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Based on record review, observation, and interview, the hospital failed to promote and protect the rights of five of five patients (Patients #14, 12, 13, 4, and 16) to receive care in a safe environment that prevented potential or actual harm.

1) Patients #14, 12, 13, and 4 were hospitalized at the time of survey. The patients had been admitted with mood instability and suffered from hallucinations and/or were court ordered to receive inpatient treatment due to a mental illness that caused the patients to be at serious risk for self-harm. In their rooms, the patients had access to thin, stretchable plastic pillow covers with a gap big enough to insert a head during a self-suffocation attempt which had the potential to be ripped and rolled to thin strips for ligature and self-strangulation during a self-harm or suicide attempt.

2) Patient #16, a female, had been admitted with serious mental and physical health diagnoses. The patient had made suicidal threats prior to her admission. Two days into her stay, male Patient #8 whose room was in immediate proximity to Patient #16's room, entered Patient #16's room around midnight. Yelling for help, Patient #16 fled her room and was followed by Patient #8 out into the hallway. Patient #8 had threatened violence against women about six hours prior to the incident but had not been placed on special observations for aggressive behavior. Patient #8 attacked Patient #16 in the hallway and pushed her to the floor, leaving Patient #16 scared, tearful, and severely anxious. After the incident, Patient #16 required medical care, remained anxious and depressed, and complained of pain for the rest of her hospital stay.

Refer to A 144

Based on record review, interview, and observation, the hospital failed to ensure the rights of five of five patients (Patients #14, #12, #13, #4, and #16) to receive care in a safe setting.

1) Patient #14 had been admitted with mood instability. The patient felt hopeless and helpless, and suffered from command hallucinations. The patient had suicidal thoughts and was noted to be depressed and isolative less than 12 hours prior to the surveyor's observation of plastic pillow covers potentially usable during a self-harming attempt and accessible to the patient.

2) Patients #12, 13, and 4 had been admitted with hallucinations and severe depression and/or were court ordered to receive inpatient mental health care due substantial risk of serious threat to self or others. The patients had access to plastic covers potentially usable in self-harm as observed during the survey.

3) Upon admission, female Patient #16 was suicidal and a danger to herself. Thirty hours into her hospitalization, a male patient (Patient #8) who had threatened physical violence toward women about six hours earlier and had a room in immediate proximity to Patient #16, entered Patient #16's room around midnight. Patient #8 followed Patient #16 out to the hallway and physically attacked her. Patient #16 complained of pain in her shoulders, ribs, and lower back for the following two days. Despite his threats of violence, Patient #8 was not on precautionary observation for aggression at the time of the incident.


Findings:

1) Observations on the hospital's patient care area on 04/03/19 at 1420, reflected two pillows with light green, thin plastic covers were observed on the beds in Room 1317. The plastic enveloped the pillow leaving an opening large enough to insert the head. Moreover, the plastic was removable from the pillow case, with the potential to be ripped and rolled into strips long and strong enough to be potentially usable for ligature and/or self-strangulation. Room 1317 was the last room at the end of a long hallway, farthest away from the nurses' station.

Record review of the hospital's Patient Roster dated 04/03/19 reflected Room #1317 was assigned to Patient #14.

Patient #14's Daily Nurse Note dated 04/02/19 at 2300 reflected the patient was "depressed, anxious...isolative..."

Record review of Patient #14's Physician Discharge Summary dated 04/07/19 reflected the patient's 13-day hospitalization between 03/20/19 and 04/03/19. The patient had been admitted with mood instability and "disturbance in thought process" and felt hopeless, helpless, and suffered command hallucinations.

Patient #14's Psychiatric Progress Notes dated 03/22/19, 03/23/19, 03/24/19, 03/25/19, 03/26/19, 03/27/19, 03/28/19, 03/29/19, and 04/01/19, reflected the patient had suicidal thoughts.

Personnel #5 acknowledged the ligature risk during an interview on 04/03/19 at 1420 and stated the plastic cover was there due to infection control reasons.

Personnel #16 stated during an interview on 04/03/19 at 1420 that the gap in plastic cover was "big enough to put a head in" and made suffocation possible during a self-harm attempt.



2) Three additional pillows with light green, thin plastic covers were observed on 04/03/19 at 1425 in Room 1314 occupied by Patients #12 and #13, and at 1435 in Room 1414 occupied by Patient #4 according to the Patient Roster dated 04/03/19.

Record review of Patient #12's Psychiatric Evaluation dated 03/28/19 at 1139 reflected the patient's diagnosis of Severe Major Depressive Disorder with Psychotic Features. The patient was noted "to respond to internal stimuli" and had poor coping skills.

Patient #12's Psychiatric Progress Note dated 04/03/19 reflected the patient had "severe depression" and suffered from hallucinations. The patient was "guarded/evasive...superficially cooperative..." and did not eat or sleep well.


Patient #13's Order of Protective Custody dated 03/26/19 reflected the patient was at a "substantial risk of serious harm to self..." and was court ordered to receive hospital care.

Patient #13's Psychiatric Physician Evaluation dated 03/27/19 at 1238 reflected diagnoses that included Alzheimer's Disease with Behavioral Disturbances. The patient had a history of inpatient psychiatric treatment for suicidal ideation in 02/2019 and early 03/2019. The patient was noted with "poor coping skills...minimizing her symptoms...seems to be responding to internal stimuli..."

Patient #13's Psychiatric Progress Note dated 04/03/13 reflected the patient had "scratched another patient without provocation to the point of bleeding...paranoid, irritable, intermittently agitated, responds to internal stimuli..."


Patient #4"s Order of Protective Custody document dated 04/03/19 reflected the patient was "...a substantial risk of serious harm to self..." and was court ordered to receive inpatient mental health care at the hospital.

Patient #4's Psychiatric Progress Note dated 04/03/19 at 1358 reflected the patient heard voices and responded to internal stimuli. Patient #4 was "depressed/sad, anxious...guarded/evasive/minimizing symptoms...poor insight/judgment..." Patient #4 had "bizarre, illogical, persecutory delusions."

Patient #4's Daily Nurse Note dated 04/03/19 at 1400 reflected the patient was "withdrawn...preoccupied...guarded..."


Personnel #8 was observed removing plastic-covered pillows from patient rooms on 04/03/19 at 1445 and stated the hospital had "quite a few of those pillows."

On 04/03/19 at 1445, at least twelve pillows with green plastic covers were piled in Personnel #16's office. Personnel #16 stated at that time that staff members were in the process of removing and replacing all pillows with plastic covers.



3) Patient #16's admission record reflected the patient was admitted on 12/29/18 at 1531.

Patient #16's Medication Administration Record dated 12/31/18 reflected the patient was in Room 1316.

The Psychiatric Evaluation dated 12/30/19 at 0959 reflected the patient was a danger to herself and had made suicidal threats. Admitting diagnoses included Mood Disorder, Hypothyroidism, Diabetes Mellitus, Hypertension and Sleep Disturbance.

Patient #16's Progress Notes dated 12/31/18 at 0040 reflected the patient " ...was yelling for help on her way out of... [the patient's room] complaining peer intrusion in her room. Peer left...[Patient #16's] room and went after ...[Patient #16]...pulled her hair and pushed her on the floor ...[Patient #16] got very scared ...tearful ...severe anxiety..."


Patient #16's Psychiatric Progress Note dated 12/31/18 reflected the patient complained of pain to her right should and lower back due to an injury "sustained on night of 12/30/18 ...male patient came in her room and attacked her ...x-rays ordered for right should, ribs, and coccyx/sacrum ...internal medicine to follow-up for pain management ...endorses anxiety and depression ..."

Patient #16's Internal Medicine Progress Notes dated 01/02/19 at 1920 reflected a pain consult and the patient's anticipated discharge date of 01/03/19.


Patient #8's Admission Orders dated 12/28/18 at 1530 reflected the patient was admitted to the inpatient unit with diagnoses that included Bipolar Disorder. The patient was in Room 1317 according to the medical chart's lab report.

Patient #8's Psychiatric Progress Note dated 12/30/18 at 1030 reflected the patient suffered from Psychosis "compromising safety of self or others."

Progress Notes dated 12/30/19 at 1730 reflected Patient #8 "became aggressive, punching the door at the exit." The patient told staff that "he'd punch a woman...he's done it plenty of times ..."

Physician Orders dated 12/29/18 and 12/30/18 did not reflect the patient was placed on aggression precautions.

Progress Note dated 12/31/18 at 0045 reflected Patient #8 "was found in peer's room standing near the window ...staff redirected...[Patient #8] from peer's room ...finds peer in the hallway and ran toward her ...pulled her hair ...pushed her on the floor ..."

Discharge Summary dated 01/11/19 at 1543 reflected Patient #8 had been " ...aggressive and violent on December 31, 2018."

During an interview on 04/12/19 at 1127 Personnel #12 denied that Patient #8 was on aggression awareness at the time of altercation with Patient #16. Personnel #12 acknowledged that aggression-related incidents had tripled from six percent of all incidents in 01/2019 to 21 percent in 02/2019 and 03/2019.

Hospital Policy # PR-01 was titled Patient Rights with an effective date of 02/01/17. The policy reflected the hospital procedure to ensure patients' rights to a safe treatment environment

Based on record review, observation, and interview, it was determined that the hospital failed to collect data and/or use data collected to identify opportunities to improve the safety of patient care units and initiate changes that would lead to improvement.

1) During the survey, twelve pillows were observed on the patient care unit with thin, stretchable plastic covers potentially serving as risk for self-strangulation, ligature, and/or suffocation during self-harm attempts. At least five of those pillows had been in immediate reach of patients prior to surveyor inquiry. Hospital administration denied awareness of the safety risk and failed to initiate opportunities for improvement.

2) Patient #8, a male, had threatened violence against women on the unit on 12/30/19. A few hours later, the patient attacked Patient #16, a female patient, leaving her anxious, depressed, and in need of medical care for her physical pain until her discharge. Data collected during and after the incident reflected that patient aggression had more than tripled over the last three months. The hospital failed to address those data with a quality and performance improvement action plan.

Findings included

1) Observations on the hospital's patient care area on 04/03/19 at 1420 reflected two pillows with light green, thin plastic covers in Room 1317. The plastic enveloped the pillows, leaving an opening large enough to potentially insert a patient's head. Moreover, the plastic was removable from the pillow case, with the potential to be ripped and rolled into strips long and strong enough to be potentially usable for ligature and/or self-strangulation. Room 1317 was the last room at the end of a long hallway, farthest away from the nurses' station.

Three additional pillows with light green, thin plastic covers were observed on 04/03/19 at 1425 in Room 1314 and at 1435 in Room 1414.

Personnel #16 stated during an interview on 04/03/19 at 1420 that the gap in plastic cover was "big enough to put a head in" and made suffocation possible during a self-harm attempt.

Personnel #8 was observed removing pillows from patient rooms on 04/03/19 at 1445 and stated the hospital had "quite a few of those pillows."

On 04/03/19 at 1445, at least twelve pillows with green plastic covers were piled in Personnel #16's office.

Personnel #8 and #10 were observed during patient care on 04/22/19 at 0722 and asked about the plastic pillow covers. The MHTs (mental health technicians) stated that they had voiced their concerns to hospital administration.


Personal #6 stated during an interview on 04/12/19 at 1320 that he was responsible for the hospital environment and denied knowledge of the plastic pillows until surveyor inquiry when he had a look at them and "said that they needed to go."


2) Progress Notes dated 12/30/19 at 1730 reflected Patient #8 told staff that he would "punch a woman."

Progress Note dated 12/31/18 at 0045 reflected Patient #8 pulled another patient's hair and "...pushed her on the floor..."

Patient #16's Psychiatric Progress Note dated 12/31/18 reflected the patient complained of pain to her right should and lower back due to an injury "sustained on night of 12/30/18 ...male patient came in her room and attacked her...internal medicine to follow-up for pain management ...endorses anxiety and depression ..."

Personnel #5 acknowledged the incident between Patient #8 and Patient #16 during an interview on 04/12/19 at 1120.

During an interview on 04/12/19 at 1127 Personnel #12 acknowledged that aggression-related incidents had tripled from six percent of all incidents in 01/2019 to 21 percent in 02/2019 and 03/2019. Personnel #12 denied that aggression on patient units was identified as an action item in the hospital quality improvement program.

Hospital policy titled "Quality Assessment & Performance Improvement Program" dated 02/01/17 reflected the procedure to "collect and aggregate all data...and identify opportunities for improvement." The data to be collected and aggravated "...to assess need for performance improvement...[and] implement an action plan..."

Based on record review and interview, the hospital's registered nursing staff failed to supervise and evaluate the nursing care for each patient depending on the patients' needs for one of one patient (Patient #16), an elderly patient with high blood pressure and changing blood sugar levels related to her diagnosis of Diabetes Mellitus.


1) Patient #16 was physically attacked by a male patient in the hallway in front of her patient room. The incident left the patient in physical pain that required medical intervention for the following three days. Although Patient #16 told nursing staff of her pain, nursing failed to assess the patient's pain level during the following 24 hours. Nursing failed to call for a physician ordered x-ray until approximately eleven hours after the incident.

2) Patient #16 had elevated blood sugar readings on 01/01/19 at lunch and at bed time. Nursing failed to administer insulin according to physician-ordered sliding scale for the patient's increased blood sugar levels.



Findings included:

1) Patient #16's Psychiatric Evaluation dated 12/30/19 at 0959 reflected the patient's admitting diagnoses that included Mood Disorder, Hypothyroidism, Diabetes Mellitus, Hypertension (high blood pressure) and Sleep Disturbance.

Progress Notes dated 12/31/18 at 0040 reflected Patient #16 "yelled for help" when another patient came into her room. Patient #16 left her room. The other patient followed Patient #16 into the hallway and physically attacked her, pulling her hair and pushing her to the floor.

Patient #16's Progress Notes dated 12/31/18 at 0630 reflected Patient #16 complained of back pain.

Patient #16's Daily Nurse Note dated 12/31/19 (day shift), timed at 1200 did not reflect a pain assessment. Daily Nurse Note dated 12/31/19 (night shift), untimed, did not reflect that a pain assessment was done.

Physician Orders dated 12/31/18 at 1103 reflected Patient #16 complained of pain in her shoulders, right ribs, and tailbone. X-rays were ordered.

Psychiatric Progress Note dated 12/31/18 reflected the patient complained of pain to her right should and lower back due to an injury "sustained on night of 12/30/18 ...male patient came in her room and attacked her ...x-rays ordered for right should, ribs, and coccyx/sacrum ...internal medicine to follow-up for pain management ...endorses anxiety and depression ..."

Physician Orders dated 01/01/19 at 1055 reflected a follow-up visit with Patient #16 due to "persistent pain to right should and lower back from injury sustained on night of 12/30/18 ..."

Patient #16's Internal Medicine Progress Note dated 01/02/19 reflected a pain consult.

Personnel #5 was interviewed on 04/12/19 at 1145 and acknowledged the above findings.

Record review of Hospital Policy titled "Pain" and dated 02/01/17 reflected the procedure to assess the patients' pain "every shift."

2) Patient #16's Capillary Blood Glucose Monitoring Log and Medication Administration Record dated 01/01/19 reflected the patient's blood sugar level of 193 mg/dL at lunch time (1130). The patient's blood sugar was 228 mg/dL on 01/01/19 at bedtime (2100).

Medication Administration Record (MAR) dated 01/01/19 reflected the sliding scale order to administer insulin lispro (Humalog) 2 units for Patient #16's elevated blood sugar level of 193 mg/dL at lunch time. The order reflected the administration of 4 units of Humalog for the patient's elevated blood sugar level of 228 mg/dL at bedtime. There was no evidence that insulin was administered for Patient #16's at lunch or bedtime according to the sliding scale orders.

Personnel #5 was interviewed on 04/12/19 at 1120, reviewed Patient #16's medical file, and confirmed Patient #16 was diabetic. Personnel #5 denied that the patient received insulin according to physician-ordered sliding scale for the patient's increased blood sugar levels on 01/01/19 at lunch or bedtime.