview was conducted with Staff #10 at 11:25 a.m. Regarding telephone logs, Staff #10 explained there was no log from the switchboard for 11/11/24 from unit N1 to be transferred to the provider on call.

An interview was conducted with Staff #11 on 11/19/24 at 11:40 a.m. Regarding the day of 11/11/24, Staff #11 states, "During that day we got the Patient-to-Patient incident reports. We had gotten a few. The unit called us at one (1) point and told us that [Patient #1] was in [Patient #4]'s face and getting in [his/her] perimeter. This was an ongoing situation from the weekend. I would not know if the unit called the doctor. Unless the Patient needs a PRN (as needed medication), or needs immediate attention, they may not call the doctor. It depends on who the nurse is, if they called, I would've called. I would like to know the game plan for the Patient if [he/she] has any behaviors. I didn't witness any of the behavior. If it was just antagonizing other patients, I would not necessarily call, but if it started getting out of control I would."