HospitalInspections.org

The Hospital was out of compliance for the Condition of Participation for Patient Rights.

Findings included:

The Hospital failed to ensure for one (Patient #1) of ten sampled patients that the Hospital provided care in a safe setting.

Refer to Tag: A-0144

Based on interviews and record review, the Hospital failed to ensure for one of ten sampled patients (Patient #1), to provide care in a safe setting to prevent a suicide attempt on the inpatient psychiatry unit. Findings include:

Patient #1 was admitted to the Hospital during November 2018 with diagnoses of schizophrenia, traumatic brain injury and depressive disorder.

The Nurse's note dated 2/15/19 at 3:35 P.M. indicated that Patient #1 was found clothed, face down and unresponsive with a plastic shopping bag over his/her head in the bathroom.

The Hospital's Visitor Guide for the inpatient psychiatric unit (2 South) indicated that no plastic bags are allowed to be brought onto the unit.

On the posted visitor sign that the Surveyor observed upon entering the unit indicated that no plastic bags are permitted on the unit and that all belongings should be placed in the lockers provided.

The Visitor's Policy, dated 9/1996 and last reviewed 3/2016 indicated that all visitors are required to leave their pocketbooks, backpacks, cellphones, or other parcels in the self service lockers off the unit.

A Nurse's Note dated 2/13/19 at 10:52 A.M., indicated that Patient #1 was had suicidal ideation with an unspecified plan.

A Physician's Progress Note, dated 2/13/19 at 1:07 P.M., indicated that Patient #1 was voicing suicidal ideation with a plan that he/she was not willing to disclose. The physician increased the level of observation to constant and increased Patient #1's antidepressant medication.

A Nurse's Note, dated 2/14/19 at 10:53 A.M., indicated that Patient #1 was no longer verbalizing suicidal ideation.

A Physician's Progress Note, dated 2/14/19 at 3:39 P.M., indicated that Patient #1 denied suicidal ideation but remained depressed. Patient #1's level of observation was decreased to five minute checks.

A Physician's Progress Note, dated 2/15/19 at 8:53 A.M., indicated that Patient #1 appeared less depressed and was smiling more and denied passive or active suicidal thoughts. Observation status decreased from five minute checks to 15 minute checks.

Review of the Hospital's Safety Events indicated that on 2/23/19, eight days after Patient #1's attempted suicide, a Mental Health Worker found a plastic bag in a patient's room. The final response to this event was written on 2/27/19 and indicated that the Quality Department will follow up with the leadership regarding safety of plastic bags on the unit.

Review of the investigation file indicated that, although the observation status of Patient #1 was decreased to 15 minute checks, the Patient remained on five minute checks through 3:35 P.M. when found unresponsive in his/her bathroom.

The Surveyor interviewed the Executive Director of Patient Safety, Quality and Risk Management at 2:20 P.M. on 2/27/19. The Executive Director of Patient Safety, Quality and Risk Management said that the visitors' lockers were removed during renovations of the unit and have not been replaced. The Executive Director of Patient Safety, Quality and Risk Management said that without the lockers the unit staff are expected to search visitors at the door and, if they have any items not permitted on the unit, they are to be locked up by the unit staff member who answered the door.

The Surveyor interviewed the Executive Director of Patient Safety, Quality and Risk Management at 11:00 A.M. on 2/28/19. The Executive Director of Patient Safety, Quality and Risk Management said the Hospital performed a Collaborative Case Review (CCR) of the incident on 2/20/19 and the review team was unable to determine how the plastic bag was obtained by Patient #1 or how the plastic bag made it onto the unit. The Executive Director of Patient Safety, Quality and Risk Management said that there were corrective actions to be implemented for increased patient safety on the unit including: create door monitor specific role, visitor log dated daily with separate page for each day, signs/orientation booklet including other languages, install wall lockers, consider open areas restrictions on patients on five minute checks, review max capacity for checks duties and institute protocol for room search/sweep when suicidal ideation increases.

The Surveyor interviewed the Charge Nurse and Nurse #1 at 12:00 P.M. on 2/28/19. The Charge Nurse and Nurse #1 said that they were unable to determine when the plastic bag came onto the unit or who brought it in. The Charge Nurse and Nurse #1 said that when visitors come, they only check the items brought in that are intended for the patients and they do not check the visitors' personal belongings. The Charge Nurse and Nurse #1 said they do not lock visitors belongings in the nursing station or a closet. The Charge Nurse and Nurse #1 said visitors come on the unit with pocketbooks, coats and bags. The Charge Nurse and Nurse #1 said that there haven't been any changes on the unit or any education provided to staff members since the attempted suicide, just reaffirmation of the preexisting policies.

The Surveyor interviewed the Chief of Nursing Services and the Executive Director of Patient Safety, Quality and Risk Management at 1:00 P.M. on 3/1/19. The Chief of Nursing Services and the Executive Director of Patient Safety, Quality and Risk Management said that they were unable to determine who brought the second plastic bag on the unit but thought it may be a security officer who was providing constant observation to a patient on the unit. The Chief of Nursing Services and the Executive Director of Patient Safety, Quality and Risk Management said that the security staff and other contracted personnel gain access onto the unit by ringing the door bell outside of the unit and a Staff member would have to let them in. The Chief of Nursing Services and the Executive Director of Patient Safety, Quality and Risk Management said that contracted personnel get education regarding safety on the unit prior to starting employment and should be aware that they can't bring at risk items onto the unit.