HospitalInspections.org

Based on observation, review of medical records and facility documentation, and staff interviews, it was determined the facility failed to ensure a safe environment by failing to utilize proper de-escalation techniques on one patient; failing to adequately access a patient after a physical altercation; and failing to utilize the shortest available cord as an anti-ligature device (A0144).

A. Based on review of the Emergency Department (ED) video surveillance film, staff interview, and review of facility documentation, it was determined the facility failed to ensure that correct crisis prevention techniques are used for patient de-escalation.

Findings include:

1. On 3/24/21 at 2:30 PM, a review of the video surveillance film of the ED locked Psychiatric Area for 1/11/21, revealed the following:

a. At 9:50 PM, Patient #1 was observed standing in the hallway, next to the nurse's station, in the presence of Staff #26, a security officer. Staff #9, a second security officer, approached the patient. Patient #1 was observed actively speaking to Staff #9 and Staff #26. Staff #9 was observed pushing the patient three times in the chest.

2. On 3/24/21 at 3:00 PM, a review of personnel files for Staff #9 revealed he/she was terminated on 1/15/21, following video footage review of the event of 1/11/21, where a patient was pushed three (3) times.

3. Upon interview, Staff #2, Staff #3, and Staff #7 confirmed that when Staff #9 pushed the patient, it was not the correct use of crisis prevention techniques for patient de-escalation.


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B. Based on medical record review, staff interviews, and review of facility policy and procedure, it was determined the facility failed to ensure their policy for occurrence reporting is implemented.

Findings include:

Reference: Facility policy titled, "Occurrences-Assessment, Reporting, and Intervention" states, "... Definitions: An occurrence is defined as any incident that is not consistent with routine hospital operation or patient/resident care, or any circumstance that threatens physical safety and well-being regardless of whether an actual injury is involved. ...Additional Items-An immediate assessment of the patient/resident is performed..."

1. On 3/24/2021, upon review of Medical Record #1, the following was indicated:

a. On 1/11/2021 at 10:54 PM, the Physician History of Present Illness Note stated, ".... In the Emergency Department [ED], the patient became agitated towards security staff and required Intramuscular [IM] medications (5/2/50) ..."

b. On 1/12/2021 at 9:00 AM, the Registered Nurse Note stated, "Patient up, out of bed, took AM [morning] Meds [medications]. Cooperative. Called his/her father complaining about hospital staff from last night."

2. On 3/24/2021 at 1:46 PM, upon interview, Staff #3 stated the following details involving Patient #1:

a. On 1/12/2021, Staff #12, a Registered Nurse, heard Patient #1 stating during a telephone conversation that they had been choked by a Security Guard the night before. Staff #12 notified Staff #3 of this information.

b. Further interview with Staff #3 indicated that after the altercation, on 1/11/21, they performed an assessment on Patient #1 and that no injuries were noted.

3. Further review of the patient's medical record revealed no documented evidence of the medical assessment after the physical altercation by the security guard.

4. Upon interview, Staff #1, Staff #2, and Staff #3 confirmed that there was no documented evidence in the medical record of the assessment performed on the patient after the physical altercation with the security guard.

C. Based on observations on two (2) of two (2) Psychiatric Units, staff interview, and review of facility documents, it was determined the facility failed to ensure use of the shortest available telephone cords, on the inpatient psychiatric units, as an anti-ligature device.

Findings include:

1. On 3/25/2021 at 11:10 AM, during a tour of STCF [Short Term Care Facility] Psychiatric Unit (Unit AG), with Staff #1, Staff #14, and Staff #16, a wall-mounted telephone was observed with a long, dangling cord in the back of the Patient Dining Room/Kitchen area.

a. Upon interview, Staff #1, Staff #14, and Staff #16 indicated that patients do not have access to this area unless a staff member is present in the room, as the door is kept locked when not in use. In addition, the room is monitored via camera.

b. Interview on 3/26/2021 at 1:20 PM with Staff #2 revealed that the telephone cord had the following measurements: fifteen (15) inches at rest and four (4) feet extended. The shortest cord available was not being used as an anti-ligature device.

2. On 3/25/2021 at 12:00 PM, during a tour of the Adult Acute Psychiatric Unit (Unit A1), with Staff #1, Staff #14, and Staff #19, a wall-mounted telephone was observed with a long, dangling cord in the back of the Patient Dining Room/Kitchen area..

a. Upon interview, Staff #1, Staff #14, and Staff #16 indicated that patients do not have access to this area unless a staff member is present in the room, as the door is kept locked when not in use. In addition, the room is monitored via camera.

b. Interview on 3/26/2021 at 1:20 PM with Staff #2 revealed that the telephone cord had the following measurements: twenty (20) inches at rest and five (5) feet extended. The shortest cord available was not being used as an anti-ligature device.