HospitalInspections.org

43881

Based on observation, review of medical records, and staff interview, it has been determined that the hospital failed to meet the Condition of Participation for Patient Rights §482.13, related to maintaining and providing care in a safe environment by failing to ensure adequate supervision of patients at risk for injurious behavior (A144), failing to prevent a patient-to-patient altercation, and failing to identify, prevent and protect patients from all forms of abuse (A145).

As a result of these findings, Immediate Jeopardy was identified on February 21, 2022, and removed on March 3, 2022, after the State Survey Agency verified that the hospital had implemented interventions to remove the immediate risk to the health and safety of patients.

Findings include:

1. A review of hospital video footage dated 12/10/2021, revealed a patient-to-patient abuse that occurred on the locked Benton Intensive Treatment Unit (ITU). Record review revealed that the patients involved in this incident had a history of violent behavior. At the time of the incident there were no staff present inside the unit to provide protection for the victim and immediately intervene.

During an interview with the Nurse Manager, Staff H on 3/1/2022 at approximately 11:00 AM, she stated patients are routinely monitored by staff who sit outside of the unit by the observation window. Additionally, she acknowledged that the staff member who wittnessed the event failed to report this to their supervisor.

2. A review of hospital video footage dated 12/10/2021, and staff interview, revealed that 53 of 53 patients with psychiatric diagnoses in the Benton Unit were subjected to a physical pat down search performed by uniformed Correctional Officers who were not hospital employees.

3. A review of hospital video footage dated 12/10/2021, and staff interview, revealed that the hospital failed to provide adequate supervision related to safety checks ordered by a physician which were signed off as completed, although upon review of the video footage, the patients were not in the staff member's view. (Refer to A 144)

On 2/21/2022 the hospital was informed of Immediate Jeopardy based on observation of the hospital video dated 12/10/2021 where abuse of a patient was observed as a patient-to-patient assault in the locked unit without staff available inside the unit to provide immediate assistance to the patient. (Refer to A-145)

The hospital provided a resolution plan which indicated that all hospital employees would be provided re-education on the abuse policy, protocols and expectations for hospital employees related to abuse identification, prevention, and reporting to supervisor staff so an investigation can be immediately initiated. This plan was scheduled to be implemented for all employees on the day of the survey and was expected to be completed by all hospital employees on 3/1/2022.

On 3/2/2022 during a return visit, it was identified that all staff had not completed the re-training process as stated in the IJ resolution.

At the conclusion of this survey on 3/3/2022 at 3:15 PM, the hospital had completed a full implementation of the IJ resolution plan, which included the following evidence:

Review of the education provided to the employees revealed re-training in resident rights, dignity, and the abuse/neglect policy with identification, reporting and investigation requirements. Attestations signed by employees were provided as completed.

Observation of the Benton ITU on 3/2/2022, revealed two staff members present inside the physical space of this unit. Review of the hospital schedule going forward revealed a Security Officer and a Mental Health Worker assigned on all shifts.

Interview with the Risk Manager on 3/2/2022, at approximately 9:00 AM, revealed that random video footage is reviewed daily to identify potential concerns.

During an interview on 3/2/2022 at approximately 2:30 PM with the hospital's Administrator, it was revealed that the use of Correctional Officers will no longer be used to conduct contraband searches.






















41728

Based on record review, surveyor observations, and staff interview, it has been determined that the hospital failed to meet the Nursing Services Condition of Participation relative to providing care in accordance with accepted standards of nursing practice.

Findings are as follows:

1. The hospital failed to supervise and evaluate the nursing care of each patient relative to their own Fall Prevention Program and a patient who experienced a fall. (Refer to A-0395)

2. The hospital failed to ensure that nursing staff keep a current nursing care plan for 2 of 4 Patients, ID #'s 1 and 3. (Refer to A-0396)

3. The hospital failed to have all licensed nurses who provide services in the hospital adhere to policies and procedures of the hospital relative to the following:

a. Reporting all abuse, including patient to patient abuse
b. Medication administration (Refer to A0398)
c. Observation of patients with provider ordered safety checks











32374

41728






43881

Based on record review, observation, and staff interview, it has been determined that the hospital failed follow their own policy to protect the rights of patients and provide a safe environment for 53 of 53 patients housed on the Benton Forensic Unit who were subjected to a full pat down body search and room search provided by non-employee Correctional Officers in full uniform brought in by hospital administrators. Additionally, the hospital failed to provide the appropriate supervision, protection, and implementation of measures to prevent and protect patients from abuse for 1 of 1 patient on the Benton Intensive Treatment Unit (ITU) Patient ID #1 and failed to provide evidence of safety checks as ordered by the physician for 3 of 4 patients that had a physician's order for 5- and 15- minute safety checks (Patient ID#'s 3, 6 and 7).

On 2/21/2022 Immediate Jeopardy was identified based on the hospital's inability to ensure that patients are provided care in a safe setting, are free from all forms of abuse, neglect, harassment, or intimidation by others. The hospital failed to have mechanisms/methods in place that protect and ensure patients are free of all forms of abuse, neglect, or harassment.

Findings are as follows:

1. The hospital's policy entitled, "Abuse and Neglect-Guidelines for Screening and Intervention," which was last approved on 6/14/2021 states in part,
"II. POLICY: ...
2. All staff at the ESH are responsible to report actual or suspected cases of abuse and/or neglect. The hospital is responsible to evaluate all allegations, observations and suspected cases of neglect, exploitation, and abuse.
3. Staff suspecting abuse or neglect must report suspicions to his/her supervisor. The supervisor is responsible for initiating appropriate actions including notifying his/her supervisor and administration.
4. The Administrator of Risk Management is responsible to notify applicable licensing bodies and authorities within 24 hours...
IV. DEFINITIONS:
A. Patient Abuse
1. Physical Abuse- Physical force that may result in bodily injury, physical pain, or impairment. The willful infliction of pain or injury upon an older person. Physical abuse may include but is not limited to such acts of violence as striking (with or without an object), hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning....
3. Emotional or Psychological abuse- The infliction of anguish, pain, distress, or mental suffering through verbal assaults, insults, threats, intimidation, humiliation, and harassment: ...
V. MANDATORY REPORTING AND JOINT COMMISSION REQUIREMENTS:
1. Rhode Island Law (23-17.8-2) requires that healthcare practitioners and facility employees report to the Department of Health any form of abuse, mistreatment, or neglect of patients in any facility."

Surveyor observation of a video footage dated 12/10/2021 of the Benton ITU locked unit, revealed that on 12/10/2021 a patient-to-patient assault occurred.

Observed on video footage was an incident where two patients, (who have a history of aggressive behaviors), were noted together in the ITU, a locked area, without staff present inside. Further review of the footage revealed that Patient ID# 3 attacked Patient ID# 1 by physically grabbing her/his arm and bending his/her hand backwards, hyperflexing it and pushing Patient ID# 1 to the floor. Direct care staff were not located inside of the treatment area where they could provide immediate assistance. A staff member was stationed outside of this locked area, viewing the patients through a window. The staff member observing at the window, failed to immediately intervene, and failed to notify a supervisor about the incident as per hospital policy.

During an interview on 2/21/2022 at approximately 9:00 AM with the Benton Nurse Staff A, she stated that Patient ID# 3 was admitted to the ITU for symptoms of aggression and unsafe behaviors. She acknowledged that both patients have behaviors which have been very difficult to manage around other patients resulting in placement in this locked unit.

During an interview on 2/22/2022 with the Nurse Manager, Staff H at approximately 8:45 AM, She acknowledged that the ITU is for placement of patients who have symptoms including aggression and who may not be safe around others, she states it is the routine practice for the Mental Health Worker assigned to work in the ITU to observe patients from a window located outside of the unit. Additionally, she acknowledged that the staff member posted outside of the unit on 12/10/2021 during the observed incident, did not report the assault to their supervisor, or provide immediate assistance to the patient victim.


2. The hospital's policy entitled, "Eleanor Slater Hospital Patient and Unit Search Policy and Procedure" Last reviewed 3/1/2019 Reveals the following:

Purpose:
To establish operational guidelines and policy/procedures for environmental and patient searches. Under the R.I. Mental Health Law all staff will respect patient's rights and dignity during the search procedures. All searches are to ensure risk mitigation and patient safety through an active review of the patients and their environment. It is expected that all prohibited and restricted items known as contraband will be properly identified and stored for disposition to security.

Scope:
This application of this policy is hospital wide. This applies to all Eleanor Slater Hospital (ESH) patients and units for the purposes of maintaining a safe treatment environment for our patients and to ensure the accurate accounting and security of patient's property.

Policy Statements:
1. It is the policy of ESH to conduct a search of the inpatient facility, patient and property ensuring respect and preservation of patients' privacy and dignity as well as safety of patients and staff on the unit. Upon admission the assigned nursing staff will search and collect all patient property and document items on the Patient Property Form and place them in the Patient Property Bag, and seal and lock the property in the designated room in the Benton, Adolph Meyer, Regan or Zambarano building. If any restricted or dangerous Items (contraband) are present the contents will be documented in the medical record and stored in the security office...

Definitions:
1. Contraband: is defined as any item determined to be a threat to patient safety or which is clinically inappropriate for psychiatric care units. (Exhibit A)

b. Pat Down Search: A pat down search is performed by the nursing staff and supervised by the RN. A pat down search may occur whenever there is strong staff concern that a patient may be hiding contraband or dangerous items on his or her person.

c. Civil Units and Forensic units - Pat down Searches: will occur on admission, transfer, and return from outside activities. If there are concerns, a pat down search may be performed upon return from unsupervised privileges in a private room; after a visitor comes onto the unit; after a return to the unit from outside or offsite activities and appointments; before transportation to and after court hearings as well as before and after contact visits....

Surveyor review of the Benton Unit video footage dated 12/10/2021, revealed approximately 12 non-employee uniformed Correctional Officers, (which were brought in by the Hospital Administration), performing physical pat downs and room searches of patients in the Benton Forensic Unit. The video revealed Correctional Officers entering the ITU of the Benton Building and conducting full pat down body searches and/or room searches which began at 9:07 AM and ended on the last unit at 11:15 AM. Officers were observed in the video to be in full uniform with tactical vests and were observed performing a full body pat down search of multiple patients housed in the Benton Forensic Unit of the hospital where patients are admitted with various psychiatric diagnosis and symptoms.

Surveyor observations of the video footage revealed Correctional Officers approaching patients who then submitted to full pat downs which consisted of the patients facing the wall and placing their hands, spread apart, and over their heads, on the wall. Their legs were spread apart on the floor and the body pat down then occurred. Male patient pat downs occurred in the hallway. Female patients were taken into their rooms.

During an interview with the Hospital Administrator, Staff I, on 2/21/2022, at approximately 9:10 AM, he acknowledged the Correctional Officers were brought in by the hospital administration without staff or patient knowledge to identify potential items which may be a safety concern to all staff and patients.

During an interview on 2/22/2022 with the Nurse Manager Staff H, at approximately 10:34 AM, she stated that all patients had been physically pat down and their rooms searched by the uniformed Correctional Officers. She acknowledged that this was not performed by the nursing staff as required per the hospital policy.

3. The hospital's "Patient Observation Policy," last approved on 2/24/2020, states in part,

"POLICY: ...ESH [Eleanor Slater Hospital] strives to create the safest environment and assigns staff to monitor patients while allowing the patients the least restrictive environment that is clinically appropriate ...

DEFINITIONS: ... 3. 5 Minute, 15 Minute [observations]: Requires an assigned staff member to visually observe and document the patient safety status at the ordered interval ...

A review of the medical record for Patient ID# 3, revealed the patient was admitted to the hospital in July of 2021 for incompetence to stand trial. She/he has diagnoses including, but not limited to, schizoaffective disorder bipolar type with symptoms of mania, delusions, disorganized mood, psychosis, loss of contact with reality. The patient had a physician's order dated 12/9/2021 for every 5 Minute observation checks.

Review of the video surveillance in the Benton ITU on 12/10/2021 from 10:40 AM until 11:30 AM revealed the following observations of staff members who had signed off safety checks as being completed although, upon review of the video footage, the patients were not in the staff member's view.

Patient ID #3 was not observed by staff every 5 minutes as viewed in the video surveillance despite the observation log being signed off as completed at 10:41 AM, 10:46 AM, 10:50 AM, 11:01 AM, 11:06 AM, 11:10 AM, 11:15 AM, 11:20 AM, 11:25 AM and 11:30 AM.

A review of the medical record for Patient ID #6, revealed she/he was admitted to the hospital in December of 2021 for incompetence to stand trial. She/he has diagnoses including, but not limited to, bipolar disorder with psychosis. Further review of the medical record revealed a provider order dated 12/10/2021 for Patient ID #6 to undergo every 5-minute checks for unpredictable behavior [and for] safety of the patient and staff.

The video footage of the Benton ITU on 12/10/2021 from 10:40 AM until 11:30 AM revealed the following:

Patient ID #6 was not observed by staff every 5 minutes as viewed in the video footage despite the observation log being signed off as completed at 10:40 AM, 10:45 AM, 10:50 AM, 10:55 AM, 11:00 AM, 11:05 AM, 11:10 AM, 11:15 AM, 11:20 AM, 11:25 AM and 11:30 AM.

A review of the medical record for Patient ID #7 revealed she/he was admitted to the hospital in December of 2021 for incompetence to stand trial. She/he has diagnoses including, but not limited, to schizophrenia. Further review of the medical record revealed an order dated 12/2/2021, safety checks every 15-minutes.

The video surveillance of the Benton ITU on 12/10/2021 from 10:40 AM until 11:30 AM revealed the following:

Patient ID #7 was not observed by staff every 15 minutes as viewed in the video surveillance despite the observation log being signed off as completed at 10:45 AM, 11:00 AM, 11:15 AM and 11:30 AM.

During an interview with the unit Nurse Manager on 2/22/2022 at 10:34 AM, she acknowledged that the Staff H, did not visually observe the patients, as per hospital policy.

4. The hospital's "Patient Rights and Responsibilities" policy, last approved on 6/24/2021, states, in part,
IV: Policy Statement Pertaining to Patients' Rights
1. The patient shall be treated with dignity and respect, [and] afforded considerate and respectful care ...

31. The patient has the right to be free from neglect, exploitation, verbal, mental, physical, and sexual abuse.

32. The patient has the right to have an environment that preserves dignity and contributes to positive self-image...

A review of the medical record for Patient ID #1 revealed she/he was admitted to the hospital in September of 2021 for psychiatric stabilization and incompetence to stand trial. She/he has diagnoses including, but not limited to, schizoaffective disorder, bipolar type, with symptoms of psychosis. Review of this patients record reveals a history of disrobing him/herself.

Surveyor review of video footage dated 12/10/2021 revealed that Patient ID #1 was observed lying on the floor of the Benton ITU common area without clothing, allowing his/her genital area to be exposed to housekeeping personnel, nursing staff and security personnel from approximately 8:28 AM until approximately 8:35 AM.

Further review of video footage from 12/10/2021 at approximately 10:17 AM revealed Patient ID #1, an ambulatory patient, lying on the floor of the ITU's common area and being picked up off the floor under his/her arms by both Staff B and Staff C and placed in a chair, which the patient then slides him/herself back to the floor. Staff B is then observed to lift the patient by his/her right arm and right leg transporting Patient ID #1 to his/her room, as Staff C, Staff D Mental Health Workers and the housekeeper observed without intervening or reporting the incident to supervisory staff.

During an interview on 2/22/2022 with the Supervisor of the Education Department at 1:15 PM, she stated that the hospital incorporates the Safety Care Certified Program into the hospital's nursing education curriculum. She further stated that lifting a patient by his/her arm and leg is not a maneuver that is taught, or that should be used when caring for a patient, as both the patient and staff member are at risk for injury.

During an interview with the Nurse Manager on 2/22/2022 at 8:45 AM, she acknowledged that Staff B carried Patient ID #1 by his/her right arm and right leg and carried him/her to his/her room in this position. She further acknowledged that this incident was observed by other staff members who were present on the unit and failed to report the incident to their Supervisory Staff.

43881

Based on record review, surveyor observation, and staff interview it has been determined that the hospital failed to prevent, report, and investigate abuse, for 1 of 1 patient (ID# 1) related to an employee to patient incident. Additionally, the hospital failed to implement mechanisms/methods to ensure patients are free from all forms of abuse and provide an immediate response to a patient-to-patient abuse incident, failing to notify his/her supervisor and administration per hospital policy, for 1 of 2 patients (Patient ID# 1) involved in a physical altercation.

Findings are as follows:

The hospital's document entitled "Abuse and Neglect-Guidelines for Screening and Intervention," which was last approved on 6/14/2021, states, in part,
"II. POLICY: ...
2. All staff at the ESH are responsible to report actual or suspected cases of abuse and/or neglect. The hospital is responsible to evaluate all allegations, observations and suspected cases of neglect, exploitation, and abuse.
3. Staff suspecting abuse or neglect must report suspicions to his/her supervisor. The supervisor is responsible for initiating appropriate actions including notifying his/her supervisor and administration.
4. The Administrator of Risk Management is responsible to notify applicable licensing bodies and authorities within 24 hours...
IV. DEFINITIONS:
A. Patient Abuse
1. Physical Abuse- Physical force that may result in bodily injury, physical pain, or impairment. The willful infliction of pain or injury upon an older person. Physical abuse may include but is not limited to such acts of violence as striking (with or without an object), hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning....
3. Emotional or Psychological abuse- The infliction of anguish, pain, distress, or mental suffering through verbal assaults, insults, threats, intimidation, humiliation, and harassment: ...
V. MANDATORY REPORTING AND JOINT COMMISSION REQUIREMENTS:
1. Rhode Island Law (23-17.8-2) requires that healthcare practitioners and facility employees report to the Department of Health any form of abuse, mistreatment, or neglect of patients in any facility.

1. Surveyor review of the medical record for Patient ID #1 revealed she/he was admitted to the hospital in September of 2021 for psychiatric stabilization and incompetence to stand trial. She/he has diagnoses including, but not limited to, schizoaffective disorder, bipolar type with symptoms of psychosis. This patient is noted to have a history of disrobing and aggressive behaviors.

Surveyor review of the medical record for Patient ID #3 revealed she/he was admitted to the hospital in July of 2021 for incompetence to stand trial. She/he has diagnoses including, but not limited to, schizoaffective disorder bipolar type with symptoms of mania, delusions, disorganized mood, psychosis, loss of contact with reality.

Review of a nursing progress note dated 12/1/2021 at 11:00 AM, revealed that Patient ID #3 had a history of aggression as noted by punching a staff member in the face several times and kicked another staff member, who attempted to intervene. This note further states that Patient ID #3 spat at these staff members, and she/he was subsequently transferred to the ITU (Intensive Treatment Unit) on this day due to exhibiting significant aggressive behavior.

Review of a nursing care plan for Patient ID #3 last revised on 2/16/2022, failed to identify aggressive behavior or provide interventions to protect other patients.

On 12/1/2021, Patient ID# 3 was admitted to the ITU which is a locked unit that houses the most unstable and potentially aggressive patients.

Surveyor observation of video footage of the ITU, revealed that on 12/10/2021 Patient ID# 3 assaulted Patient ID# 1. There was no staff member physically present inside of the ITU to intervene or protect Patient ID# 1 during the altercation. The Mental health Worker (MHW) was noted viewing from outside of the unit at a window and failed to notify his/her supervisor and administration per the hospital policy. The MHW was observed to respond to the altercation by knocking on the window from outside the unit before entering the unit 19 seconds later when Patient ID# 1 was pushed to the floor. Additionally, the staff member failed to notify nursing per hospital policy, which resulted in a failure to provide immediate response to the incident implement an investigation into the incident.

During an interview with the hospital's Risk Manager, Staff K, on 2/22/2022 at approximately 9:55 AM, he acknowledged that this incident should have been reported to the Nursing Supervisor and Risk Management as per the mandatory reporting requirements and hospital policy. Additionally, he stated that since the abuse was not reported, the incident was not investigated nor were applicable licensing bodies or authorities notified.

During a surveyor interview on 2/21/2022 with the Nurse Supervisor, Staff J, at approximately 11:15 AM, he acknowledged that Patient ID #3 is aggressive, and that neither the Team or Nursing care plans addressed Patient ID #3's aggressive behaviors.

During an interview with the Nurse Manager, Staff H, on 2/22/2022, she stated this is the normal process for the MHW to be posted at the viewing window outside of the locked area. Additionally, she stated all staff are trained on observations and it is the hospitals protocol for all staff to immediately inform the unit nurse who will implement a immediate response and determine what actions will be taken for any concerns or issues which occur with a patient on any observation status.

2. A review of the medical record for Patient ID #1 revealed she/he was admitted to the hospital in September of 2021 for psychiatric stabilization and incompetence to stand trial. She/he has diagnoses including, but not limited to, schizoaffective disorder, bipolar type, with symptoms of psychosis. Review of this patients record reveals a history of disrobing him/herself.

Surveyor review of video footage dated 12/10/2021 revealed that Patient ID #1 was observed lying on the floor of the Benton ITU common area without clothing.

Further review of video footage from 12/10/2021 at approximately 10:17 AM revealed Patient ID #1, an ambulatory patient, lying on the floor of the ITU's common area and being picked up off the floor under his/her arms by both Staff B and Staff C and placed in a chair, which the patient then slides him/herself back to the floor. Staff B is then observed to lift the patient off the floor by his/her right arm and right leg transporting Patient ID #1 to his/her room in this position, as Staff C, Staff D Mental Health Workers and the housekeeper observed without intervening or reporting the incident to supervisory staff.

During an interview on 2/22/2022 with the Supervisor of the Education Department at 1:15 PM, she stated that the hospital incorporates the Safety Care Certified Program into the hospital's nursing education curriculum. She further stated that lifting a patient by his/her arm and leg is not a maneuver that is taught, or that should be used when caring for a patient, as both the patient and staff member are at risk for injury.

During an interview with the Nurse Manager on 2/22/2022 at 8:45 AM, she acknowledged that Staff B carried Patient ID #1 by his/her right arm and right leg and carried him/her to his/her room in this position. She further acknowledged that this incident was observed by other staff members who were present on the unit and failed to report the incident to their Supervisory Staff.























41728

41728

Based on record review, staff interview and policy review, it has been determined that the hospital failed to evaluate the care for 1 of 1 patient, ID# 1 following a fall in accordance with accepted standards of nursing practice and hospital policy.

Findings are as follows:

The hospital's "Fall Prevention Program" policy, last revised in September 2020, states in part,

"B. Post Fall Management:

1. In the event of a fall where there is no apparent injury or a minor injury, the RN [Registered Nurse] will assess the patient prior to moving the patient:
a. check for visual signs of injury ...
b. Vital signs and blood pressure ...
d. Notify the physician ..."

Surveyor review of the medical record for Patient ID #1 revealed she/he was admitted to the hospital in September of 2021 for psychiatric stabilization and incompetence to stand trial. She/he has diagnoses including, but not limited to, schizoaffective disorder, bipolar type, with symptoms of psychosis.

Surveyor review of the medical record for Patient ID #3 revealed she/he was admitted to the hospital in July of 2021 for incompetence to stand trial. She/he has diagnoses including, but not limited to, schizoaffective disorder, bipolar type, with symptoms of mania, delusions, disorganized mood, psychosis, loss of contact with reality.

Surveyor observation of hospital video footage of the Intensive Treatment Unit (ITU) revealed that on 12/10/2021 a patient-to-patient incident occurred resulting in Patient ID# 1 suffering a fall.

Review of hospital video footage at 10:21 AM of this incident revealed that Patient ID #1 falls to the floor after being pushed by Patient ID #3. Patient ID #1 remains on the floor as Staff F, an RN, comes to the doorway and fails to check Patient ID #1 for visual signs of injury or vital signs.

During an interview with the Nurse Manager Staff H, on 2/22/2022 at 8:45 AM, she acknowledged that there was no evidence that a nursing assessment was performed after Patient ID #1 was pushed and fell to the floor. She further stated that per hospital policy, nursing is responsible for performing an assessment on any patient who has fallen, and then notifying the provider of the fall and assessment findings.


43881

Based on record review and staff interview, it has been determined that the hospital failed to develop a nursing care plan for 2 of 2 relevant sample patients, who had an altercation while housed together in the Intensive Treatment Unit (ITU), (ID #'s 1 & 3) relative to difficult behaviors, including aggression.

Findings are as Follows:

1. Record review for Patient ID #1 revealed she/he was admitted to the hospital in September of 2021 for psychiatric stabilization and incompetence to stand trial. She/he has diagnoses including, but not limited to, schizoaffective disorder, bipolar type, with symptoms of psychosis.

Review of nursing notes from his/her date of admission through January 2022, revealed multiple nurses notes that indicated she/he had episodes of disrobing in the common areas.

During a phone interview with the Chief Medical Officer on 2/21/2022 at approximately 9:45 AM, she stated that this patient's behaviors have been an ongoing symptom of his/her illness since admission.

During a surveyor record review of the nursing care plan last updated on 2/9/2022, this plan failed to reveal evidence that this disrobing behavior was identified or addressed.

During a surveyor interview with Staff A, Registered Nurse on 2/22/2022 at approximately 11:30 AM, she indicated that Patient ID #1 continues to have disrobing behaviors. Additionally, she was unable to provide evidence the patient's behaviors had been identified and addressed in the patients Nursing or Team Care Plan.

2. Record review for Patient ID #3 revealed she/he was admitted to the hospital in July of 2021 for incompetence to stand trial. She/he has diagnoses including, but not limited to, schizoaffective disorder, bipolar type with symptoms of mania, delusions, disorganized mood, psychosis, loss of contact with reality.

Review of a nursing progress note dated 12/1/2021 at 11:00 AM, revealed that Patient ID #3 punched a staff member in the face several times and kicked another staff member on the knee when attempting to intervene. Patient ID #3 also spat at these staff members; She/he was subsequently transferred to the ITU on this day for significant aggression.

Review of video footage revealed that on 12/10/2021 at approximately 10:21 AM, Patient ID #3 was observed hyperextending Patient ID #1's hand and wrist and pushed him/her to the floor.

Review of a Nursing Care Plan last revised on 2/16/2022, failed to provide evidence that the hospital developed a care plan to address Patient ID #3's aggressive behaviors towards staff and patients.

During a surveyor interview on 2/22/2022 with Staff A, at 11:25 AM, she acknowledged that neither the Team or Nursing Care Plans addressed Patient ID #3's aggressive behaviors.


43881

Based on record review, video review, and staff interview, it has been determined that the hospital failed to ensure nursing care was provided in accordance with the hospital policies and procedures for 1 of 1 patient (Patient ID #1) related to mistreatment, and medication administration for 1 of 2 patients, (Patient ID #7).

Findings are as follows:

1. Surveyor review of the video footage from 12/10/2021 at approximately 10:17 AM revealed Patient ID #1 lying on the floor of the Intensive Treatment Unit (ITU) common area and being picked up off the floor under his arms by both Staff B and Staff C and placed the patient in a chair. Patient ID #1 then slid him/herself back to the floor. Staff B is then observed picking up and transporting Patient ID #1 by his/her right arm and right leg and carrying him/her into their room. This incident was observed by Mental Health Workers, Staff C, Staff D, and the housekeeper, who were located in the common area of the ITU.

During an interview with the Hospital Risk manager on 2/22/2022, at approximately 11:00 AM, he stated the incident was not reported by staff and therefore an investigation was not completed.

During an interview on 2/22/2022 with the Supervisor of the Education Department at 1:15 PM, she stated that the hospital incorporates the Safety Care Certified Program into the hospital's nursing education curriculum. She further stated that lifting a patient by his/her arm and leg is not a maneuver that is taught, or that should be used when caring for a patient, as both the patient and staff member are at risk for injury.

During an interview with the Nurse Manager on 2/22/2022 at 8:45 AM, she acknowledged that Staff B carried Patient ID #1 by his/her right arm and right leg and carried him/her to his/her room in this position. She further acknowledged that this incident was observed by other staff members who were present on the unit and failed to report the incident to their Supervisory Staff.

2. The hospital's "Fall Prevention Program" policy, last revised in September 2020, states, in part,

"B. Post Fall Management:
1. In the event of a fall where there is no apparent injury or a minor injury, the RN [Registered Nurse] will assess the patient prior to moving the patient:
a. check for visual signs of injury ...
b. Vital signs and blood pressure ...
d. Notify the physician ..."

Surveyor review of the medical record for Patient ID #1 revealed she/he was admitted to the hospital in September of 2021 for psychiatric stabilization and incompetence to stand trial. She/he has diagnoses including, but not limited to, schizoaffective disorder, bipolar type, with symptoms of psychosis.

Surveyor observation of video surveillance of the ITU revealed that on 12/10/2021 Patient ID# 1 was pushed to the floor in a patient altercation as follows:

10.21.28 AM: Patient ID #1 is falling to the floor from Patient ID #3's push. Patient ID #1 remains on the floor as Staff C who entered the room to assist verbally deescalates Patient ID #3.

10.22.32 AM: Patient ID #1 remains on floor as Staff E, an Occupational Therapist, enters the room to assist the patient. Staff F, a Registered Nurse, comes to the doorway and appears to have a conversation with Staff C but does not enter the common area to assess the patient.

During an interview with the Nurse Manager on 2/22/2022 at 8:45 AM, she acknowledged that there was no evidence that a nursing assessment was performed after Patient ID #1 was pushed and fell to the floor. She further stated, that as per hospital policy, nursing is responsible for performing an assessment on any patient who has fallen, and then notifying the provider of the fall and assessment findings.

3. The hospital's "Medication Management" policy, last approved in August 2021, states, in part,

"PURPOSE: To insure the accurate and safe administration of medication by nurses ...
I. POLICY
A. ADMINISTRATION: ...
3. Nurses administering oral medication must observe the patient to ensure that the dose has been swallowed...

VII. PROCEDURES RELATING TO THE METHODS OF MEDICATION ADMINISTRATION ...
1. ORAL ADMINISTRATION:
PROCEDURE:
1. Give patient medication and remain with the patient until medication is swallowed ..."

The hospital's "Patient and Unit Search" policy, last approved in March 2019, states, in part,
"...SEARCH PROCEDURE:
1. PERSONAL SEARCHES:
MOUTH SEARCH:

1. The RN will explain the procedure and request that the patient open his or her mouth and the RN will visually inspect the oral cavity. If medication is observed, the RN will ask the patient to swallow it, offering a glass of fluid and will reexamine the mouth ...

3. The RN will document results of the mouth search in the progress notes ..."

Surveyor review of video surveillance from 12/10/2021 at 8:47 AM revealed Staff G, an RN, placing a tray of medication on the common area table for Patient ID #7. Staff G failed to observe and monitor while administering the medication per the hospital policy and remain with the patient until the medication was swallowed. Staff G was noted in the video footage to look away several times while the patient was supposed to be taking the medication; furthermore, Staff G failed to perform a mouth search to confirm the patient swallowed the medication(s), as per policy.

During an interview with the Nurse Manager, Staff H on 2/22/2022 at 11:18 AM, she acknowledged that Staff G did not physically administer the medication to Patient ID #7. Additionally, she acknowledged that Staff G failed to ensure Patient ID #7 put the medication in his/her mouth and Staff G did not verify that Patient ID #7 swallowed the medications she/he was to take.



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