HospitalInspections.org

Based on document review and interview, the facility failed to provide care in a safe setting for 1 of 10 patient (Patient 2) medical records reviewed.

The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review and interview, the facility failed to provide care in a safe setting for 1 of 10 patient (Patient 2) medical records reviewed.

Findings include:

1. Facility Policy titled, Patient Bill of Rights, Policy #149, last approved 10/01/2024, indicated under V. Procedure, Patient Bill of Rights address the following: 6. The patient has the right to receive care in a safe setting.

2. Review of Patient 2's medical record on 11/22/2024 at 11:48 a.m. in the provider note, patient 2 reported wakening to find another patient in their room naked from the waist down and a possible assault.

3. Review of Patient 3's medical record on 11/22/2024 at 5:40 a.m. indicated patient was found in another patient's room naked from the waist down attempting to sexually assault patient.

4. Review of Incident Report dated 11/22/2024 indicated the following:
a. S2 (Security Associate) falsified charting in 15-minute observation checks in patient 2's medical record. The 15-minute observation checks were not completed as documented during the time of the incident.
b. Video surveillance indicated patient 3 went into patient 2's room and was in patient 2's room for approximately 20 minutes before staff found patient 3 assaulting patient 2.

5. Interview with A2 (Director of Nursing Inpatient, Emergency Department, and Urgent Care) and A6 (Clinical Manager of Adult Psychiatric Unit) on 01/02/2025 at approximately 4:00 p.m. confirmed the above information related to the assault on patient 2 on 11/22/2024.

Based on document review and interview, nursing services failed to monitor patient resulting in an assault for 1 of 10 patient (Patient 2) medical records reviewed; and failed to obtain and/or document 1:1 observation orders for 1 of 10 patient (Patient 3) medical records reviewed.

Findings include:

1. Facility Policy titled, Patient Observation Levels, Policy #: PM2 - 522, last approved 06/30/2022, indicated under III. Procedure, 1. Physician order may be placed for 1:1, eye sight, or Q15 observation level for patients that present with but not limited to: Suicidal Ideation with or without a plan (*NOTE: please refer to policies Suicide identification and management and Psychiatric services policy Suicide Risk assessment reassessment observation and interventions for psychiatric patients and Assault Precautions Policy), Exit seeking behaviors, Aggressive behaviors, Acute confusion, High fall risk. NOTE: An RN can initiate an observation level order but only a physician can discontinue or decrease an order.

2. Review of Patient 2's medical record on 11/22/2024 at 11:48 a.m. in the provider note, patient 2 reported wakening to find another patient in their room naked from the waist down and a possible assault.

3. Review of Patient 3's medical record indicated the following:
a. On 11/22/2024 at 5:40 a.m. indicated patient was found in another patient's room naked from the waist down attempting to sexually assault patient.
b. Medical record lacked order for 1:1 observation.
c. Nursing note on 11/22/2024 at 7:19 a.m. indicated patient was on 1:1 observation.
d. Provider note on 11/23/2024 indicated to continue 1:1 supervision with sitter for patient's safety.

4. Review of Incident Report dated 11/22/2024 indicated the following:
a. S2 (Security Associate) falsified charting in 15-minute observation checks in patient 2's medical record. The 15-minute observation checks were not completed as documented during the time of the incident.
b. Video surveillance indicated patient 3 went into patient 2's room and was in patient 2's room for approximately 20 minutes before staff found patient 3 assaulting patient 2.

5. Interview with A2 (Director of Nursing Inpatient, Emergency Department, and Urgent Care) on 01/02/2025 at approximately 11:35 a.m. confirmed in interview with S2, S2 confirmed they falsified the documenation regarding the 15-minute observation checks for patient 2 during the time of the incident, the 15-minute checks were not completed, and patient 2 was assaulted during this time.

6. A6 (Clinical Manager of Adult Psychiatric Unit) on 01/02/2025 at approximately 2:30 p.m. indicated nursing can initiate an order for observation levels and communicate with the provider. The medical record orders should reflect the 1:1 order and patient 3's medical record did not have an order for 1:1 observation.

Based on document review and interview, facility failed to ensure accurate documentation in 1 of 10 patient (Patient 2) medical records reviewed.

Findings include:

1. Review of Patient 2's medical record indicated on 11/22/2024 15-minute observation checks were completed as ordered between 5:00 a.m. and 6:00 a.m.

2. Review of Incident Report dated 11/22/2024 indicated S2 (Security Associate) indicated staff falsified 15-minute observation check documentation in patient 2's medical record and the 15-minute checks were not completed as documented during the time of the incident. Video surveillance indicated patient 3 was in patient 2's room for approximately 20 minutes before staff entered patient 2's room.

3. Interview with A2 (Director of Nursing Inpatient, Emergency Department, and Urgent Care) and on 01/02/2025 at approximately 11:35 a.m. confirmed S2 during the investigation indicated they did not complete the 15-minute checks as ordered and documented that they were completed.