Macneal Hospital

“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: 34411 A. Based on document review, observation, and interview, it was determined that for 1 of 2 Behavioral Health Units observed, the Hospital failed to ensure the contraband checks were performed twice a day, as required per policy. Findings include: 1. The Hospital’s policy titled, “Contraband” (dated 9/2024), was reviewed and required, “Inpatient Behavioral Health Services shall take reasonable measures to provide a safe and secure environment for all patients, visitors, and staff ...Procedure: Belongings and/or Room Checks During Course of Hospitalization. Staff to complete routine room check each shift with or without patient presence ...” 2. On 10/16/2024 at 11:15 AM, an observational tour of the Adult Intensive Treatment Unit (35 North) was conducted. During the tour, the Room Checks/Contraband sheets, from 9/1/2024-10/15/2024, were observed for completion. The sheets lacked the required twice a day (every shift), checks, as required, on the following dates: 9/1, 9/5, 9/8, 9/10-9/30/2024, 10/1-10/5, and 10/9-10/10/2024. 3. On 10/16/2024 at 11:25 AM, an interview was conducted with the Behavioral Health Manager (E #2). E #2 stated that room checks are required twice a day. E #2 acknowledged that the room checks that were reviewed, were not completed as required. B. Based on document review and interview, it was determined that for 5 of 11 (Pt #13-Pt #17) patients reviewed for rounding observation forms, the Hospital failed to ensure that the registered nurse rounded on the patient every 2 hours, as required. Findings include: 1. The Hospital’s policy titled, “Patient/Unit Rounds (dated 9/2024), was reviewed and required, “ ...Procedure: A Nurse conducts patient rounding every 2 hours and documents the patient location, position, evaluated for pain, and ADL [assistance for daily living] assistance ...” 2. On 10/16/2024 at 11:15 AM, an observational tour of the Adult Intensive Treatment Unit (35 North) was conducted. During the tour, the Patient Observation rounding sheets were reviewed. The rounding sheets for the 11 patients on census were reviewed. Five of the 11 (Pt #13-Pt #17) patients’ sheets lacked the required 2-hour rounding by the registered nurse: -Pt #13’s patient observation sheet indicated that Pt #13 was on standard level observations, and the every 2 hour RN (Registered Nurse) rounds were not documented on 10/16/2024 from 12:00 AM - 12:00 PM. - Pt #14’s patient observation sheet indicated that Pt #14 was on standard level observations, and the every 2 hour RN rounds were not documented on 10/16/2024 from 12:00 AM - 12:00 PM. - Pt #15’s patient observation sheet indicated that Pt #15 was on standard level observations, and the every 2 hour RN rounds were not documented on 10/16/2024 from 12:00 AM - 12:00 PM. - Pt #16’s patient observation sheet indicated that Pt #16 was on standard level observations, and the every 2 hour RN rounds were not documented on 10/16/2024 from 12:00 AM - 12:00 PM. - Pt #17’s patient observation sheet indicated that Pt #17 was on standard level observations, and the every 2 hour RN rounds were not documented on 10/16/2024 from 4:30 AM - 12:00 PM. 3. On 10/16/2024 at 11:30 AM, an interview was conducted with the Behavioral Health Manager (E #2). E #2 stated that the nurses are required to round every 2 hours and document. E #2 acknowledged that the five patients’ rounding sheets lacked documentation of RN rounding.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 2 patient’s (Pt. #1) allegation of abuse reviewed, the hospital failed to follow the procedure for responding to allegations of abuse by removing accused staff from patient care during investigation. Findings include: 1. On 10/16/2024, the clinical record for Pt. #1 was reviewed. On 6/17/2024, Pt. #1 was admitted with diagnoses of schizophrenia and bipolar disorder (type of mental illness). On 6/24/2024 at 11:52 AM, E #7 (Social Worker/Discharge Planner) documented, “(Pt. #1) told writer (Pt. #1) feels unsafe (at the hospital) due to being punched in the face ...(by a hospital staff)...” 2. On 10/16/2024, the incident and follow-up reports (completed by E #2/Manager, Behavioral Health) regarding Pt. #1’s allegation of physical abuse was reviewed. The reports indicated that on 6/24/2024 at 11:52 AM, Pt. #1 stated that E #3 (Mental Health Counselor) threw Pt. #1 on Pt. #1’s bed and punched Pt. #1 in the face. The investigation was completed on 6/25/2024. However, E #3 continued to work on another unit providing patient care as a sitter on 6/24/2024 from 3:00 PM through 11:00 PM. (E #2 stated it was ok for E #3 to work on another unit while investigation was ongoing). 3. On 10/16/2024, the hospital’s policy titled, “Management of Patient Allegations of Physician or Staff Sexual or Physical Abuse and Neglect” (7/2023) was reviewed. The policy indicated, “ ... Definitions: Abuse - means any physical ... abuse intentionally inflicted by a hospital employee ... Procedures ... Attachments 1 with Physical - Mental - Sexual Abuse Flow Map ... From Line of Staff: Allegation of Abuse. Report allegation to supervisor or manager ... Supervisor/Manager: Immediately notify risk management ... Consider immediate removal or accused employee from the situation/environment of care ...” 4. On 10/17/2024 at approximately 9:18 AM, a telephone interview was conducted with E #10 (Risk Manager). E #10 confirmed that the investigation regarding Pt. #1’s allegation of abuse was completed on 6/25/2024. E #10 stated that the hospital follows its policy regarding removal of alleged staff from the unit while the investigation is ongoing. E #10 stated that the hospital’s manager will determine the appropriate action regarding suspension or removal of the alleged staff.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 34411 Based on document review and interview, it was determined that for 1 of 3 (Pt #12) clinical records reviewed for restraints, the Hospital failed to ensure that the patient’s plan of care was updated after the use of restraints. Findings include: 1. The Hospital’s policy titled, “Restraint Use Non-Violent and Non-Self Destructive, Violent and Self-Destructive” (dated 5/25/2023), was reviewed and required, “ ...Documentation: Plan of care will be updated in accordance with the individualized needs of the patient ...” 2. The clinical record for Pt #12 was reviewed on 10/16/2024. Pt #12 was admitted to the Adult Intensive Treatment Unit (35 North) on 9/19/2024, with a diagnosis of bipolar disorder. Pt #12’s clinical record indicated that the patient was placed in restraints on 9/20/2024 and received an emergency prn (as needed) medication on 9/24/2024. Pt #12’s clinical record lacked an updated/modified treatment plan to include restraint as a focus area. 3. On 10/16/2024 at 11:30 AM, an interview was conducted with the Behavioral Health Manager (E #2). E #2 stated that patient’s master treatment plan should be updated after a restraint episode, to add “restraint” as a problem area.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 3 patients’ (Pt. #1) clinical records reviewed regarding use of restraints for violent behavior, the hospital failed to ensure that a physician’s order for the application of restraint was obtained. Findings include: 1. On 10/15/2024, the clinical record for Pt. #1 was reviewed. On 6/17/2024, Pt. #1 was admitted with diagnoses of schizophrenia and bipolar disorder (type of mental illness). On 6/23/2024, E #3 (Mental Health Counselor) documented, “... (Pt. #1) turned towards (E #3) ... yelled aggressively ... started approaching (E #3) with (Pt. #1’s) hand’s up... (Pt. #1) was restrained by holding (2 legs) and arms down on (Pt. #1’s) bed ... until more staff and security came ...” The clinical record lacked a physician’s order regarding use of physical hold as a restraint. 2. On 10/15/2024, the hospital’s policy titled, “Restraint Use” (5/2023) was reviewed and included, “... IV. Definitions. Physical restraint - any manual method, physical, or mechanical device... that immobilizes or reduce the ability of the patient to freely move his or her arms... V. Procedure... b. Obtaining a restraint order... 1. Obtain order for restraint from the LIP who is authorize for the care of the patient...” 3. On 10/15/2024 at approximately 11:30 AM, findings were discussed with E #12 (Manager, Behavioral Health). E #12 could not provide a physician’s order regarding use of physical hold/restraint on Pt. #1. E #12 stated that a physician’s order should have been obtained.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 3 patients’ (Pt. #1) clinical records reviewed regarding use of restraints for violent behavior, the hospital failed to ensure that the face-to-face assessment within one hour after initiation of restraints was completed, as required. Findings include: 1. On 10/16/2024, the clinical record for Pt. #1 was reviewed. On 6/17/2024, Pt. #1 was admitted with diagnoses of schizophrenia and bipolar disorder (type of mental illness). On 6/23/2024, E #3 (Mental Health Counselor) documented, “... (Pt. #1) turned towards (E #3) ... yelled aggressively ... started approaching (E #3) with (Pt. #1’s) hand’s up... (Pt. #1) was restrained by holding (2 legs) and arms down on (Pt. #1’s) bed ... until more staff and security came ...” The clinical record lacked the required face-to-face evaluation within one hour of placing the violent restraints. 2. On 10/16/2024, the hospital’s policy titled, “Restraint Use” (5/2023) was reviewed and included, “... IV. Definitions. Physical restraint - any manual method, physical, or mechanical device... that immobilizes or reduce the ability of the patient to freely move his or her arms... V. Procedure... b... 3. Violent and Self-Destructive Behavior... b. One-Hour Rule Initiation of Restraints. An LIP (licensed independent practitioner) or qualified supervisory nurse must see the patient within one hour after initiation of the restraints to evaluate the patient’s: immediate situation, reaction to the intervention, medical condition...” 3. On 10/16/2024 at approximately 11:30 AM, findings were discussed with E #12 (Manager, Behavioral Health). E #12 stated that the required face-to-face evaluation by LIP within one hour of placing the restraint should have been completed.”