HospitalInspections.org

Based on interview and record review, the facility failed to provide 1:1 observation for 1 (P-2) of 12 patients as prescribed by the physician resulting in an altercation and subsequent injury to another patient (P-1). Findings include:

Review of the medical record for P-2 revealed was a 71-year-old male who was admitted to the facility 10/11/2024-1/7/2025 with a diagnosis of bipolar disorder, current episode depressed, severe, without psychotic features, generalized anxiety disorder, post-traumatic stress disorder (PTSD) unspecified, and unspecified intellectual disabilities. P-2 had an extensive psychiatric hospital admission history and was known to exhibit aggressive behavior toward staff and other patients. He was often non-compliant with medications and would display erratic behaviors and paranoia. P-1 was described as being "territorial" and "protective." He did not like anyone invading his space, his room, or touching his belongings. On 10/12/2024, P-2 was on 1:1 status after verbalization of suicidal tendencies.

Review of the medical record for P-1 revealed she was a 73-year-old female who was admitted to the facility 12/6/2024-12/11/2024 with a diagnosis of dementia with unspecified severity with psychotic disturbance and unspecified dementia with unspecified severity with other behavior disturbance. P-1 was admitted to the facility with "severe agitation, combativeness, altered mental status, and psychosis...She was also experiencing paranoia, delusions, and visual hallucinations." Physician notes indicated her symptoms would worsen with increased confusion. P-1 was a low fall risk, and her level of observation was for checks every 15 minutes. Nursing notes dated 12/10/2024 stated P-1 was "ambulating about the common area (milieu) attempting to go into other patients (sic) rooms. patient (sic) requiring redirection..."

Review of internal facility documentation revealed a discrepancy in events between the 12/10/2024 incident report and the undated root cause analysis (RCA). The incident report stated, "(P-1) was intrusive with another pt (P-2). Other pt (P-2) closed his door and she (P-1) put herself on the floor and said she fell." The RCA stated, ""(P-1) attempted to go into another patient's bedroom. The occupant of the bedroom (P-2) grabbed her wrists and told her that it was his bedroom and attempted to move her to the side. (P-1) yelled and put herself on the floor landing on her right side..." After experiencing increasing pain in the right hip area, an x-ray was obtained and showed a fracture of the ischium (pelvis).

On 1/6/2025 at 1445, during review of P-2's medical record, Staff B stated P-2 had been ordered to have 1:1 observation status; however, the investigation found he was not being monitored as he was supposed to be. Staff B explained that had P-2 been monitored appropriately, the staff could have redirected P-1 prior to her trying to enter P-2's room and/or could have informed P-1 they would take care of the situation relieving him of the responsibility. "This (incident) should never have happened."

Facility policy #CC.13 titled "Suicide Precautions" issued 4/2019 states, "All patients placed on suicide precautions will be assigned an acuity level based upon the severity of the suicidal thoughts, plan or behavior. The levels are as follows... 1-to-1 observation at all times: This is the most restrictive toward the patient and involves continuous monitoring and phsycial proximity to the patient at all times. Staff must be within arm's reach or 3 feet at all times including toileting and showering. Nursing staff must maintain a continuous log which indicates the patient's location every 15 minutes and documents the patient's thoughts and behaviors throughout each shift. Patients on this level are considered highest risk and documentation must reflect the need for continued 1-to-1 or improvement in behaviors and thoughts."

Based on interview and record review, the facility failed to provide an appropriate order for seclusion for 2 (P-2, P-11) of 2 patients reviewed according to facility policy resulting in the potential for adverse patient outcomes and loss of patient rights. Findings include:

Review of the medical record for P-2 revealed he was placed into seclusion 12/19/2024 for being a danger to himself and others. Review of the seclusion order revealed an area titled "Maximum Duration." In the section was a box marked with a hand-written time frame of 0946-1104. The order was signed 12/19/2024 at 0946.

On 1/6/2025 at 1600, Staff B was queried as to the specific time frame in the order to which she stated it was the start and stop time of the seclusion. Staff B was then queried as to how the practitioner would know the patient would only need 1 hour and 18 minutes of seclusion at the time the order was written to which she stated they would not know that. Staff B agreed that documentation of the seclusion with the exception of the patient monitoring section was most likely completed at some time after the seclusion had been discontinued.

On 1/7/2025 at 1357, Staff N stated the nurse fills out the 6-page restraint/seclusion document, including the orders, and gets signatures in the appropriate areas from the provider. Whomever would be monitoring the patient during restraint/seclusion would fill out that portion separately.

Review of the medical record for P-11 revealed she was placed into seclusion 11/18/2024 for being a danger to herself and others. Review of the seclusion order revealed the "Maximum Duration" was hand-written in as "eight minutes." The seclusion was initiated at 0635 and discontinued at 0643. The order was signed "11/18" at 0635.

On 1/7/2025 at 0950, Staff B was queried how the practitioner could have known the patient would only need 8 minutes of seclusion to which she stated, "They couldn't."

Facility policy #NU 20 titled "Restraints/Seclusion) last revised 11/2024 states, "Physical restraint...Seclusion: is the involuntary confinement of a patient alone in a room, which the patient is physically prevented from leaving, for any period of time. Seclusion may only be used for the management of violent or self-destructive behavior. This type of intervention requires a physician/provider order...ORDERS FOR RESTRAINTS... Restraint orders are time-limited and specific to the patient's assessed status, and are never written as a PRN (as needed) order. 3. Restraint orders include the following components: Date and time the order is written, Type of restraint to be used, Reason for restraint, Alternatives considered, Length of time the patient is to be restrained, Behavioral criteria for the release from restraints/seclusion...Behavioral restraint orders must be written every four (4) hours...Notify the attending physician/provider as soon as possible after restraint instituted... In an emergency, if a patient presents an immediate danger to self or others, a restraint may be applied by or under the supervision of a registered nurse who is responsible for documenting the circumstances requiring the restraint/seclusion and immediately notifying the physician. The RN must document the justification for the emergency application of restraints, including measures taken to address behavior prior to the decision to apply restraints, type of restraint applied, name of the physician called, and the time of the call. A written order must be obtained prior to or immediately after application of restraint or seclusion."