HospitalInspections.org

Based on record review and staff interview, it has been determined that the hospital failed to ensure nursing services specific to safety protocols were supervised by a registered nurse.

Findings are as follows:

1. The hospital failed to ensure staff who were assigned by the Charge Nurse, completed environmental safety checks, (Refer to A-0398).

2. The hospital failed to ensure staff who were assigned by the Charge Nurse, ensured "restricted" items were signed off as returned by the patient or retrieved by staff, (Refer to A-0398)

Based on record review and staff interview, has been determined that the hospital failed to ensure policies and procedures were followed relative to environmental safety checks which includes the assurance that "restricted" items used by patients, including razors and nail clippers, were returned to staff to ensure the safety of the environment. The hospital failed to ensure restricted items used by patients were returned for 5 of 8 patients reviewed (Patient ID #s who used razors and/or nail clippers and documented such per hospital policy in 3 of 7 units toured, (Delmonico 2, Delmonico 3, and Riverview 3). Additionally, the hospital failed to ensure environmental safety checks were completed by assigned staff for 5 of 7 units toured, (Delmonico 2, Delmonico 4, Delmonico 3, Delmonico 3C and Riverview 3).

Findings are as follows:

The hospital's policy titled, "Nursing Safety: Environmental Safety Check" effective 5/22/2023 states in part,
"Policy:

The purpose of this policy is to mitigate risk through an active review of environmental concerns. This includes proper storage and monitoring of prohibited and restricted items ...

Procedure for Environmental Check ...
1. The day/evening charge nurse or designee will assign a minimum of one staff member to complete the unit environmental safety check within each period.
2. The assigned person will inspect common areas, patient rooms (occupied/ unoccupied) and bathrooms for prohibited/restricted items and other safety concerns.
3. The staff person will bring a copy of the restricted items log with them and update all entries on the original log as needed.
4. Content of checks
...d. In addition, the back side of the Environmental Safety Check Sheet contains additional items to be monitored on three specialty units: Addictions, Adolescents and Geriatrics ...
...Restricted Use Items:
Restricted items may be used by patients on appropriate levels or with a doctor's order. They are to be stored in appropriate storage areas when not in patient use (locked cubby, locked closet, locked drawer, designated secure area on unit or hospital safe).
...nail clippers ...Razors"

Review of blank document titled, "Restricted Use Item Log" states in part,
"Prior to 3rd shift all items that cannot remain with patient overnight must have time in with staff initials ..."

On 5/31/2023, it was reported by the hospital that on this day, Patient ID #1 was found by a nurse around 9:20 PM laying on the ground bleeding from a wound on the inner forearm, approximately 3 to 4 inches in length, which the patient had inflicted on themselves with a hospital issued razor. According to the report the patient was transferred to an acute care hospital and received 3 sutures and was returned to Butler Hospital.

Record review for Patient ID #1 revealed she/he originally presented to Butler Hospital in May of 2023 after being treated at an acute care hospital for an intentional Propranolol overdose. Patient ID #1's history includes, but is not limited to, suicide attempts via Tylenol overdose and cutting their wrists, anxiety, and depression.

Patient ID #1's outpatient records were reviewed prior to his/her readmission which revealed a document titled, "Attending Physician Assessment" completed on 5/22/2023. This document stated that following Patient ID #1's Young Adult Program admission in the summer of 2022, Patient ID #1 had been "struggling with suicidal thoughts and non-suicidal self-injury." Additionally, the physician states in his assessment that after discharge from the Young Adult Program, Patient ID #1 "had recurrent episodes of NSSI [non-suicidal self-injury] by cutting with a disposable razor blade." Additionally, Patient ID #1's outpatient record further revealed that Patient ID #1 "engaged in cutting" the morning of his/her readmission to Butler Hospital, which was corroborated with the patient's parent who disclosed that the patient was observed at home with a bloody towel wrapped around their wrist.

Patient ID #1's record revealed she/he was subsequently discharged from Butler Hospital in May, 2023 and readmitted 3 days later on 5/22/2023 after indicating she/he was experiencing worsening depression, stating "now would be a good time to die," and expressing thoughts of wanting to slit his/her wrists. This patient was placed on 5 minute observation checks for risk of suicide and self injury. The patient was changed from 5 minute observation checks to 15 minute observation checks on 5/23/2023. Review of progress notes from 5/23/2023 through 5/30/2023 revealed no evidence of self injurious behavior.

During a tour of Delmonico 4 on 6/5/2023 at 1:50 PM where Patient ID #1 resides, an interview was conducted with Employee A, Charge Nurse, who indicated that she was shocked that Patient ID #1 cut themselves with a razor. When asked how the unit ensures items such as razors are monitored on the unit, she revealed that the Charge Nurse assigns an environmental safety check task for the shift and it is the responsibility of the assigned staff to ensure that environmental safety checks are completed, and that restricted items or sharps, such as razors, are returned by the patients during the hour that the staff member is conducting the patient observation checks.

This unit's "Sharps" binder was reviewed with Employee A, which revealed a document titled, "Restricted Use Item Log" dated 5/31/2023 which revealed that staff provided Patient ID #1 with a razor at 8:49 PM on this day. The document further reveals that the razor was retrieved by staff. However, the razor was retrieved after Patient ID #1 had cut his/her right arm with it.

In addition to reviewing the "Restricted Use Item Log," the "Environmental Safety Check Sheet" was reviewed from 5/31/2023 through 6/5/2023. According to the document, during the day shift and the evening shift, staff are to inspect bedrooms and bathrooms for restricted or prohibited items. Additionally, staff are responsible for checking that the appropriate doors on the unit are locked, paths are clear, and equipment and beds are intact. This document failed to reveal evidence that the environmental safety checks were signed off as completed by staff on the evening shift of 6/2/2023 and 6/3/2023.

As part of the survey, additional units were toured, and failures were identified with additional units relative to the "Restricted Item Use Log" where staff failed to document retrieval of razors or nail clippers and failure to complete the "Environmental Safety Check Sheet" on different days during different shifts per hospital policy. These failures are as follows:

1. Record review of the "Restricted Use Item Log" for Delmonico 2 revealed that on 5/26/2023, Patient ID #3 was provided with a razor at 1:12 PM.

The log failed to reveal evidence that the razor was returned by the patient or retrieved by staff per hospital policy.
Record review of the "Restricted Use Item Log" for Delmonico 3 revealed that on 5/30/2023, Patient ID #4 was provided with a razor at 10:05 AM and on 5/28/2023 Patient ID #5 was provided with a razor at 8:11 AM.

The log failed to reveal evidence that the razor and nail clippers were returned by either patients or retrieved by staff per hospital policy.

Record review of the "Restricted Use Item Log" for Riverview 3 revealed that in May of 2023, Patient ID #6 was provided with nail clippers and Patient ID #7 was provided both a razor and nail clippers.

The log failed to reveal evidence that the razor and nail clippers were returned by either patients or retrieved by staff per hospital policy.

2. Record review of the "Environmental Safety Check Sheet" for Delmonico 2, failed to reveal evidence that these safety checks were completed per hospital policy during the day shift on 6/3/2023.

Record review of the "Environmental Safety Check Sheet" for Delmonico 3, failed to reveal evidence that these safety checks were completed per hospital policy on the following dates during the following shifts:
- Day shift on 6/4/2023
- Day shift on 5/26/2023
- Evening shift on 5/12/2023
- Day shift on 5/6/2023
- Evening shifts on 5/2/2023, 5/4/2023, and 5/6/2023
- Day shift on 4/28/2023
- Evening shifts on 4/24/2023, 4/26/2023, 4/27/2023, and 4/29/2023
- Evening shifts on 4/11/2023, 4/12/2023, 4/14/2023, and 4/15/2023

Record review of the "Environmental Safety Check Sheet" for Delmonico 3C, failed to reveal evidence that these safety checks were completed per hospital policy on the following dates during the following shifts:
- Day shifts on 5/27/2023 through 5/29/2023 and 5/31/2023 through 6/2/2023
- Evening shifts on 5/31/2023 through 6/2/2023
- Day shift on 5/24/2023
- Evening shifts on 5/23/2023 through 5/25/2023
- Day shifts on 5/14/2023, 5/15/2023, 5/18/2023
- Evening shift on 5/17/2023
- Day shifts on 5/5/2023, 5/8/2023, 5/10/2023, and 5/11/2023
- Evening shifts on 5/5/2023, 5/9/2023, and 5/10/2023
- Day shifts on 4/30/2023 and 5/1/2023
- Evening shifts on 4/30/2023, 5/1/2023, 5/3/2023, and 5/4/2023
- Evening shifts on 4/21/2023 and 4/26/2023
- Day shift on 4/22/2023
- Day and evening shifts on 4/15/2023 through 4/17/2023
- Evening shift on 4/20/2023

Record review of the "Environmental Safety Check Sheet" for Riverview 3, failed to reveal evidence that these safety checks were completed per hospital policy on the following dates during the following shifts:
- Day shift on 6/3/2023
- Evening shift on 6/4/2023
- Day shifts on 5/17/2023 and 5/18/2023
- Evening shift on 5/19/2023
- Day shifts on 5/27/2023 and 5/29/2023
- Day and evening shifts on 5/20/2023 and 5/21/2023
- Day shifts on 5/24/2023 and 5/26/2023

During a surveyor interview on 6/5/2023 at 2:50 PM with the Delmonico 2 Director who was covering for the Delmonico 4 unit, she acknowledged that the "Environmental Safety Check Sheet" was not signed off as completed for the Delmonico 4 unit on the dates identified above. Additionally, she acknowledged that the items in the restricted use log were not signed back in as returned by the patients or retrieved by staff. The Director stated that it is the expectation that the environmental safety checks are completed per hospital policy by the assigned staff.

During a surveyor interview on 6/6/2023 at 10:30 AM with the Unit Director in charge of Delmonico 3 and Delmonico 3C, she indicated that the charge nurse assigns two staff members to complete the "Environmental Safety Check Sheet" and she is responsible for ensuring that these checks are completed. The Director acknowledged that the "Environmental Safety Check Sheet" was not signed off as completed by staff on the dates identified above for Delmonico 3 and 3C, and indicated she expects assigned staff to complete this. The Director revealed she was able to identify the assigned staff who had not completed the "Environmental Safety Check Sheet" on the non-complaint days but was unable to provide evidence of a correction plan to address this issue.

During a surveyor interview on 6/6/2023 at 12:00 PM with the Riverview 3 Director, she indicated that the charge nurse on the unit makes sure the "Environmental Safety Check Sheet" is completed by the assigned staff. The Director acknowledged that the "Environmental Safety Check Sheet" was not signed off as completed by staff on the non-compliant dates listed above and acknowledged that the patients who used restricted items, such as razors and nail clippers, were not signed back in as returned by the patients or retrieved by staff on the dates listed above.

During a surveyor interview with the Director of Risk Management on 6/6/2023 at approximately 3:00 PM, she was made aware of the incomplete documentation concerns identified on Delmonico 2, Delmonico 3, Delmonico 3C, Delmonico 4 and Riverview 3 relative to the environmental safety checks and the restricted items log.