HospitalInspections.org

Based on observation, medical record review, document review and interview, the facility failed to ensure that patients received care in a safe setting.

Specifically, the facility failed to ensure:

1. That potentially suicidal patients were appropriately screened, assessed, and monitored (Patient #2, and #3).
2. A safe environment for infants in order to minimize the potential risk for harm or abduction.
3. That physicians' orders are written for each patient placed in Restraints or Seclusion (Patient #4, #7 and #8).

These failures placed patients at risk for harm.

Findings include:

Review of medical record for Patient #2 noted a 32-year-old patient who was evaluated in the Emergency Department on 5/17/16 at 1:31 AM for cannabis induced psychosis with hallucinations. The patient had a recent admission from 5/3 to 5/10/16 in which he attempted to hang himself and was determined to be high risk for suicidality. On 5/17/16 at 2:28 AM, psychiatrist evaluation noted the patient was positive for depression, suicidal ideation, hallucinations, substance abuse and insomnia. On 5/18/16, 5:30 AM, the patient was admitted to an inpatient psychiatric unit with orders by a Nurse Practitioner that notes, "Patient Monitoring Intensive Q 15 minutes."


On 5/18/16 at 3:00 PM, the patient was found hanging with a bedsheet around his neck. The patient later expired on 5/29/16.

There was no documentation in the medical record that the patient's suicide risk was reassessed and an appropriate level of monitoring implemented.

Review of medical record for Patient #3 identified a 26-year-old who was evaluated in the Emergency Department on 9/12/16 at 8:12 PM for suicidal ideation. The patient's psychiatric history included suicidal ideation, depression, and eating disorder. The patient was identified as a high risk for suicide and orders for one to one observation was written by the Emergency Department physician.

There was no documented evidence that the patient was monitored in accordance with physician's order for 1:1 observation. Instead, the patient was monitored via a video camera and was able to apply a self-made noose without staff knowledge. The patient was evaluated for redness around her neck.

On 4/28/17 at 2:55 PM, during tour of the behavioral health area of the Emergency Department, five psychiatric patients were being monitored remotely via video. Staff V, Registered Nurse reported she was monitoring all five patients and that she goes into the room "only as needed." Staff V had no written documentation of the level and frequency of monitoring for each patient.


2. During a tour of the pediatric Unit located on the 6th floor, it was noted that the alarm system on one of the exit doors that was part of the facility's "Infant/Child Security Alarm System" did not alarm.

See Tag 0144


3. Review of medical records revealed there was no physician orders for patients placed in Restraints and Seclusion in accordance with regulations and the facility's policy.

See Tag 0168

Based on observation, interview and document review the facility failed to provide a safe environment for patients.

Specifically, staff did not ensure:

1. Potentially suicidal patients were appropriately assessed and monitored in two (2) of sixteen (16) medical records reviewed. (Patient #2, and #3).
2. A safe environment for infants in order to minimize the potential risk for harm or abduction.

These failures placed patients at risk for harm.

Findings include:

1. Review of the medical record for Patient #2 revealed a 32-year-old male that was brought to the Emergency Department (ED) by his parents on 5/17/16 at 1:31 AM and evaluated for altered mental status. The psychiatrist evaluated on 5/17/16 at 2:28 AM notes, "patient was here for psychiatric evaluation". The patient stated he was smoking marijuana but today feels that the marijuana was laced with something. He reported auditory hallucinations that encourages suicidal ideation as well as paranoid delusions of people coming after him. The physician noted the patient was positive for depression, suicidal ideation, hallucinations, substance abuse and insomnia. Orders written by Licensed Independent Practitioner on 5/17/16 at 3:26 PM included, "Patient Monitoring Intensive Q 15 minutes."

The patient was transferred from the ED to the behavioral health unit after clearance for admission on 5/18/16 at 5:30 AM

On 5/18/16 at 11:41 AM, Unit Physician acknowledged a previous psychiatric admission at the facility between 5/3/16 to 5/10/16. During this admission, on 5/3/16, the patient attempted to strangle himself; he tied a noose around his neck and then called the police. The patient was determined to be a high risk for suicidality on 5/3/16 at 10:18 PM based on the Columbia Suicide Severity Rating Scale.

There was no documentation of a suicide risk assessment upon admission of the patient to the inpatient psychiatric unit. The patient was maintained on Q 15 minutes observation.

On 5/18/16 at 3:00 PM, the physician documented that after patient had taken his lunch tray to his room he was found behind the barricaded door to his room, and behind the door to the bathroom hanging with the bedsheet around his neck. He was pulseless and not breathing.



Review of the medical record for Patient #3 revealed a 26-year-old female who was brought to the Emergency Department on 9/12/16 at 8:12 PM by Emergency Medical Services personnel with suicidal ideation. The patient has a history of suicide ideation, depression, and eating disorder. She reported to the hospital that she had worsening suicidal ideation leading to the anniversary of her first suicide attempt 10 years ago.

The emergency room record showed that on 9/12/16 at 11:37 PM patient was identified a high risk for suicide. An order for constant observation (1:1) was written on 9/12/16 at 8:47 PM.

The hospital's policy titled, "Levels of Patient Observation" last revised 08/2016, states that for patients who are actively suicidal or have self-injurious behavior, nursing staff should be within arm's length from the patient while maintaining visual contact at all times.

The medical record had no documented evidence that the patient was placed on constant observation in accordance with the facility policy or per order.

On 9/13/16 at 5:15 PM, ED nurse noted that patient's father came to visit and found that the patient had braided a piece of cloth and used it to tie around her neck. The patient was assessed for redness to the neck.
The patient told her father that she tried to hang herself from the bedside using the braided robe, but the knot did not hold. She also reported to her father that she was "inadequately supervised."

During interview on 4/27/17 at 3:00 PM Staff U Attending Physician for the Emergency room, staff acknowledge that there was no documented evidence of monitoring for Patient #3 prior to the suicide attempt. Staff stated the patient was in the access area of the ED where patients are monitored on camera.

On 4/28/17 at 2:55 PM, during tour of the behavioral health area of the Emergency Department, Staff V, Registered Nurse was observed monitoring five patients in the access area through a video screen, which was located on a desk in the nursing station.

During interview with Staff V on 4/28/17 at 3:05 PM, Staff stated that she was the only nurse on the unit and that she was observing five (5) patients that were in their rooms. Staff V was asked for documentation of patients who were on observation and how often she evaluated these patients. Staff replied that there was no written documentation of the observation and that she goes into the room "only as needed."



2. During a tour on 4/25/17 of the 6th floor Pediatric Unit (6 North), it was noted that the alarm system on one of the exit doors was not working as required. This exit door was located to the side of the main entry (NE) and was near a bank of elevators leading to the main lobby and outside. The door had a sign on it stating, "Alarm will sound if door is pushed."

On 4/25/15 at 10:25AM, this Surveyor pushed and held the door open for five minutes. There was no audible sound from this action. At 10:44AM, a Security Officer arrived on the unit.

The above tour was conducted with (Staff F) Nursing Service Administrator, (Staff Q) Clinical Nurse Educator and (Staff B) Nursing Supervisor of the unit. Staff stated that the alarm system for infant abduction was tested each month by the Security Department and were not aware the exit door alarm was not working.

On 4/26/17 at 10AM, Security Staff reported that the alarm was tested after it was brought to their attention and they confirmed that the door did not alarm due to "a loose connector on the exciter."

There was no evidence that the facility ensured that its Infant/Child Security Alarm System was maintained in good repair to assure the safety of infants in accordance with the facility's policy.

Review of the written Policy #230001 Subject: Infant/Child Security Alarm System, last revised 12/15, states the following:
1. A door ajar event will display when a monitored exit remains open for 1 minute.
2. The impacted zone will issue an audible notification.
3. Security personnel will respond in person to the site of an exit alarm.




26259

Based on medical review and interview the hospital did not ensure that physician's order are written for patients in restraint and seclusion. These findings were evident in three (3) of six (6) medical records (Patient #4, #7 and #8).

Findings include:

Review of the medical record for Patient #4 identified a 48-year-old male who was brought to the Emergency Department (ED) on 4/13/17 by the police. ED nurse noted the patient was acting "very manic, delusional and talking of God."
The restraint flow sheets showed that on 4/14/17, the patient was in restraint from 1:30 AM - 9:30 AM.

There was no documentation of a physician's order for the restraints.

Review of the medical record showed that Patient #7 was a 26-year-old female with a history of borderline personality disorder, bipolar disorder and pseudo seizures (Non-epileptic seizures that are psychological in origin) who was brought in to the emergency room by (EMS) Emergency Medical Service on 2/18/17 due to asthma attack. On 2/20/17, the patient was treated and was medically cleared when she became "disruptive and aggressive". She was sent to the Behavioral Health Unit of the hospital for evaluation and management.

On 2/21/17 at 1:45AM, the physician wrote an order for the patient to be in seclusion for two (2) hours.
Review of the restraint/seclusion flow sheet showed that the patient was in the seclusion room from 12 AM to 4:30 AM on 2/21/17.

There was no documentation that the order for seclusion was timely obtained. The patient was kept in seclusion beyond the 2 hours ordered by the physician and there was no renewal of the seclusion order.

Similarly, on 2/26/17, the patient was in seclusion from 5:15 PM-6 PM without a corresponding physician's order for seclusion.

On 2/21/17 at 12:30 AM, the physician wrote an order for 4-point restraints for 2 hours.
Review of the restraint flow sheets for 2/21/17 documented Patient #7 was in 4 points restraints for three hours from 12:45 AM to 3:45 AM; the period of restraint extended beyond the 2 hours ordered by the physician.

There was no indication that the restraint order was renewed.


Review of the medical record for patient #8 identified a 22-year-old male who came into the emergency room on 11/8/16 for paranoid behavior. He had a history of multiple hospitalizations, schizoaffective disorder and bipolar disorder. On 11/9/16, he was transferred to the Behavioral Health Unit of the hospital.

The patient was in seclusion on 11/12/16 from 5 PM to 5:45 PM and from 9:15 PM to 11:45 PM.

There was no documentation of a physician's order for both instances when the patient was placed in seclusion.

In addition, on 11/12/16 while the patient was in the seclusion room, he was placed in 4-point restraints from 4:45 PM to 10:40 PM.

There was no documented evidence of an order for 4-point restraint.

Review of the hospital's policy and procedure titled, "Restraint and Seclusion", last reviewed 08/2016, states the procedure for restraint requires a restraint order from a (LIP) License Independent Practitioner.

During interview on 5/01/17 at 12:10 PM, (Staff D) Administrator for the Behavioral Health Unit staff acknowledged findings.