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Tag No.: A0115
The Condition of Patient Rights has not been met.
1. Based on clinical record reviews, interviews and policy review the facility failed to provide adequate supervison to prevent a sexual encounter between two patients (Patient #8 and #11).
2. Based on observations of 4 of 4 units and interviews with facility staff during a tour of the facility, the facility failed to ensure that emergency equipment was readily accessible in the event of a medical emergency.
3. Based on observation, review of manufacturer recommendations, review of policy and procedures, and interviews for 4 of 4 inpatient units with glucometers, the hospital failed to ensure that single use glucometer devices were not available for use on multiple patients.
4. Based on review of facility policy and interviews, the hospital failed to utilize the 9-1-1 system as a first call for emergencies.
5. Based on review of the clinical record, review of policies and procedure, and interviews for 2 of 2 patients (Patient #5 and # 6) reviewed for emergency medical transfers, the hospital failed to utilize the 9-1-1 system as a first call for emergencies.
Please refer to A144
Tag No.: A0144
1. Based on clinical record reviews, interviews and policy review the facility failed to provide adequate supervision to prevent a sexual encounter between two patients (Patient #8 and #11). The finding includes the following:
a. Patient #8 was admitted on 9/28/18 on a Physician Emergency Certificate (PEC) with violent and aggressive behaviors. A treatment plan dated 11/21/18 indicted the patient's problem list included mood dysregulation with aggression towards others and impulsivity. A treatment plan dated 1/2/19 indicated that the patient's diagnoses include disruptive mood disorder, Post Traumatic Stress Disorder (PTSD), conduct disorder and substance abuse. The identified problems were mood dysregulation with aggression towards others and impulsivity with a goal for Patient #8 to be able to express feelings safely without engaging in aggression towards others. Patient #8 had no history of sexually inappropriate behaviors.
Patient #8's clinical record identified that on 12/9/18, the patient was to be monitored every fifteen minutes. The observation monitoring flow sheets dated 12/9/18 indicated that the patient was monitored at 11:00 AM, 11:05 AM, 11:15 AM, 11:30 AM, 11:45 AM and 12:00 PM.
A progress note dated 12/9/18 at 9:00 PM indicated that Patient #8 notified RN #8 that he/she had a sexual encounter with a peer (Patient #11). A progress note dated 12/9/18 at 10:20 PM indicated that Patient #11 entered Patient #8's room between 11:00 AM and 12:00 PM on 12/9/18 and had a sexual encounter. Patient #8 indicated that he/she was upset, angry and ashamed. The physician was notified, the patient's room was moved and both patients were placed on full separation.
b. Patient #11 was admitted to the facility on 3/16/18. Review of a psychiatric evaluation dated 12/4/18 indicated that the patient had a history of developmental trauma with documented physical and emotional trauma as well as physical abuse and suspected sexual abuse. The patient had been unable to form healthy attachments which had also compromised his/her social development. Patient #11's treatment plan dated 12/4/18 indicated diagnoses of disruptive mood dysregulation disorder, reactive attachment disorder, and borderline personality. The active problems were noted as mood lability with aggression towards other and a past history of self-harm. The goal identified was that Patient #11 would demonstrate safe with his/herself and others and the community by participating in group therapy to learn how to safely express her feelings. Patient #11 had no history of sexually inappropriate behaviors.
Review of Patient #11's clinical record indicated that the patient was to be monitored every fifteen minutes. The record indicated that Patient #11 was monitored on 12/9/18 at 11:00 AM, 11:15 AM, 11:20 AM, 11:30 AM, 11:45 AM and 12:00 PM.
A nurse's note dated 12/9/18 at 9:00 PM indicated that peers on the unit were very reactive and dysregulated by Patient #11 notifying them of a sexual encounter he/she had with another peer (Patient #8). The patient was taking no responsibility or remorse for the incident.
Subsequent to the event both patients were placed on full separation precautions and Patient #8's room was moved. The incident was reported to the police and the Department of Children and Families (DCF).
The facility investigation identified that on 12/9/18, Children's Service Worker (CSW) #11 was assigned to monitor the hallway where Patients #8 and #11's bedrooms were located. Review of the Standard observation sheet for 12/9/18 indicated that CSW #11 completed fifteen minute checks for all patients on the unit during the period of 11:00 AM through 12:00 PM. Although Patient #8 and #11 were monitored 7 times between 11:00 AM and 12:00 PM, a sexual encounter could not be ruled out as CSW #11 left the hallway unattended while performing fifteen minute check during that period of time.
Interview with the Behavioral Health Supervisor on 3/21/19 at 1:50 PM indicated that a staff person is always assigned to be a hall monitor. Prior to the incident this staff person was stationed at the far end of the unit and since the incident the hall monitor has been relocated to the middle of the unit for better visibility. Tour of the unit on 3/21/19 at 1:45 PM identified that one staff member was the hall monitor and one staff was completing the observation checks.
Review of the Youth Care: Precautions and Observation policy indicated Youths are to observed every fifteen minutes and randomly once each hour, by assigned staff. Review of the Patient Rights policy indicated in part that Patients/Youths have the right to humane and dignified treatment at all times, to be informed of their rights upon admission, and respect for personal dignity and privacy.
2. Based on observations of 4 of 4 units and interviews with facility staff during a tour of the facility, the facility failed to ensure that emergency equipment was readily accessible in the event of a medical emergency. The findings include:
Observations of the Acadia, Manhasset, Passaic and Sachem units on 6/29/18 identified that the emergency equipment utilized in response to a resident medical emergency was limited to an emergency cylinder of oxygen, one nasal cannula, one to two adult and pediatric rebreathers and one ambu bag. The emergency cart did not have any equipment that would clear an airway in the event of an airway obstruction.
During interviews with Registered Nurse #'s 4, 5, 6 and #7, all indicated that if a resident was unresponsive and required their airway to be cleared during a resuscitative effort, a suction device/machine would be required and was not readily available. Further interviews identified that a suction machine was available in the "copy room" which was approximately a 3 to 4 minute walk away.
Subsequent to surveyor inquiry, equipment to provide a mechanism to clear an airway was provided to all four emergency carts on all four units.
3. Based on observation, review of manufacturer recommendations, review of policy and procedures, and interviews for 4 of 4 inpatient units with glucometers, the hospital failed to ensure that single use glucometer devices were not available for use on multiple patients. The findings include:
a. Observation during tour of the medication rooms on the Sachem, Passaic, Acadia, and Manhassett units on 11/6/18 identified one glucose meter for general use on each of the units. There were no current patients requiring finger stick blood glucose monitoring. Observation further identified there were additional units, new in boxes, available in the medication rooms. Interview with RN #1 on 11/6/18 and review of the equipment checklists dated 7/2018 to 11/2018 for all four units identified that staff clean the unit with a 0.55% bleach wipe and test the device with the control solution in accordance with manufacturer recommendations. RN #1 further identified that if a diabetic patient is admitted, a new glucometer is provided to the patient and labeled with the patient's name and the glucometer in the medication rooms were for emergencies and hadn't been used on a patient in a long time. Single use glucometer devices were available on all the units to be used on multiple patients although the manufacturer directed the devices were for single patient use only.
Review of the manufacture guidelines for the blood glucose meter identified that the monitoring system is for single patient use only and should not be shared. The meter should be cleaned and disinfected once a week using only Clorox germicidal wipes containing 0.55% bleach.
On 11/6/18, the hospital revised the glucometer waived testing procedure to direct that glucose meters are single patient use, each patient will have their own glucose monitor labeled with their name, and each unit will have a blood glucose monitor to test patients in an emergency. Once used, that meter will be labeled with that patient's name for future use or discarded. All staff who conduct glucose blood monitoring will be in-serviced on the new policy.
4. Based on review of facility policy and interviews, the hospital failed to utilize the 9-1-1 system as a first call for emergencies. The finding includes:
a. Interview with the Director of Nurses on 11/6/18 and review of the Medical Care for Youths policy directed when there is a need for immediate urgent response to a serious illness or injury which is imminently life threatening (medical emergency) the overhead page will be utilized to initiate the internal emergency response and activate responders. Staff were directed to utilize the overhead page, telephone the campus facility emergency number (11 digit number) and request that an ambulance be dispatched. The campus facility emergency operator will be responsible for the dispatch of an ambulance. Interview with Police Officer #1 on 11/6/18 at 2:40 pm identified that hospital staff call the dispatch center using the 11 digit number, the call is transferred to the town dispatch center, and the police department will get dispatched as well. The hospital failed to implement the 9-1-1 emergency number as a first call for emergencies.
5. Based on review of the clinical record, review of policies and procedure, and interviews for 2 of 2 patients (Patient #5 and # 6) reviewed for emergency medical transfers, the hospital failed to utilize the 9-1-1 system as a first call for emergencies.
a. Patient #5 was admitted to the hospital on 12/13/17 with diagnoses that included post-traumatic stress disorder, bipolar disorder, borderline personality trait disorder, and a history of self-harm.
The physician order dated 2/9/18 directed to decrease mobility to on grounds. Hospital documentation identified on 2/10/18 at 7pm, the patient self-reported ingestion of an AA battery and a 2 week supply of medication and disclosed a plan to "hang self and had the means to do it". The patient showed staff several pieces of shredded bed sheet and had tried to tie around neck in front of staff, but staff intervened and removed the cloth. The patient was placed on 1:1 constant observation for self-harm. The patient was sent to the emergency room and evaluated. An x-ray revealed no foreign object. When the patient returned from the hospital, the patient admitted to lying about the ingestion of the objects, remained on 1:1, stripped room (removing all potentially harmful items from bedroom, closets locked, room shift every shift), two strong blankets, and crushed medications before ingestion.
An Incident Report dated 2/11/18 identified at 2:30 pm, the patient had a verbal interaction with another patient, charged at another patient, and engaged in a fist fight. No injuries were noted and the patients were placed on full separation. Review of the clinical record on 11/6/18 failed to identify documentation of a focus treatment plan review subsequent to the 2/11/18 assault incident. Review of the Treatment Planning Process identified a focused treatment plan review meeting will occur as soon as possible but no later than the next business day after an incident of self-injury. A progress note should be written following the meeting.
The weekly nurse's note dated 2/28/18 at 4:16pm identified that the patient was on unit mobility (under direct staff supervision at all times, 5-minute checks for assault/self-harm, and room stripped/assault proofed. The significant event report dated 2/28/18 identified that at 9:15pm the patient came out of the TV room after another patient left the room. Staff went into the room to obtain the remote, however the batteries were missing. The patient admitted to swallowing the batteries and "wanted to die". An x-ray was performed and identified 2 batteries in the upper left abdomen. The patient was assessed by the physician which identified no apparent physical distress and staff monitored the patient for any adverse reactions. Safety interventions included initiating 1:1 monitoring at the patient's doorway with night light on, stripped and searched room, strong blankets, staff to observe respirations for 24 hours, and to notify the physician if coughing or choking. The patient expelled a battery via a bowel movement a few days later. The hospital failed to maintain a safe environment to prevent the ingestion of batteries in a patient known to demonstrate self-harm behaviors.
Interview with the Medical Director and review of the clinical record on 11/6/18 failed to identify documentation of a focus treatment plan review subsequent to the 2/28/18 self-harm incident. Review of the Treatment Planning Process identified a focused treatment plan review meeting will occur as soon as possible but no later than the next business day after an incident of self-injury. A progress note should be written following the meeting.
b. Patient #6 was admitted to the hospital on 11/17/17 with diagnoses that included chronic depression with frequent self-harm ideation and self-harm attempts which included attempts to hang self and choke self with a nightgown. Physician orders dated 2/6/18 directed staff to ask the patient if he/she is having any unsafe thoughts prior to using the bathroom or entering the bedroom. If the patient is not feeling safe or having unsafe thoughts to ask the registered nurse to assess the patient. Staff will also pocket search before entering the bathroom or bedroom. The Precaution/Observation Form dated 2/13/18 identified a safety plan directed in part, ask the patient if he/she feels safe or is having any unsafe thoughts prior to using the bathroom or entering the bedroom. If unsafe, ask the registered nurse to assess the patient. Staff will also pocket search before entering the bathroom or bedroom.
The nurse's note dated 2/14/18 at 10:15pm identified that a pocket search was conducted and there was no contraband at 6:20pm prior to the patient using the bathroom. The clinical record lacked documentation that staff inquired if the patient felt safe or had any unsafe thoughts. According to an incident report dated 2/14/18, a Child Service Worker (CSW) checked on the patient at 6:20pm by knocking on the door and the patient responded. At 6:28pm CSW #1 knocked on the bathroom door, there was no patient response so a same sex (as patient) staff member was requested to enter the bathroom immediately. Upon entering the bathroom, the patient was sitting against the shower stall with the shower running and was fully clothed. Staff removed an article of clothing that was tightly wrapped around his/her neck several times and staff was able to cut it with scissors. According to the on-call physician note dated 2/14/18 at 9:35pm, it was reported that the patient was found gray, purple, dusky, unresponsive and not breathing with blood from nose. A tightly tied knot from sleeves of a shirt was twisted around neck and when loosened, the patient gasped for a breath. The patient was assessed and noted with neck flexed and shoulders drooped with sudden awakenings with possible response from hypoxia. Staff was unable to obtain blood pressure due to patient refusals and agitation. The patient's heart rate dropped from 140 to 96 beats per minute about 20 minutes into observation and color was pink. The patient was agitated and began to hit self and required medication. Pulse ox was 98% on room air (normal >95%). The patient was transported to the emergency department at Hospital #1 but was diverted to Hospital #2 when the patient started to punch self in the face enroute to the hospital while in the ambulance. The patient returned to the facility on 2/15/18 at 3:15am. 2:1 observation (2 staff for 1 patient) for self-harm was initiated, stripped room, 2 strong blankets, unit mobility, head, neck, hands visible at all times, night light on during evening and night shifts to visualize patient, no brassieres, long sleeves, no parties and neurological assessments according to physician orders.
Although the patient was on standard checks, every 15 minutes and the checks were documented on Standard Observations Form, the clinical record lacked documentation to reflect the checks. Interview with CSW #1 on 11/6/18 identified that he conducted the patient checks on 2/14/18 and all the patients on the unit are listed on a check sheet and are not part of the clinical record. The Precaution and Observation policy identified that 15-minute checks are documented on the Standard Observation Form that remains on the unit, however, the checks are not filed into the patient's clinical record.
Review of the clinical record on 11/6/18 failed to identify documentation of a focus treatment plan review subsequent to the 2/14/18 self-harm/suicide attempt. According to hospital documentation, a focused treatment review was conducted but the progress note was not written. Review of the Treatment Planning Process identified a focused treatment plan review meeting will occur as soon as possible but no later than the next business day after an incident of self-injury. A progress note should be written following the meeting.
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6. Based on clinical record review, review of facility documentation, staff interviews, and policy review, for 1 of 11 patients reviewed (Patient #12) the hospital failed to ensure the safety of the patient by failing to conduct a comprehensive personal belongings search in accordance with facility policy and the Registered Nurse (Head Nurse) job description. The findings include:
Patient #12 was admitted to the Psychiatric Hospital for stabilization of persistent mood dysregulation, impulsivity and symptoms of depression including chronic suicidal ideation.
According to a hospital investigation dated 12/21/18, Patient #12 was home on holiday pass and had purchased "sleeping pills". S/he consumed an unknown amount of the pills while at home and upon his/her return to the hospital as an attempt at overdose.
P#12 indicated on 12/1/18 at 3:00 PM, he/she had brought the sleeping pills back to the hospital in his/her backpack. P#12 indicated Registered Nurse (RN) #8 escorted P#12 to the unit and placed P#12's backpack behind the nurse's station. Shortly after, P#12 requested his/her backpack and RN#12 removed the backpack from behind the nurse's station and returned it to P#12. P#12 removed the sleeping pills from the backpack and placed them in his/her clothes drawer. A progress note dated 12/1/18 authored by RN#8 indicated P#12 was wanded, his/her belongings were searched and no contraband was found.
According to the report P#12 indicated on 12/2/18 s/he ingested the sleeping pills at 4:30 PM and again at 7:15 PM. P#12 indicated the pills made him/her sleepy and although several staff inquired about the sleepiness, P#12 did not inform the staff of the sleeping pill ingestion. Review of the medical record lacked documentation that the patient was assessed when P#12 exhibited a decrease in wakefulness.
P#12 reported on 12/5/18 s/he had told RN#8 about ingesting the sleeping pills on 12/2/18. P#12 reported RN#8 then took the sleeping pills from P#12 and asked P#12 to keep the incidents with the sleeping pills between P#12 and RN#8. Review of the medical record failed to identify that P#12 had possessed contraband, that a psychiatrist had been notified of the ingestion of unprescribed medication, and that P#12 had been assessed. In addition the medical record lacked documentation that the treatment plan had been revised and/or risk severity designation with corresponding appropriate actions was reviewed.
The hospital investigation report indicated on 12/11/18 P#12 reported to Psychiatrist #1 the ingestion of the sleeping pills however did not initially identify the staff member s/he had notified of the pill ingestion. Several days later RN#8 approached P#12 and asked P#12 if s/he had told anyone about the pills and instructed P#12, if asked, to say s/he had told Clinician #1 about the pill ingestion. According to the report during questioning by Supervisor #1 P#12 identified RN#8 as the staff member s/he notified of the sleeping pill ingestion and subsequent confiscation of the pills by RN#8. An investigation was initiated immediately and RN#8 was removed from patient care areas pending further investigation.
During an interview with the Director of Nursing (DON) on 3/21/19 at 1:20 PM the investigation identified although RN #8 conducted a search of P#12's belongings it appeared as though the search was not thorough. Prior to and at the time of the incident nursing would document the wanding and/or belonging search in a progress note. At the time of the incident a progress note by RN#8 indicated P#12 had been scanned with the wand however the documentation did not reflect his/her backpack had been searched. Subsequent to the incident documentation, including contents of the search, is placed in a progress note, on the daily report sheet and in the supervisory report.
During an interview with Supervisor #1 on 3/25/19 at 11:40 AM he/she indicated during an interview with RN#1 he/she had indicated that P#12's belongings had been searched and P#12 told RN#1 that the pills were in P#12's bra however P#12 indicated the pills were in a pocket of his/her backpack. Supervisor #1 indicated when RN#1 had become aware of P#12's ingestion of the pills at home, in addition to in the hospital, RN#1 should have obtained an order for a full search, notified the Supervisor and contacted the Psychiatrist so the patient could be evaluated medically and the patients suicidal risk reassessed. Supervisor #1 indicated RN#1 did not inform anyone or act in accordance with hospital policy.
The hospital policy for Search of Room, indicated all youths shall be checked (including clothing, pockets and personal possessions) for contraband when returning from visits. The security guard will conduct a cursory search of any bags/items that the youth intends to bring back to the unit. Upon arrival to the unit staff will perform a second, more thorough check of the packages/bags/items, and can utilize the hand-held metal detector wand for this search. Bags should be checked thoroughly as not all contraband is metal based. The policy indicated a progress note would be written indicating that a search of the youth's personal possessions occurred and the documentation would include any unsafe items identified.
The hospital policy for Assessment and Management of Suicidal Risk indicated any change in suicidal ideation will prompt a reassessment by the psychiatrist. According to the policy the assessment will be documented in a psychiatric progress note and will result in a risk severity designation with corresponding appropriate actions planned.
Tag No.: A0162
Based on clinical record review, review of facility policies, facility documentation, and interviews for 1of 3 patients reviewed for use of seclusion/restraints (Patient #24), the hospital failed to ensure the patient was assessed for the need for seclusion in accordance with facility policy and/or the Registered Nurse (Head Nurse) job description. The findings include:
Patient (P) #24 was admitted to the hospital on 5/21/18 for management of bipolar disorder.
A note by Registered Nurse (Head Nurse) #3 dated 7/29/18 at 3:40 PM indicated P#24 continued threatening to harm peers and staff and attempted to incite a riot with the other patients. P#24 was redirected to his/her room and refused to follow directives. Subsequently P#24 went to his/her room and proceeded to slam and kick the room door repeatedly. Support staff was called from another unit and upon arrival P#24 was escorted to the time out room (TOR)/seclusion and remained under observation by staff. P#24 was offered Seroquel multiple times but refused.
According to the Master Treatment Plan (MTP) dated 7/30/18, P#24 exhibited behaviors indicative of dysregulation such as hypervigilant, hyper verbal behaviors and s/he continued to be very argumentative.
Facility documentation (report submitted by Agency #1's Special Investigations Unit (SIU) and a Labor Relations Administrative Investigation report), dated 9/17/18, indicated once P#24 voluntarily entered the time out room (seclusion), Children Services Worker (CSW) #10 remained outside the room to monitor P#24. P#24 continued to pace around the room and was verbally aggressive. RN#11 (medication Nurse) approached the time out room to offer P#24 medication. CSW #10 placed the door key in the lock in the event P#24 attempted to strike and/or leave the room, P#24 refused the medication and did not approach the door therefore CSW#10 removed the key from the lock and closed the door. According to the reports CSW #10 did not recall intentionally locking the door.
Although the medical record contained an initial nurse's note, the medical record failed to identify an assessment of imminent risk that justified the use of seclusion. Imminent risk, as defined by the hospital Emergency Safety Intervention (ESI) policy is defined as when a youths behavior places them or others at immediate risk for injury if no emergency safety intervention occurs immediately.
The hospital failed to complete the Emergency Safety Intervention (ESI) form which is required by policy when seclusion is implemented. The ESI form contains the physician's/licensed independent practitioner (LIP) order for the seclusion, renewal of the order every half an hour, physician/LIP assessment/reassessment, registered nurse assessment/reassessment, observation by staff, notification of the family/guardian, discontinuation of the intervention and debriefing with the patient and staff.
During an interview with the Director of Nursing (DON) on 4/22/19 at 11:15 AM s/he indicated RN#3 should have initiated the ESI form because s/he was aware P#24 was dysregulated, knew other youths on the unit had been removed and assistance from other units had been required. The DNS indicated RN#3 claimed s/he was not aware P#24 had gone to the timeout room. However the DNS identified RN#3 was present when P#24 was instructed to go to the time out room and P#24 remained in the room for 20 Minutes therefore RN#3 should have been aware of P#24's location The DNS indicated in this case RN#3 was responsible for initiating and completing the ESI form.
According to facility documentation (report submitted by Agency #1's Special Investigations Unit (SIU) and a Labor Relations Administrative Investigation report), based on the information obtained during the investigation medical abuse/neglect was not substantiated. However CSW #10 and RN#3 were pending disciplinary action by the hospital at the time of the investigation, for not following the hospital ESI protocol.
Review of the hospital ESI policy indicated seclusion is the involuntary confinement of a youth in a room/area whether alone or with staff supervision, in a manner that prevents the person from leaving or that the youth perceives s/he cannot leave the room/area. A staff directed youth confinement to a room/are is also considered seclusion. Additionally the ESI policy indicated the Registered Nurse (RN) is responsible for ensuring that all required elements of the ESI order form are completed prior to the conclusion of the shift following termination of the intervention.
According to the Registered Nurse (Head Nurse) Job Description the Head Nurse is responsible for the supervision and implementation of programs, policies, procedures, individual treatment plans (ITP's) and other activities during his/her assigned shift. Responsibilities include assuring the youths psychological, physical and safety needs, completing nursing assessments, care plans, progress notes, and reports of significant events/incidents in addition to other documentation.
Tag No.: A0395
Based on clinical record review, review of facility documentation, staff interviews, and policy review, for 1 of 11 patients reviewed (Patient #12) the hospital failed to ensure the safety of the patient by failing to conduct a comprehensive personal belongings search in accordance with facility policy and the Registered Nurse (Head Nurse) job description and/or assess the patient when a change in wakefulness and/or suicide risk was identified. As a result, the patient consumed sleeping pills brought back from an offsite visit. The findings include:
Patient #12 was admitted to the Psychiatric Hospital for stabilization of persistent mood dysregulation, impulsivity and symptoms of depression including chronic suicidal ideation. \
According to a hospital investigation dated 12/21/18, Patient #12 was home on holiday pass and had purchased "sleeping pills". S/he consumed an unknown amount of the pills while at home and upon his/her return to the hospital as an attempt at overdose.
P#12 indicated on 12/1/18 at 3:00 PM, he/she had brought the sleeping pills back to the hospital in his/her backpack. P#12 indicated Registered Nurse (RN) #8 escorted P#12 to the unit and placed P#12's backpack behind the nurse's station. Shortly after, P#12 requested his/her backpack and RN#12 removed the backpack from behind the nurse's station and returned it to P#12. P#12 removed the sleeping pills from the backpack and placed them in his/her clothes drawer. A progress note dated 12/1/18 authored by RN#8 indicated P#12 was wanded, his/her belongings were searched and no contraband was found.
According to the report P#12 indicated on 12/2/18 s/he ingested the sleeping pills at 4:30 PM and again at 7:15 PM. P#12 indicated the pills made him/her sleepy and although several staff inquired about the sleepiness, P#12 did not inform the staff of the sleeping pill ingestion. Review of the medical record lacked documentation assessments had been made when P#12 exhibited a decrease in wakefulness.
P#12 reported on 12/5/18 s/he had told RN#8 about ingesting the sleeping pills on 12/2/18. P#12 reported RN#8 then took the sleeping pills from P#12 and asked P#12 to keep the incidents with the sleeping pills between P#12 and RN#8. Review of the medical record failed to identify that P#12 had possessed contraband, that a psychiatrist had been notified of the ingestion of unprescribed medication, that P#12 had been assessed.
The hospital investigation report indicated on 12/11/18 P#12 reported to Psychiatrist #1 the ingestion of the sleeping pills however did not initially identify the staff member s/he had notified of the pill ingestion. Several days later RN#8 approached P#12 and asked P#12 if s/he had told anyone about the pills and instructed P#12, if asked, to say s/he had told Clinician #1 about the pill ingestion. According to the report during questioning by Supervisor #1 P#12 identified RN#8 as the staff member s/he notified of the sleeping pill ingestion and subsequent confiscation of the pills by RN#8. An investigation was initiated immediately and RN#8 was removed from patient care areas pending further investigation.
During an interview with the Director of Nursing (DON) on 3/21/19 at 1:20 PM the investigation identified although RN #8 conducted a search of P#12's belongings it appeared as though the search was not thorough. Prior to and at the time of the incident nursing would document the wanding and/or belonging search in a progress note. At the time of the incident a progress note by RN#8 indicated P#12 had been scanned with the wand however the documentation did not reflect his/her backpack had been searched. Subsequent to the incident documentation, including contents of the search, is placed in a progress note, on the daily report sheet and in the supervisory report.
During an interview with Supervisor #1 on 3/25/19 at 11:40 AM he/she indicated during an interview with RN#1 he/she had indicated that P#12's belongings had been searched and P#12 had told RN#1 that the pills had been in P#12's bra however P#12 indicated the pills were in a pocket of his/her backpack. Supervisor #1 indicated when RN#1 had become aware of P#12's ingestion of the pills at home, in addition to in the hospital, RN#1 should have obtained an order for a full search, notified the Supervisor and contacted the Psychiatrist so the patient could be evaluated medically and the patients suicidal risk reassessed. Supervisor #1 indicated RN#1 did not inform anyone or act in accordance with hospital policy.
The hospital policy for Search of Room, indicated all youths shall be checked (including clothing, pockets and personal possessions) for contraband when returning from visits. The security guard will conduct a cursory search of any bags/items that the youth intends to bring back to the unit. Upon arrival to the unit staff will perform a second, more thorough check of the packages/bags/items, and can utilize the hand-held metal detector wand for this search. Bags should be checked thoroughly as not all contraband is metal based. The policy indicated a progress note would be written indicating that a search of the youth's personal possessions occurred and the documentation would include any unsafe items identified.
The hospital policy for Assessment and Management of Suicidal Risk indicated any change in suicidal ideation will prompt a reassessment by the psychiatrist. According to the policy the assessment will be documented in a psychiatric progress note and will result in a risk severity designation with corresponding appropriate actions planned.
According to the Registered Nurse (Head Nurse) Job Description the Head Nurse is responsible for the supervision and implementation of programs, policies, procedures, individual treatment plans (ITP's) and other activities during his/her assigned shift. Responsibilities include assuring the youths psychological, physical and safety needs, completing nursing assessments, care plans, progress notes, and reports of significant events/incidents in addition to other documentation. In addition the Head Nurse may be responsible for conducting contraband searches to ensure youth safety.
Tag No.: A0396
Based on clinical record review, review of facility documentation, staff interviews, and policies, for 1 of 11 patients reviewed (Patient #12) the hospital failed to revise the Master Treatment Plan (MTP) after the patient hid medications in his/her personal belongings while on a leave of absence and consumed in an attempt to harm-self. The finding includes:
Patient #12 was admitted to the Psychiatric Hospital for stabilization of persistent mood dysregulation, impulsivity and symptoms of depression including chronic suicidal ideation.
Review of the MTP dated 11/21/18 identfied the patient had a problem with self injurious behaviors with interventions that included meet with Social Worker, attend groups, monitor mental status, and assess for thoughts of self harm.
According to a hospital investigation dated 12/21/18, Patient #12 was home on holiday pass and had purchased "sleeping pills". S/he consumed an unknown amount of the pills while at home and upon his/her return to the hospital as an attempt at overdose.
P#12 indicated on 12/1/18 at 3:00 PM, he/she had brought the sleeping pills back to the hospital in his/her backpack. P#12 indicated Registered Nurse (RN) #8 escorted P#12 to the unit and placed P#12's backpack behind the nurse's station. Shortly after, P#12 requested his/her backpack and RN#12 removed the backpack from behind the nurse's station and returned it to P#12. P#12 removed the sleeping pills from the backpack and placed them in his/her clothes drawer. A progress note dated 12/1/18 authored by RN#8 indicated P#12 was wanded, his/her belongings were searched and no contraband was found.
According to the report P#12 indicated on 12/2/18 s/he ingested the sleeping pills at 4:30 PM and again at 7:15 PM. P#12 indicated the pills made him/her sleepy and although several staff inquired about the sleepiness, P#12 did not inform the staff of the sleeping pill ingestion.
P#12 reported on 12/5/18 s/he had told RN#8 about ingesting the sleeping pills on 12/2/18. P#12 reported RN#8 then took the sleeping pills from P#12 and asked P#12 to keep the incidents with the sleeping pills between P#12 and RN#8. Review of the medical record failed to identify that P#12 had possessed contraband, that a psychiatrist had been notified of the ingestion of unprescribed medication, that P#12 had been assessed. Review of the MTP failed to identify that the plan was revised to address the behavior of smuggling medications into the facility following a leave of absence.
During an interview with Supervisor #1 on 3/25/19 at 11:40 AM he/she indicated when RN#8 had become aware of P#12's ingestion of the pills at home, in addition to in the hospital, RN#8 should have obtained an order for a full search, notified the Supervisor and contacted the Psychiatrist so the patient could be evaluated medically and the patients suicidal risk reassessed. In addition the mater treatment plan should have been updated to address the incident and interventions put in place.
The hospital policy for Focused Treatment Plan reviews indicated when a youth is involved in an incident of self injury a Focused Treatment Plan Review meeting will occur as soon as possible but no later than the next business day. The goal of the review is to assess the youth's treatment plan and revise with focus on preventing further incidents. A progress note should be written following this meeting to include recommended changes to the treatment plan.