HospitalInspections.org

Based on document review and interview, the facility failed to ensure care in a safe setting in 8 instances. (P 1, P 2, P 3, P 4, P 5, P 6, P 7 & P 8)

Findings include:

1. The hospital policy titled, "Patient Rights And Responsibilities", Policy No RE 09, last reviewed 06/2021, indicated patients have the right to be treated in a safe environment with reasonable protection from physical or emotional abuse or harassment.


2. P 1's medical record was reviewed and indicated the patient was a 81 y/o (year/old) admitted on 3/24/23 at 8:09 pm, on an emergency detention order, with the diagnosis of including ,but not limited to, schizoaffective disorder, paranoid schizophrenia, cardiomyopathy, emphysema and hypertension. Admission Review Documentation dated 3/24/23 at 2:07 pm indicated P 1 was transferred from H 3 (Acute Care Hospital) after an incident at H 2 (Rehabilitation Facility) where he/she stabbed a staff member with a writing instrument in the face/head/neck unprovoked. P 1 was not allowed to return to H 2 following the discharge from H 3. P 1 was aggressive with staff at H 3 while refusing a lab drawl attempt, refuses medication, had a recent arrest in 09/23 for swallowing and spraying bleach on customers at a retail store, upon assessment P 1 was oriented to person/place, suspicious/paranoid, guarded, aggressive and hostile. P 1 is currently a court ordered inpatient at H 1.

3. Incident Reports (IR) reviewed related to P 1's aggression and/or violence are as follows:
a. IR dated 3/28/23 at 5:00 pm indicated P 1 pushed P 7 causing him/her to fall for getting too close to P 1's food.
Incident Report (IR) dated 8/15/23 at 5:00 pm indicated P 1 pushed P 2 to the ground for walking near him/her. No injuries noted for P 2. No new orders for P 1.
b. IR dated 4/4/23 at 7:00 am indicated P 1 hit P 7 in the face because P 7 grabbed P 1. P 7 sustained a cut on the nose and a nose bleed. No new orders for P 1.
c. IR dated 5/3/23 at 8:20 am indicated P 1 punched P 4 in the head for grabbing a spoon near P 1 in the Milieu. No injuries were noted for P 4. No new orders for P 1
d. IR dated 5/5/23 at 4:00 pm indicated P 1 pushed P 4 down to the ground for entering his/her room. No injuries were noted for P 4. No new orders for P 1
e. IR dated 5/20/23 at 9:25 pm indicated P 1 pushed P 5 while the patient was ambulating in the Milieu next to P 1' room location. No injuries were noted for P 5. No new orders for P 1.
f. IR dated 5/30/23 at 4:05 pm indicated P 1 poured 1 1/2 cup of water on and pushed P 5 for reaching for a cup that didn't belong to P 5. P 5 slid on the poured water and fell in the milieu. No injuries noted for P 5
g. IR dated 5/31/23 at 11:45 am indicated P 1 dumped P 6 out of his/her wheelchair for entering P 1's room. P 6 sustained two skin tears. No new orders for P 1.
h. IR dated 6/6/23 at 8:00 pm indicated P 1 poured a full cup of water on and punching P 5 in the head for coming into his/her space.
i. IR dated 6/18/23 at 4:00 pm indicated P 1 spilled water on, placed both hands over P 5 's eyes to gouge his/her eyes out for touching him/her by the nurse's station. P 5 sustained a red bruise below the right eye. No new orders for P 1.
j. IR dated 7/30/23 at 2:45 pm indicated P 1 hit P 3 in the head with a small cup for going towards P 1 room. P 3 required an emergency send out as a result of this altercation. No new orders for P 1.
k. IR dated 8/5/23 at 12:10 pm indicated P 1 splashed water in the face of and hit P 3 in the head with a fist for opening the door to P 1's room. P 3 sustained a cut to the right side of the head which required an emergency send out. No new orders for P 1.
l. IR dated 8/5/23 at 8:49 pm indicated P 1 threw a cup of water on P 3 while yelling and verbally threatening him/her. P 3 fell on the floor as a result of the thrown water. No injuries were noted from the fall. No new orders for P 1.
m. IR dated 9/4/23 at 12:45 pm indicated P 1 pushed P 8 down because he/she was tired of P 8.
The MR lacked documentation of initiation of adequate interventions related to (r/t) patient # 2's aggression to ensure other patients were not physically assaulted.


4. In interview on 9/12/23 at approximately 12:00 pm with administrative staff member A 6 (Licensed Practical Nurse), confirmed that P 1 refuses meds, pushes, hits, pours/throws/splashes water on, and is at baseline aggressive towards other patients and A 6 is fearful that P 1 will potentially kill another patient based on displayed behaviors. Staffing is short on days of admission, the facility needs stricter guidelines for admission.

5. In interview on 9/12/23 at approximately 12:30 pm with administrative staff member A 7 (Lead Mental Health Tech), confirmed the facility needs more staff, P 1 is a very violent patient, staff is to sit by his/her door but staffing numbers aren't increased to accommodate and feels there are some admissions of very sick patients that need a higher level care than this facility can provide.

6. In interview on 9/12/23 at approximately 2:30 pm with administrative staff member A 8 (Nurse Practitioner), confirmed P 1 is very well known for violence against others, no increased level of observation was ordered until 6/19/23 and no prn medications are ordered after acts of violence because P 1 is clam post incidents, no adequate interventions were put in place to ensure the above patients received care in a safe setting.

7. In interview on 9/13/23 at approximately 5:30 pm with administrative staff member A 5 (Interim Chief Executive Officer), confirmed the facility is understaffed, P 1's base line is aggressive, the facility was responsible for care in a safe setting and no adequate interventions were put in place to ensure the above patients received care in a safe setting

Based on interview the facility failed to provide credential files for review

Findings include:

1. Files requested by surveyor on 9/13/23 at approximately 10:30 am and again at 3:30 pm.

2. Interview on 9/13/23 at approximately 5:30 pm with administrative staff member A 9 (Interim Chief Executive Officer), confirmed credential files are unable to reviewed at this time due to appropriate personnel in charge of files is currently on berevement leave and no other staff member has access to credential files.

Based on document review and interview the facility failed to provide adequate staffing in 12 instances.


Findings include:

1. The hospital policy titled, "Patient Acuity and Staffing Guide", Policy No. NU 96, last reviewed on 09/2020, indicated the goal of staffing the nursing unit is to ensure patient safety in healthcare delivery.

2. Staffing Matrix indicated if the census was 17-20 patients the minimum staffing requirement is 2 nurses and 3 aides.

3. 1. Staffing Matrix indicated if the census was 17-20 patients the minimum staffing requirement is 2 nurses and 3 aides. Staffing policy indicated the staff to patient ratio was to be 1:4.
2. Staffing Pattern Worksheet was reviewed for the dates listed on incident reports and indicated 12 out of 27 days were understaffed per the facility's staffing matrix . Facility dates understaffed are as follows:
a. 3/25/23 - 2 RN / 2 BHA on for day (7:00 am - 7:30 pm) and night shift (7:00 pm - 7:30 am) with a census of 18.
b. 3/28/23 - 2 RN / 2 BHA for day shift and 2 RN / 2 BHA for night shift with a patient census of 17.
c. 4/9/23 - 2 RN / 2 BHA for day shift and 2 RN / 2 BHA for night shift with a patient census of 17.
d. 5/3/23 - 2 RN / 2 BHA for day shift with a census of 17.
e. 5/14/23 - 2 RN / 2 BHA for day shift and 2 RN / 2 BHA for night shift with a patient census of 18.
f. 5/ 15/23 - 2 RN /2 BHA for day shift with a census of 18.
g. 5/30/23 - 2 RN / 2 BHA for day shift and 2 RN / 2 BHA for night shift with a patient census of 19.
h. 6/14/23 - 2 RN / 2 BHA for day shift with a census of 17.
i. 6/16/23 - 2 RN / 2 BHA for day shift and 2 RN / 2 BHA for night shift with a patient census of 19.
j. 6/18/23 - 2 RN / 2 BHA for day shift with a census of 18.
k. 7/3/23 - 2 RN / 2 BHA for day shift with a census of 19.
l. 9/10/23 - 2 RN / 2 BHA for night shift with a census of 19 .

4. In interview on 9/12/23 at approximately 12:00 pm with administrative staff member A 6 (Licensed Practical Nurse), confirmed that P 1 refuses meds, pushes, hits, pours/throws/splashes water on, and is at baseline aggressive towards other patients and A 6 is fearful that P 1 will potentially kill another patient based on displayed behaviors. Staffing is short on days of admission, the facility needs stricter guidelines for admission.

5. In interview on 9/12/23 at approximately 12:30 pm with administrative staff member A 7 (Lead Mental Health Tech), confirmed the facility needs more staff, P 1 is a very violent patient, staff is to sit by his/her door but staffing numbers aren't increased to accommodate and feels there are some admissions of very sick patients that need a higher level care than this facility can provide.

6. In interview on 9/12/23 at approximately 2:30 pm with administrative staff member A 8 (Nurse Practitioner), confirmed P 1 is very well known for violence against others, no increased level of observation was ordered until 6/19/23 and no prn medications are ordered after acts of violence because P 1 is clam post incidents, no adequate interventions were put in place to ensure the above patients received care in a safe setting.

7. In interview on 9/13/23 at approximately 5:30 pm with administrative staff member A 9 (Interim Chief Executive Officer), confirmed the facility is understaffed, P 1's base line is aggressive, the facility was responsible for care in a safe setting and no adequate interventions were put in place to ensure the above patients received care in a safe setting.

Based on document review the facility failed to obtain an oxygen saturation three times a day as ordered in one of ten patients. (P 10)

Findings include:

1. The hospital failed to follow their policy titled, "Oxygen Therapy", Policy No. NU 04, last reviewed 06/2023, by not ensuring nurses or STNA/CNA/MHT assess oxygen saturation (SPO2) three times daily with vitals signs and as needed.

2. P 10's 's medical record (MR) indicated the patient was an 81 y/o (year/old) admitted on 8/21/2023,with the diagnosis of including ,but not limited to, moderate dementia with behavioral disturbances, hypertension, chronic obstructive pulmonary disease, hyperlipidemia and polyosteoarthritis.
a. Orders Dated 8/21/23 indicated O2 (oxygen) at 2 L (liters) NC (nasal cannula) PRN (as needed) for SOB (shortness of breath) or SPO2 (oxygen saturation) less than 90%, Oxygen for saturations less than 90% - 2LNC , Vital signs TID (three times a day) and PRN.
b. SPO2 readings are as follows:
i. 8/21/23 - 98% at 5:50 pm, 96 % at 8:19 pm
ii. 8/22/23 - 96 % at 3:10 pm, 97 % at 9:15 pm
iii. 8/25/23 - 98% at 9:55 am, 94% at 2:48 pm
c. The medical record lacked documentation of a pulse oximetry reading three times a day with vital signs on 8/21/23, 8/22/23 and 8/25/23.