HospitalInspections.org

Based upon review of adverse occurrence investigations, medical record review, and interview, the hospital failed to ensure investigations of adverse occurrences reported to the Health Standards Section of the Department of Health and Hospitals were accurate. This was evidenced by:
1) failure to identify the correct observation levels on the Youth Enhanced Unit (YEU) on 5/25/14 related to their investigation of alleged physical abuse reported by patient #F13 against SF13 Mental Health Technician (MHT); and
2) failure to identify observation levels of the patients on the YEU who were involved with patient/s (#F2, F3) on patient (#F1) abuse on 05/18/14 and 05/19/14. Findings:

1) Review of the investigation, dated 05/30/14, of allegations of physical abuse made by patient #F13 against SF13 MHT revealed "Conclusion: There were two staff members on the unit at the time of the incident. One staff member was on a break at the time of the incident. The census was 10 patients with all regular observation levels with no Close Visual Observations (CVO) or 1-on-1's...".

On 6/3/14, the staffing and patient observation levels was requested for 5/25/14. Review of the patient observation levels and interview with SF5/RN Interim Director of Nursing (DON) on 6/3/14 at 10:05 a.m. revealed on 5/25/14, there was one patient on Constant Visual Observations and two patients on Constant Visual Observations While Awake.

Further interview with SF5/RN Interim DON and SF8 Patient Advocate on 6/4/14 at 8:50 a.m. revealed when asked about the investigation conclusion which identified there were no patients on CVO observation levels, SF8 Patient Advocate responded that he thought he had heard someone say there were no patients on the YEU that were on Constant Visual Observations. There failed to be evidence the investigative report was reviewed by the Director of Nursing to ensure the information reported was accurate.

2) Review of the investigative report, staffing levels and patient observation levels on the YEU (for the incident that occurred on 05/19/14 and reported to the State) revealed, a census of 8 with 3 staff members assigned; however there were two patients (F2, F22) who were on observation levels of CVO. Continued review of the investigative report failed to indicate that there were 2 patients on CVO as identified in the above sentence.

According to an interview, 06/03/14 at 3:15pm with SF11RN, there were 2 patients (from the census of 8) on Constant Visual Observation level (F2, F22) on 05/19/14 in the YEU. SF11RN stated she had left the unit, leaving SF9MHT and SF10LPN to watch the 8 patients present. SF11RN further stated that SF12LAC was also present and had started the 9:00am group session when she left the unit. SF11RN stated Patient F1 was sitting next to SF9MHT (during the group session at 9:00am), when patient F3 came out of her room and began hitting patient F1 with her closed fist. At this time SF10LPN interceded and escorted patient F3 back to her room; however as this was happening, patient F2 began hitting patient F1. SF9MHT inserted herself between patients F1 and F2 and it was at this time SF12LAC called a Code Green (code used to notify all hospital staff that additional staff required due to patient/s causing incident/s) to the YEU.

Review of the investigation, dated 05/27/14, and noted as the final report, revealed "Staff members on duty for the Youth Enhanced Unit at the time of the incident: (name)SF9MHT, (name)SF10LPN, (name)SF12LAC-Licensed Addition Counselor, and (name)SF11RN (was off the unit at the cafeteria)...The patients were on appropriate levels of precaution, adequate and appropriately trained staff were present in the room during the event and witnessed the episode, the event occurred too quickly for the staff to have prevented it, and the staff responded appropriately in addressing the incident..." The investigative report failed to indicate that there were 2 patients (F2, F22), on CVO.

Interviews, 06/04/14 at 8:40am, with SF5 Director of Nursing (DON) and SF8 Patient Advocate confirmed the final report did not accurately state what happened during the incident relative to adequate staffing and the levels of precautions (there were 2 patients on CVO), especially when one of the patients on CVO (patient F2) was also involved in the incident as one of the attackers.


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