Delaware Psychiatric Center

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 45764 Based on review of medical records, policies and other hospital documentation, staff interview, video surveillance review, and observation, it was determined that the hospital failed to ensure the safety of 1 of 7 patients (Patient #3) in the record sample as evidenced by the patient sustaining a serious injury of unknown origin and staff failing to identify the injury immediately. Findings include: Hospital policy “Risk Management: Abuse Neglect, Mistreatment, and Significant Injury (PM 46)”, dated 12/10/19, stated, “...DPC [Delaware Psychiatric Center] administers quality care in a safe, skillful, and humane manner consistent with each client’s needs. All care will be free from preventable risk and from any form of abuse, neglect, mistreatment, financial exploitation, or significant injury by any staff person...” Hospital policy “Nursing Services: Nursing Assignments (NS 148)”, dated 11/13/23, stated, “...The registered nurse shall provide individualized, safe, comprehensive, and continuous care by utilizing the nursing process. Both licensed and unlicensed staff are accountable for completing daily staff assignments and ensure optimal care is provided to each client...” Hospital policy “Client Management: Special Precautions and Supervision of Clients”, dated 11/9/23, stated, “...The four facility approved levels are...1:1 Supervision...occurs when the staff member is assigned to stay within one arm’s length of the client...Unless otherwise specified in the doctor’s order, continuous visual supervision is ensured, even in the bathroom, shower, and bedroom...Assign the staff member to implement special precautions at the beginning of the shift and monitor the staff member intermittently during the shift...Plan for staff rotation at least every 2 hours, to prevent fatigue and ensure continuous supervision...” A review of Patient #3’s medical record revealed Patient #3 was admitted to DPC on 1/8/75 and discharged administratively on 2/29/24, after DPC staff discovered Patient #3 sustained a serious injury while inpatient at DPC on 2/8/24. The patient was transferred to the local acute care hospital on 2/8/24 and later discharged to a longterm care facility. Per Patient #3’s medical record from the local acute care hospital, a CT Chest/Abd/Pelvis with contrast was performed on 2/8/24, and included a reading at 9:07 PM of a “Comminuted fracture of the proximal left humeral shaft with surrounding intramuscular hematoma ... Acute fracture of the T8 vertebral body resulting in 20% loss of height ...”. Per the DPC medical record, Patient #3’s baseline was that he/she utilized a wheelchair for mobility, was able to walk short distances with a walker, required staff assist to perform ADLs (activities of daily living), and was taking a bloodthinning medication. Behavioral Health Notes from 1/31/24 at 12:27 PM stated, “...Client is confused. Client is AAO [Alert and Oriented] x 1. Client with neurocognitive and physical decline. Client with increased confusion at baseline ...”. Additionally, Patient #3 was ordered for 1:1 observation, as explained in the Behavioral Health Note from 2/7/24 at 10:56 AM - “ ...Client is currently placed on 1:1 observation for safety of self due to falls on all 3 shifts ...”. A review of video surveillance on 5/9/24 at 9:15 AM with Employee #s 2, 3, & 7, from the date 2/7/24 at 8:20 PM revealed Patient #3 entered the room with the ability to use both upper extremities. The video footage dated 2/8/24 at approximately 8:00 AM reveals an abnormality in the patient’s posture in the wheelchair at the location of the patient’s left shoulder. Employees #s 2, 3, & 7 concurred with this observation. Per the medical record, Nursing Narrative Note for evening shift (3:00 PM to 11:00 PM), dated 2/7/24 at 9:16 PM, stated, “ ...Maintained on 1:1 observation @ [at] 2 arm’s length with privacy for safety of self/fall risk x 24 hrs [hours] ...3 staff assist with ADLs [activities of daily living], client fights while be [sic] given ADLs. No incident ...”. Nursing Narrative Note for the midnight shift (11:00 PM to 7:00 AM), dated 2/8/24, stated, “ ...Maintained on 1:1 observation @ 2 arm’s length for safety of self/fall risk x 24 hrs/Bowel & Bladder Regimen/O2 Use ...Client was resting in bed awake at the beginning of the shift, with his O2 tubing in his hands refusing to put it on ...Redirection was very difficult at this time ...Client repositioned Q2H [every two hours], still with difficulties and resistant. Compressed bed wedge cushion used to support client on his side during repositioning. Protective mat in place next to both sides of bed in case of fall ...Client is two staff assist with ADL’s ...Client denies any pain or discomfort. No incident ...”. Patient #3’s Special Support Precautions Flow Sheet, where 1:1 observations are documented via a narrative note every 15 minutes, stated, on 2/8/24 at 5:45 AM, “ ...Client awake in bed washed, oxygen intact ...”. In reviewing the midnight shift’s 1:1 notes, this was the only note that addressed the patient being physically manipulated. The 1:1 staff member assigned, Employee #10, was not interviewed for the hospital’s investigation as the employee was out of the country. Progress Note - Physician, dated 2/8/24 at 12:18 PM, stated, “ ...Noted this AM to have pain + [and] bruising left shoulder and left upper arm [sic]. New onset, no known injury ...Exam ...Left upper arm with bruise over entire deltoid and biceps muscle distribution. + [Positive] guarding of left arm, unable to raise left arm above head ...Transfer to ED to ensure this bleed is stopped ...” Medical record review for Patient #3, once the patient arrived at the local acute care hospital, included a forensic exam, completed on 2/8/24. Evidence disclosed during the exam included a splinted left upper extremity with known humeral fracture as found in diagnostic studies. Forensic report also included a descriptor of the T5-T6 compression fractures and T8 acute fracture. Additional skin examination revealed scattered bruising and abrasions, bodywide, and in various stages of healing. DPC staff reported the incident of serious unknown injury on 2/9/24. Facility staff indicated that an investigation of the unknown injury included video surveillance review, staffing review, and either staff interviews or written witness statements from all staff having direct contact with the patient on 2/7/24 and 2/8/24. Per the hospital investigation, of the 20 staff members identified as having contact with Patient #3 from 2/7 to 2/8/24, 19 were either interviewed or provided witness statements. All staff denied any knowledge of how the injury occurred. Upon completion of the hospital investigation on 2/15/24, it was evident that not all staff with direct patient contact were interviewed. Interviews with remaining staff, including Employee #10, were then completed on 5/8/24 at 10:00 PM by a State Police Detective. No additional information regarding how the injuries were sustained was gleaned from the additional staff members. The hospital’s investigation concluded that no evidence could be found to suggest how Patient #3 sustained injuries. However, Patient #3 entered the room via wheelchair for the night on 2/7/24 at 8:20 PM moving both upper extremities, and exited on 2/8/24 at 8:00 AM without the use of his left upper extremity. Hospital staff failed to recognize the serious injury to Patient #3 immediately after being sustained, as evidenced by the physician assessment of Patient #3 on 2/8/24 at 12:18 PM.”