HospitalInspections.org

Based on patient chart review and interviews the facility failed to:
1.) Provide the patient with a safe plan for basic dignity and comfort while in the hospital.
2.) Provide a safe environment by having guidelines and training for employees to place a patient safely on a "room lock out" in 1(#1) of 5 (1-5) charts reviewed.

Review of patient #1's chart revealed patient #1 was admitted on 7/14/16, voluntary, with a diagnosis of suicidal ideation, major depression, recurrent, without psychosis. Review of the psychiatric evaluation on 7/15/16 patient #1 was a 16 y/o female with a long history of depression admitted due to suicide attempted by cutting her right thumb with a butcher knife prior to admission on 7/14/16. The cut required 9 sutures. Patient #1 was placed on suicide precautions and "C" Status. A physician order was found to down grade the patient to a "D" status on 7/15/16.

Review of the policy and procedure "BHC/Observation Status Categories" stated, "Observation Status "C" (Close Observation-Unit Restricted) Definition: This is designed for patients who are viewed as a high risk for impulsive acts and need closer observation by the staff. Procedures include:
A. Patients are unit restricted and must be supervised when on unit patio.
B. Sharp and electrical appliances may be used only with constant visual supervision.
An entry will be made every 15 minutes on the Observation Rounds Sheet by the staff assigned to the patient.

Review of "D" status definition, "This is designed for patients who are at risk for impulsive acts.
A. Patients may leave the unit, but must be accompanied by a staff member. The staff member may accompany more than one patient at a time.
B. Patients are not building restricted, but must be accompanied by staff at all times.
C. Sharp and electrical appliances may be used only with constant visual supervision.
D. Patients must be supervised on patios.
An entry will be made every 15 minutes on the Observation Rounds Sheet by the staff assigned to the patient."

Review of the nurse's notes on 7/16/16 at 7:45PM staff #5 documented, "Called to unit by staff #6. He states patient removed stitches from her thumb. Patient observed sitting on her floor in her room with her head down. She states she did it because she was angry at a staff member from the day shift. Wound to thumb on right hand gaping open with 1 stitch still intact. Small amount of bleeding observed. MD notified by unit staff who ordered transfer to ED for evaluation. Notified charge nurse of order for patient transfer."

Review of the nurse's notes revealed the patient returned from the ER at 1:40AM on 7/17/16. Patient #1 required sutures to close the wound. The next documentation was on 7/17/16 at 6:59AM. Staff #6 documented, "Patient approximately slept for 5 hours. Lights on at the day area for patient safety."

Review of physician orders revealed an order dated 7/17/16 at 9:21AM. The order stated, "Communication lock out of room, bathroom privileges only sleep on mattress in day area. Instructions: lock out of room, bath room priv only. Sleep on mattress in day area." (sic)

Review of the physician progress notes for 7/17/16 at 1:52PM stated, "Patient was sent to the ER yesterday evening d/t removing the sutures to right hand/thumb with her teeth before removal was due-pt stated it was d/t being angry with staff. Per staff, pt. had required much redirection during the day-making racist comments towards a staff member, staff splitting, disrespectful, attention seeking, impulsive, had tore off bandage to right hand/thumb and smeared blood on her leg. Pt has been hard to direct at times, oppositional, defiant, disruptive to unit." The physician ordered the patient to be placed on a "C" status but there was no documentation found on why the patient was locked out of her room.

Review of the MHT Observation Notes revealed the patient was in the group room sleeping each night from 7/17/16- 7/23/16. On 7/23/16 patient #1 was downgraded to a "D" status but no order was found to discontinue the room lock out. Review of the MHT Observation Rounds revealed patient #1 was in her room sleeping on 7/24/16.

A tour was conducted on the adolescent unit with staff #2 and #3 on 8/31/16. Review of the patient's room revealed the patient was next to the nurse's station. The group room was to the right of the nurse's station and had multiple glass windows to see into the room. There would have been no privacy for patient #1 while she was sleeping. Staff and other patients could see into the room at all times.

An interview with staff #2 stated patient #1 was placed on "lock out" due to her removing her sutures and attempting to harm herself. Staff #2 reported that the physician wanted her to sleep in the group room since it was closer to the nurse's station and had glass windows. The staff could monitor the patient more closely. The staff put patient #1's mattress on the floor of the group room and she was required to sleep there. If patient #1 wanted to lay down during the day she would have to lay on the very hard plastic chairs. Patient #1 was not allowed to lie down in her room. Patient #1 was allowed to enter her room to shower and use the bathroom with staff supervision only. Staff #2 stated there was no policy, procedure, or guidelines for room "lock out."

An interview was conducted with staff # 7, 8, and 9 on 8/31/16. Staff #7 stated she did not know what a room lock out was. Staff #7 stated she has never had to do one but she was a float to the unit. Staff #8 stated she rarely has to do a lock out but most of the time it's due to a bulimic patients vomiting and they are locked out of areas for about an hour after each meal. Staff #9 stated a lock out can be just to keep patient out of an area for a short time to prevent them from hurting themselves. Each staff member interviewed had a different perspective on what a room lock out was due to no policy or guidelines in place.

Review of the chart revealed patient #1 was on a 15 minute observation. There was no order for a closer observation. An interview with staff #4 (MD) on 8/31/16 revealed the patient was put on a room lock out to prevent her from self-mutilation. Staff #4 stated that she could be watched closer if she was not allowed to go into her room unsupervised. Staff #4 was asked how patient #1 was monitored closer if the observation status was not changed. Staff #4 stated that looking back on the situation now he can see where changing the status would have been the preferred thing to do.

An interview with staff #1, 2, and 3 on 8/31/16 confirmed that the staff did not have clear guidelines on room lock outs. Staff #1, 2, and 3 confirmed the staff needed those guidelines on how to have a safe environment and retain patient privacy.