HospitalInspections.org

Based on record review, and interview, the facility failed to provide care in a safe environment when a self-harming patient was provided a sharp object.

Patient #1 was on a one-to-one observation due to the risk of self-harm. The staff member, responsible for monitoring the patient, gave the patient a tape dispenser with a metal cutter. The patient cut herself with the tape dispenser and, was sent to the local hospital, where she required 5 stitches to close the wounds.


Findings:

Review of the facility provided policy Precautions (effective May 2021) reflected,
"9. Management of the Patient on Precautions:
9.1. All nursing staff whose job duties require them to function in the patient care areas will assess the patient area for contraband and other potentially harmful objects at the beginning of and throughout each shift."

Review of the facility provided admission note for Patient #1 reflect, "This is a 17-year-old female admitted to ASH on a voluntary, ...Patient is transferred to ASH for transition to lesser restrictive setting. During her admission to ASH from 9/5/2023 to 11/16/2023 Patient #1 reportedly had 13 notable aggressive events which led her to being declared Manifestly Dangerous through the Facility Review Board. Her physical aggression towards others seemed to occur for no apparent reason and without warning or when staff intervened in her attempts to self-harm. Her violence towards others included kicking, punching in the head area, slamming staff members' heads into walls, hair pulling, biting, and strangling. Patient had not shown remorse and voiced homicidal ideation towards peers and staff.

Review of the Patient #1's Level of Observations, dated 11/6/23, these orders were in place at the time of the incident on 1/25/24, reflected the following:

Patient's Level of Supervision: 1: 1
order details
"I. No personal belongings in room due to high risk of self-injurious behaviors. All personal
belongings will stay in the Nurse's station and will be provided to patient at Nurse's discretion.
on an as- needed basis if deemed safe.
2. Patient to have a pair of clothing provided by Nurse/staff. Additional layer of clothing to
be provided upon her request.
3. Can have bed linens and blankets as long as patient is keeping her hands out of the blanket
where they are visible to the staff.
Reason:
4. NO HOODED SHIRTS OR JACKETS 1 EA Continuous
Reason: Self Injurious - Risk of self -harm behaviors. Risk of manipulating the existing healed wound and causing new injuries under the blanket."

Review of the facility provided policy Precautions (effective May 2021) reflected,
"9. Management of the Patient on Precautions:
9.1. All nursing staff whose job duties require them to function in the patient care areas will assess the patient area for contraband and other potentially harmful objects at the beginning of and throughout each shift."

Review of the facility provided event report dated 1/25/24 at 8:30 pm reflected, "Patient #1 was in her bedroom putting up pictures on the wall with paper tape, once she used up the
tape, she asked for more and the therapist handed a tape to a staff (Staff #6, Patient Care Technician) to give it to her without paying attention that the tape had a metal cutter. A few minutes later there was a situation on the unit staff (Staff #6, PCT) turn her head to watch her back. Then Pt was seen by her 1:1 staff, doing swinging motion on her forearms. Pt sustained several cuts from old scars on both forearms. Two cuts on L/arm of about 2 inches each, one with scant bleeding and the other one deeper with active bleeding and one cut to L/antecubital area. and four cut to r/arm of about 2 inches each, 3 very superficial and one with scant bleeding.
Patient Description of How the injury Occurred: "I cut myself, I cut myself, look, look. I tried hard not to do it".

During an interview, on the morning of 1/29/24, in a conference room, when asked about the incident, Staff#11, Assistant Chief Nursing Officer stated, "At around 8:30 pm the patient was in her room. She was on a one-to-one with Staff #6. The therapy activity had been to making posters and Staff #6 was helping her (Patient #1) hang a poster in her room. Staff #6 ran out of tape and asked the therapist for more. The therapist staff handed the tape dispenser to Staff #6 and told her not to give it to the patient. She (Staff #6) originally started handing Patient #1 the pre-cut tape, she (Staff #6) started to physically help Patient #1. Staff #6 eventually handed Patient #1 the tape dispenser. Staff #6 got distracted by activity on the unit and Patient #1 quickly slashed herself with the cutter. After the event Staff #6 met with the manager; they went back and reviewed the one-to-one policy. The staff recognized her mistake, she was placed on administrative leave pending the results of the investigation."

During a telephone interview on the afternoon of 2/2/24, when asked about the incident on 1/25/24, Staff #6 stated, "I was sitting outside the patients room. Patient #1 was hanging up pictures, she had a roll of tape. When she ran out of tape, I asked the therapist for more. The Therapist gave me a plastic tape dispenser, like the kind you get at the store, you know the cheap kind.
I didn't notice it had a metal cutter. She (the therapist) didn't tell me not to give it to Patient #1. I should have caught it. When asked how the disposable tape dispenser could cause so much damage, Staff #6 stated, "She (Patient #1) had previous scars to her left arm, she reopened the scars with the tape dispenser.