HospitalInspections.org

The Condition of Participation for Patient Rights has not been met.

A. Based on clinical record review, observations, interviews with staff, review of hospital documentation and policy review for 2 of 2 patients (Patient #11 and Patient #17) reviewed for self-harm and neglect, the hospital failed to:

1. Failed to ensure that the patient was free from neglect by failing to ensure the patient received care in a safe setting when staff failed to maintain continuous observations;

2. Failed to adequately supervise the patient; and

3. Failed to ensure the patient was free from neglect for failing to ensure the environment was free of hazards to avoid physical harm of the patient resulting in immediate jeopardy.


Please refer to A144, A145

Based on observation, clinical record review, review of hospital policy, review of hospital documentation and staff interview for 2 of 2 sampled patients (Patient #11 and #17) reviewed for self-harm behaviors, the facility failed to ensure the patient was supervised and/or continuous observation was maintained and/or failed to ensure the environment was free of hazards which resulted in harm of the patient resulting in immediate jeopardy. The findings include:

1. Patient # 17 was admitted to facility on 2/6/19. Review of the hospital discharge summary dated 2/6/19 identified the patient was admitted to the emergency department (ED) for acts of self-harm. The report identified the patient ingested a nail, part of a razor, top of a beer can and while waiting to be evaluated the patient inserted a piece of plastic fork into the genital area. The summary further identified that the patient had suicidal ideation.

Review of the nursing admission assessment dated 2/6/19 identified recently the patient had thoughts of self-harm and/or self-mutilating behaviors. Review of the medical history dated 2/6/19 identified schizophrenia, history of bipolar disorder, anti-social disorder and PICA (eating items that are not food).

Review of the readmission psychosocial history and assessment dated 2/7/19 identified diagnoses including impulsive behaviors, intermittent anger, depression, anxiety and symptoms of post-traumatic stress disorder (PTSD). The note identified a long history of suicidal ideation and PICA. The note further identified to develop a therapeutic relationship with patient, work with family towards discharge and stabilize psychiatric symptoms by improving medication adherence and active involvement in treatment.

Review of the Treatment plan dated 2/16/19 identified a history of self-harm behaviors and PICA. Interventions included medications as ordered, stress management groups, coping skills, rapport building, and tools to recognize and cope with anxiety.

Review of nursing notes, social service notes and physician notes dated from time of admission (2/6/19) thru 3/23/19 identified the patient as medication compliant, a level 4 (unsupervised buildings and ground, meaning any psychiatric conditions present are considered either resolved or sufficiently stabilized that staff supervision is not always required) and attending groups and therapies.

a. Review of incident report dated 3/24/19 at 11:50AM identified the patient reported he/she inserted a pen in the urethra and swallowed a paper clip. The physician was notified and assessed the patient and the patient was transferred to the ED for evaluation. The report further identified the patient had an increase in self-harming behaviors and that staff was to ensure they are viewing the resident from the front at all times, and a room search to be completed.

Nurse's notes dated 3/24/19 at 11:50AM identified patient requested to speak to writer and the patient reported that he/she inserted a pen into the urethra and swallowed a paper clip. The note further identified that the pen was visible in the urethra area, the patient was assessed by the physician and was transferred to the hospital.

A Psychiatry note dated 3/24/19 at 12:10PM identified that he/she was asked to see the patient after the patient inserted a foreign object (pen) into the urethra area and swallowing a paper clip. The note identified after a phone call, the patient was upset and became involved in self-injurious behaviors and was transported to the ED.

Review of the hospital ED report dated 3/24/19 identified the patient arrived complaining about a pen that was inserted into the urethra and a paper clip the patient swallowed. The report identified a pen was palpated at the base of the penis and scrotum and a chest x-ray confirmed an uncoiled paper clip in the stomach. The report further identified the patient was taken to the operating room for removal of the foreign objects. Nurse's notes dated 3/24/19 at 9:40PM identified the patient returned from the hospital, the physician was notified and the patient was placed on continuous observation status.

Review of facility policy for Continuous Observation identified the patient requires ongoing monitoring to ensure his/her safety and/or safety of others. The nursing staff assigned provides that by maintaining unimpeded access and visualization of the patient at a distance determined by the level of risk and clinical need.

Interview with the Program Director on 4/4/19 at 2:30PM stated that when a patient is on continuous observation the staff are to have an unobstructed view at all times and they must be able to see the patients hands, neck and face at all times. Special observation orders dated 3/25/19 at 11AM directed to maintain the patient on continuous observation status for 24 hours.

b. Review of Incident report dated 3/25/19 at 10:30PM identified that the patient reported that when he/she went to take medications at 8AM, he/she grabbed a pen from the medication room door when the nurse wasn't looking. The report noted that when the patient needed to use the bathroom he/she inserted the pen into the urethra while the staff person performing the continuous observation was outside the bathroom stall. The MD was made aware and the patient was assessed and complained of pain and being unable to urinate. The patient was transferred to the ED for an evaluation. The Mental Health Associate (MHA) failed to maintain visual contact with the patient's hands, face, and neck at all times in accordance with hospital policy.

Physician progress note dated 3/25/19 at 11:15PM noted assessed patient after patient stated that he/she inserted a pen into the urethra around noon because he/she was upset over a conversation. The note further identified that the patient was complaining of pain in the urethra and was unable to urinate. The note identified the patient was transferred to the ED for an evaluation.

Nurse's notes dated 3/25/19 at 11:30PM identified the patient was maintained on CO (continuous observation) this shift for protection of self. The note identified at 10:30PM the patient reported that he/she inserted a pen into the urethra. The note further identified that the patient reported that he/she took the pen during the morning medication pass when the nurse turned her back and inserted the pen while in the bathroom after he/she asked the MHA for privacy. The note further identified that he/she had been trying to remove the pen but was unable to and could not take the pain anymore. The physician was made aware of the event, the patient was assessed and sent to the ED for an evaluation. The Mental Health Associate (MHA) failed to maintain visual contact with the patient's hands, face, and neck at all times in accordance with hospital policy.

Review of the hospital report dated 3/25/19 identified patient admitted to the ED after inserting a pen into the urethra, having difficulty urinating, is in severe pain and blood was noted at the tip of the meatus. The note identified that upon examination the patient appeared to be uncomfortable and having 400cc of urine in his/her bladder. The note further identified that the patient went to the operating room and had a cystoscopy and endoscopy with foreign body removal.

Nurse's notes dated 3/26/19 at 6:35AM identified patient returned from hospital at 3:50AM and was on continuous observation related to protection of self. Interview on 4/9/19 at 9:50AM with MHA #5 who was assigned to care for the resident stated that she was assigned to do continuous observation on Patient # 17. MHA #5 stated that about 11:40M she assisted the patient to the bathroom and while the patient was urinating, she stood behind the patient and could not see the patient's hands. MHA# 5 stated that she did receive report from the nurse and was told not to leave the patient alone and to watch the patients hands at all times. MHA # 5 stated that she observed the patient as best as she could but the bathroom stalls are small and she could not fit in the stall with the patient. MHA #5 failed to maintain continuous observation of the patient's hands, face and neck at all times in accordance with hospital policy.

c. Review of incident report dated 3/26/19 at 11:31AM identified that the patient was on continuous observation and the patient reported that he/she inserted a pen into the urethra around 11:30AM. The report noted that the bathroom door was half open and staff had full sight of patient and saw the patient adjust self but did not think anything of it.

Physician progress note dated 3/26/19 at 1:30PM identified the patient reported inserting a pen into the urethra when he/she went to the bathroom at 11:30AM. The patient was examined and the physician was able to palpate something at the base of the penis and the patient complained of pain and inability to urinate. The note further identified the patient stated he/she was inserting pens into his/her urethra out of anger and frustration. The patient was transferred to the ED for an evaluation.

Nurse's notes dated 3/26/19 at 2:30PM identified that the patient remained on continuous observation for protection of self. The note identified the patient continued to make threats stating "I'm going back to the hospital", "I inserted a pen into my urethra and it hurts and I'm going back to the ED".

Nurse's notes dated 3/26/19 at 3:30PM identified at approximately 3PM a unit search was conducted and 6 pens were found, 2 of the pens were found under the floor tile in the patient's room.

Review of the hospital discharge summary dated 3/26/19 identified the patient presented with foreign body in urethra and was sent to the OR for a cystoscopy. Additionally, the patient was started on Keflex 500mg 3 times a day for 7 days.

Special observation orders dated 3/26/19 at 5:53PM directed the patient was to be on a one to one with 2 staff members at all times to prevent insertion of objects into the urethra, room search every shift for items patient can ingest and/or insert. Patient to use large toilet stall, patient to sit facing staff, no privacy, when finished going to bathroom may wipe self after showing staff hands, and when in bed hands are to be visible at all times.

Nurse's notes dated 3/26/19 at 9PM identified patient returned from ED, refused to wear sweatpants as ordered and was on a one to one with 2 staff members.

Interview with RN # 5 on 4/5/19 at 1:40PM stated that on 3/26/19 she overheard Patient # 17 say "it was already done." RN # 5 stated she spoke to the patient and asked what's going on and the patient stated that he/she inserted a pen into his/her urethra. RN # 5 stated that she assessed the patient and saw a pen sticking out from the patient's urethra, notified the MD and transported the patient to the ED. RN # 5 stated that a unit and room search were completed and found 6 pens, 4 on the unit and 2 pens under the tile floor in the patient's room. RN # 5 stated that she spoke to the MHA's prior to doing the CO and instructed them that the patients hands have to be visible at all times. RN # 5 further stated that during the investigation the MHA's reported that while the patient was in the bathroom they stood behind the patient and his/her hands were not visible.

Interview with MHA # 6 on 4/5/19 at 2:50PM stated she was doing the continuous observation on 3/26/19 between 11:15AM and 12:15PM. MHA # 6 stated that she took the patient to the bathroom and the patient squatted over the toilet and his/her hands were positioned on the inner thighs. MHA # 6 stated that she was standing at the doorway and MHA # 7 was behind her. MHA # 6 stated that she did not know why she told the nurse something different when asked but couldn't remember exactly how the patient was or where she stood while the patient in the bathroom. Although MHA #6 identified that she was standing at the doorway while the patient was in the bathroom, she also reported to RN #5 that she stood behind the patient and the patient's hands were not visible.

Interview with MHA # 7 on 4/5/19 at 3:05PM stated that she did the environmental check prior to the patient going into the bathroom and observed the patient sit on the toilet. MHA # 7 stated that the patient was not visible to her because the door was half closed and when she questioned MHA # 6 about having the door open to watch the patient, MHA # 6 stated that "the patient needed privacy and couldn't go to the bathroom in front of us". MHA # 7 further stated that she told the nurse what happened and that she would not cover for MHA # 6. MHA #6 and MHA # 7 failed to maintain continuous observation of the patient's hands, face and neck at all times in accordance with hospital policy.

Special observation orders dated 3/27/19 at 10:55AM directed one to one with 2 male staff, patient to have hands visible at all times, patient to wear sweatpants and if refuses check pockets before goes into bathroom and CO, room search room every shift for items patient can ingest/insert, while in bathroom patient is to sit on the toilet facing staff, no privacy and may wipe self after showing hands are empty, when in bed hands visible at all times and continue finger foods. Additionally at 2:40PM the order was updated to include when the patient was in blue room, one staff is to be at arm's length and one staff to sit in doorway, male staff only. Further review of the Special Observation orders from 3/27/19 through 3/30/19 at 11:30PM directed the orders continued as written.

d. Review of incident report dated 3/31/19 at 8:10PM identified the nurse was called to evaluate the patient who was bleeding from the urethra. The note identified staff reported that the patient placed his/her hands in his/her pants for a moment and was immediately redirected by staff and when the patient's hands came out of his/her pants blood was observed on his/her hands and pants. The report stated that the patient identified placing a pen in the urethra. The area was assessed, pressure was applied to the site and the physician was notified and the patient was transferred to the ED. Physician progress noted dated 3/31/19 at 11:20PM identified patient inserted pen into the urethra and stated he/she got the pen from another patient who admitted to giving the patient the pen.

Nursing notes dated 3/31/19 at 12:35AM identified patient reported he/she inserted a pen into the urethra area between 9:30PM-10:30PM while making a phone call. The patient was assessed and the patient was trying to pull the pen out but was directed to stop and blood was noted in the patient's genital area. The physician was notified and the patient was transferred to the ED.

Review of the hospital report dated 3/31/19 identified the patient presented after ingesting a cartridge of a pen and was spitting up blood and had inserted a pen into the urethra and was having pain. The patient was taken to the OR and a endoscopy and cystoscopy were performed with foreign body removal.

Nurse's notes dated 3/31/19 at 10:15AM identified the patient returned from the ED, the unit and sleeping area were checked for any items. As a nursing intervention, the patient's bed was placed in the center of the room sp staff can be each side of the bed but the patient refused and pushed the bed against the wall.

Special Observation orders dated 3/31/19 at 10:40AM directed the patient to be a two to one male staff to prevent insertion of objects into genital area, patient to have hands visible at all times. Patient to wear sweatpants, no underwear, if patient refuses, check pockets before the patient goes into bathroom and room search every shift for items the patient can ingest/insert. When the patient is in the bathroom use large toilet stall. Patient to sit facing staff when defecating or urinating, no privacy, patient may wipe self after showing hands are empty and hands to be visible at all times. Additional orders noted that patient is to eat away from peers and when in blue room one staff is to be at arm's length and the other to sit at doorway.

Interview with RN # 6 on 4/5/19 at 10:10AM stated that he was called to Patient # 17's room and upon entering the room saw the patient with blood on his/her hands and sweatpants. RN # 6 stated he assessed the patient and noted clood around the genital area and the physician was notified and the patient was transported to the ED. RN # 6 stated that they were not able to determine how the patient obtained a pen but identified that the patient had previously had an upsetting phone call and that when he/she was using the bathroom tried to close the stall door on staff.

Interview with MHA # 8 on 4/8/19 at 3:05PM stated that he was doing CO with RN #7 and sitting an arm's length away from the patient when the patient put his/her hands down the pants and when he/she pulled his/her hands out, there was blood on his/her hands. MHA # 8 stated that the patient reported that he/she inserted it earlier and at that time was pushing the object in further.

Interview with RN # 7 on 4/9/19 at 1:35PM stated he was providing CO and the patient was lying on the bed. RN # 7 stated that the patient had his/her fingers under the waistband of the pants and RN # 7 instructed the patient to take his/her hand out and when he/she finally did there was blood on his/her hand and at that time, he called the charge nurse. RN # 7 asked the patient how he/she obtained a pen and the patient would not divulge. MHA #8 and RN #7 failed to maintain continuous observation of the patient's hands, face and neck at all times in accordance with hospital policy which resulted in the patient being able to insert foreign objects into the urethra.

Observations on 4/4/19 at 9:45AM identified while entering B4 North unit Patient # 17 was observed in a observation room in front of the nursing station. The patient was noted standing on the side of the bed and 2 staff were observed seated in chairs on the other side of the bed with their heads down, not maintaining continuous observation. One staff member was observed holding a folder and the other staff had his hands folded on his lap and looking down. Observation with the Program Manager on 4/4/19 at 11:57 AM, Patient # 17 was observed noted standing at the bedside and 2 staff members were observed with their heads down not looking at the patient in accordance with the CO policy. Interview with the Program Director at that time stated that staff are to be looking at the patient's hands, face and neck at all times for safety.

Interview with the Chief Nurse Executive on 4/5/19 at 9:30 AM stated that as of 4/4/19 on the second shift the hospital modified and/or implemented rounds to be completed by the charge nurse 4 times per shift at random times and 2 times by the RN Supervisor. The rounds are completed to ensure staff are adhering to hospital policy regarding observational status to ensure patient safety. The Chief Nursing Executive further stated that all staff are being re-educated on continuous observations prior to working their shift and all staff will receive report from the charge nurse at the start of their shift regarding specific patient needs. Nursing report, shift procedure, and accountability rounds were revised to ensure behavioral plans and guidelines and any MD orders for special observations are reviewed during each shift report.

Interview with the Program Director of 4/5/19 at 2PM stated that as of 3/26/19, the hospital added a second staff member to do environmental rounds for Patient # 17, ensuring that staff would check the environment for hazards prior to the patient entering the area. The Program Director further stated that staff did not follow the hospital policy for CO regarding watching the patient's hands, face and neck at all times since he/she was able to obtain pens.

Review of the clinical record with the Program Director on 4/5/19 at 2PM identified although there was on order for room searches every shift effective 3/26/19 at 4:20PM the clinical record noted the only documented room search was completed on 3/26/19 at 8PM.




2. Patient # 11's diagnoses included Paranoid Schizophrenia and self-harming behaviors.

Review of the treatment plan dated 12/26/18 identified self-harming behaviors. Interventions included RN to assess for warning signs of self-harming behaviors such as increased anxiety or agitation, assist with identifying situations that trigger self-harming thoughts/urges, and discuss positive coping skills.

Physician orders dated 1/8/19 identified the patient as a Level 3 (does not constitute an imminent risk to self or others, not an elopement risk and has awareness of his/her circumstances of admission and has some working relationship with peers).

a. Review of an incident report dated 1/14/19 at 12:45PM identified the patient reported that he/she inserted an earring into the genital area because the patient was upset. The report identified the physician was made aware and removed the earring from the patient. Additionally the report noted that the patient's jewelry was removed from the room.

Physician orders dated 1/14/19 at 12:45PM directed to place patient on every 15 minute checks for unpredictable behaviors and room search to remove all jewelry items.

Physician progress note dated 1/14/19 at 1:15PM identified the earring was extracted without pain or injury.

Physician orders dated 1/21/19 at 1:45PM identified renew every 15 minute checks by 1 day and to be assessed by the treatment team.

Physician orders dated 1/22/19 directed the patient to be a level 1 (Restricted to the unit, patient behaviors present management difficulties requiring close monitoring). Interview with MD #3 on 3/28/19 at 3:30 PM identified that the patient had unpredictable behaviors and needed to be supervised, which included 15 minute monitoring checks.

Review of the annual treatment plan dated 1/23/19 identified self-harm. Nursing interventions included assess for warning signs of self-harming behaviors such as increased anxiety/agitation, help patient identify situations that trigger self-harming thoughts and discuss positive coping skills.

Review of the treatment plan on 3/28/19 at 10:00 AM with the Chief of Patient Care Services identified although the treatment plan identified the behavior of placing an earring in the genital area, the treatment plan lacked documentation of new interventions regarding monitoring the patient to ensure he/she did not attempt it again.


b. Review of an incident report dated 1/31/19 at 5:00 AM identified the patient reported inserting a sharp object in the genital area (screw from wheelchair). The report identified a genital exam was completed on the patient and 2 round sharp objects were removed. The patient admitted to also swallowing a metal disc from a necklace and inserting a third screw. Additionally, the report identified the patient was sent to the ED and 5 metal objects were found in the lower intestine.

Review of nurse's notes dated 1/31/19 at 6:30AM identified that while staff was assisting the patient to the bathroom the patient identified that he/she inserted a sharp object (screw from wheelchair) into the genital area last evening during snack time because he/she thought they were being raped. The note further identified that a scant amount of blood was on the patient's brief and bed sheet and the nursing supervisor and MD were notified.

Physician orders dated 1/31/19 at 8:25AM identified a level change to every 15 minute checks for safety and room search for contraband related to continuous self-destructive behaviors ie: inserting items in the genital orifice.

Physician orders dated 1/31/19 3:50PM directed continuous observation all shifts for unpredictable behaviors/medical monitoring and room search for harmful items.

Review of the Focused treatment plan dated 2/1/19 identified the patient inserted and/or ingested foreign objects, was sent to the ED for an evaluation and when returned was placed on continuous observation.

Review of special observation orders dated 2/1/19 through 2/5/19 identified continuous observations for unpredictable behaviors. Special observation orders dated 2/6/19 through 2/10/19 at 9:15AM identified continuous observation on 1st and 2nd shifts and every 15 minute checks on 3rd shift, and may not have small objects.

Special observation orders dated between 2/10/19 and 3/25/19 identified special observation orders for a combination of continuous observation and every 15 minute checks due to the patient's unpredictable and fluctuating self-injurious/ self-destructive behaviors. Special instructions included: may not have small objects, fall risk, no personal belongings, and room search every shift.

Review of the monthly psychiatry progress note dated 3/22/19 identified the patients psychiatric condition continues to fluctuate. Remains disorganized, paranoid, impulsive and unpredictable.

Special observation orders dated 3/26/19 through 3/27/19 at 4PM identified continuous observation on 2nd shift, every 15 minute checks 1st and 3rd shifts, room search every shift and no personal belongings.


c. Review of an Incident Report dated 3/27/19 identified that at 2:55PM the patient reported he/she attempted self-harm by inserting tin foil into the urethra. The report further identified the patient was seen by the MD and the tin foil was removed and the patient was placed on continuous observation on all shifts.

A Social Service note dated 3/27/19 at 3:46PM identified that while speaking with the patient, the patient was weepy and had a disorganized thought process. The note further identified that the patient reported that he/she inserted tin foil into the genital area in an act to harm self.

Review of a medical progress note dated 3/27/19 at 3:30PM identified asked to see patient after admitting to placing a piece of foil (from a pudding cup) up in the urethra. The patient was assessed and noted to have a folded piece of foil in the urethra that was easily removed and no trauma was identified in the area. The note further identified the patient was placed on continuous observation.

Special observation orders dated 3/27/19 at 4PM directed constant observation all shifts for self-injurious behaviors, room search every shift and no personal possessions.

Interview with MD # 2 on 3/27/19 at 4:15PM identified that the patient had a history of ingesting and/or inserting items in the urethra. MD # 2 stated that it usually occurs when the patient is upset over something. MD # 2 stated that the patient was just taken off continuous observation and placed on every fifteen minute checks on the day shift the previous day. MD #2 stated that although the patient's checks were decreased from continuous observation to every fifteen minute checks on days, staff still need to supervise the patient and ensure the environment is free from objects/hazards that the patient could obtain.

Interview with MD # 3 on 3/27/19 at 4:15PM stated that Patient # 11 had improved behaviors and had recent medication adjustments. MD # 3 stated that although the patient was changed to every fifteen minute checks he/she still required monitoring and supervision due to the unpredictable behaviors.

Interview with LPN # 1 on 3/27/19 at 4:30PM stated that she was aware of Patient # 11's history of swallowing and inserting foreign objects into him/her and not allowing the patient to have small objects. LPN # 1 stated that staff do not open food items for patients. LPN # 1 did not respond when asked why she would leave foreign objects/items and/or small objects with the patient who has a history of eating non edible items and/or inserting items in the urethra.

Interview with the Program Director on 3/27/19 at 4:40PM stated that staff should not have left the (food) wrappers with the patient due to the patient's history and several orders of the patient not being able to have small objects. The Program Director further stated that staff are made aware from the nurse when receiving report of what a patient's status is while on CO.

The hospital failed to ensure adequate supervision for Patient #11 who had fluctuating self-injurious/ self-destructive behaviors to prevent self-injurious behaviors. In addition, staff failed to ensure that small objects such a food wrappers were removed from the patient's surroundings.

Immediate Jeopardy was identified under Patient Rights on 4/12/19. An onsite visit conducted on 4/12/19 verified that Immediate Jeopardy was corrected as of 4/4/19 when the hospital began educating staff regarding continuous observation (CO) and random nursing audits began to ensure staff were following the CO policy.

Based on observation, clinical record review, review of hospital policy, review of hospital documentation and staff interview for 1 of 2 sampled patients (Patient #17) reviewed for neglect, the facility failed to ensure the patient was free from neglect for failing to supervise and/or maintain continuous observation and/or failed to ensure the environment was free of hazards to avoid physical harm of the patient resulting in immediate jeopardy. The findings include:

Patient # 17 was admitted to facility on 2/6/19. Review of the hospital discharge summary dated 2/6/19 identified the patient was admitted to the emergency department (ED) for acts of self-harm. The report identified the patient ingested a nail, part of a razor, top of a beer can and while waiting to be evaluated the patient inserted a piece of plastic fork into the genital area. The summary further identified that the patient had suicidal ideation.

Review of the nursing admission assessment dated 2/6/19 identified recently the patient had thoughts of self-harm and/or self-mutilating behaviors. Review of the medical history dated 2/6/19 identified schizophrenia, history of bipolar disorder, anti-social disorder and PICA (eating items that are not food).

Review of the readmission psychosocial history and assessment dated 2/7/19 identified diagnoses including impulsive behaviors, intermittent anger, depression, anxiety and symptoms of post-traumatic stress disorder (PTSD). The note identified a long history of suicidal ideation and PICA. The note further identified to develop a therapeutic relationship with patient, work with family towards discharge and stabilize psychiatric symptoms by improving medication adherence and active involvement in treatment.

Review of the Treatment plan dated 2/16/19 identified a history of self-harm behaviors and PICA. Interventions included medications as ordered, stress management groups, coping skills, rapport building, and tools to recognize and cope with anxiety.

Review of nursing notes, social service notes and physician notes dated from time of admission (2/6/19) thru 3/23/19 identified the patient as medication compliant, a level 4 (unsupervised buildings and ground, meaning any psychiatric conditions present are considered either resolved or sufficiently stabilized that staff supervision is not always required) and attending groups and therapies.

a. Review of an incident report dated 3/24/19 at 11:50AM identified the patient reported he/she inserted a pen in the urethra and swallowed a paper clip. The physician was notified and assessed the patient and the patient was transferred to the ED for evaluation. The report further identified the patient had an increase in self-harming behaviors and that staff was to ensure they are viewing the resident from the front at all times, and a room search to be completed.

Nurse's notes dated 3/24/19 at 11:50AM identified patient requested to speak to writer and the patient reported that he/she inserted a pen into the urethra and swallowed a paper clip. The note further identified that the pen was visible in the urethra area, the patient was assessed by the physician and was transferred to the hospital.

A Psychiatry note dated 3/24/19 at 12:10PM identified that he/she was asked to see the patient after the patient inserted a foreign object (pen) into the urethra area and swallowing a paper clip. The note identified after a phone call, the patient was upset and became involved in self-injurious behaviors and was transported to the ED.

Review of the hospital ED report dated 3/24/19 identified the patient arrived complaining about a pen that was inserted into the urethra and a paper clip the patient swallowed. The report identified a pen was palpated and a chest x-ray confirmed an uncoiled paper clip in the stomach. The report further identified the patient was taken to the operating room for removal of the foreign objects. Nurse's notes dated 3/24/19 at 9:40PM identified the patient returned from the hospital, the physician was notified and the patient was placed on continuous observation status.

Review of facility policy for Continuous Observation identified the patient requires ongoing monitoring to ensure his/her safety and/or safety of others. The nursing staff assigned provides that by maintaining unimpeded access and visualization of the patient at a distance determined by the level of risk and clinical need.

Interview with the Program Director on 4/4/19 at 2:30PM stated that when a patient is on continuous observation the staff are to have an unobstructed view at all times and they must be able to see the patients hands, neck and face at all times. Special observation orders dated 3/25/19 at 11;00AM directed to maintain the patient on continuous observation status for 24 hours.

b. Review of an incident report dated 3/25/19 at 10:30PM identified that the patient reported that when he/she went to take medications at 8:00AM, he/she grabbed a pen from the medication room door when the nurse wasn't looking. The report noted that when the patient needed to use the bathroom he/she inserted the pen into the urethra while the staff person performing the continuous observation was outside the bathroom stall. The MD was made aware and the patient was assessed and complained of pain and being unable to urinate. The patient was transferred to the ED for an evaluation. The Mental Health Associate (MHA) assigned to Patient #17 failed to ensure the environment was free of environmental hazards to avoid physical harm of the patient and/or failed to maintain visual contact with the patient's hands, face, and neck at all times in accordance with hospital policy.

Physician progress note dated 3/25/19 at 11:15PM noted assessed patient after patient stated that he/she inserted a pen into the urethra around noon because he/she was upset over a conversation. The note further identified that the patient was complaining of pain in the urethra and was unable to urinate. The note identified the patient was transferred to the ED for an evaluation.

Nurse's notes dated 3/25/19 at 11:30PM identified the patient was maintained on CO (continuous observation) this shift for protection of self. The note identified at 10:30PM the patient reported that he/she inserted a pen into the urethra. The note further identified that the patient reported that he/she took the pen during the morning medication pass when the nurse turned her back and inserted the pen while in the bathroom after he/she asked the MHA for privacy. The note further identified that he/she had been trying to remove the pen but was unable to and could not take the pain anymore. The physician was made aware of the event, the patient was assessed and sent to the ED for an evaluation. The Mental Health Associate (MHA) failed to ensure the environment was free of environmental hazards to avoid physical harm of the patient and/or failed to maintain visual contact with the patient's hands, face, and neck at all times in accordance with hospital policy.

Review of the hospital report dated 3/25/19 identified patient admitted to the ED after inserting a pen into the urethra, having difficulty urinating, is in severe pain and blood was noted. The note identified that upon examination the patient appeared to be uncomfortable and having 400cc of urine in his/her bladder. The note further identified that the patient went to the operating room and had a cystoscopy and endoscopy with foreign body removal.

Nurse's notes dated 3/26/19 at 6:35AM identified the patient returned from the hospital at 3:50AM and was on continuous observation related to protection of self.

Interview on 4/9/19 at 9:50AM with MHA #5 who was assigned to care for the resident stated that she was assigned to do continuous observation on Patient # 17. MHA #5 stated that about 11:40AM she assisted the patient to the bathroom and while the patient was urinating, she stood behind the patient and could not see the patient's hands. MHA# 5 stated that she did receive report from the nurse and was told not to leave the patient alone and to watch the patients hands at all times. MHA # 5 stated that she observed the patient as best as she could but the bathroom stalls are small and she could not fit in the stall with the patient. MHA #5 failed to ensure the environment was free of environmental hazards to avoid physical harm of the patient and/or failed to maintain visual contact with the patient's hands, face, and neck at all times in accordance with hospital policy.


c. Review of incident report dated 3/26/19 at 11:31AM identified that the patient was on continuous observation and the patient reported that he/she inserted a pen into the urethra around 11:30AM. The report noted that the bathroom door was half open and staff had full sight of patient and saw the patient adjust self but did not think anything of it.

Physician progress note dated 3/26/19 at 1:30PM identified the patient reported inserting a pen into the urethra when he/she went to the bathroom at 11:30AM. The patient was examined and the physician was able to palpate something and the patient complained of pain and inability to urinate. The note further identified the patient stated he/she was inserting pens into his/her urethra out of anger and frustration. The patient was transferred to the ED for an evaluation.

Nurse's notes dated 3/26/19 at 2:30PM identified that the patient remained on continuous observation for protection of self. The note identified the patient continued to make threats stating "I'm going back to the hospital", "I inserted a pen into my urethra and it hurts and I'm going back to the ED".

Nurse's notes dated 3/26/19 at 3:30PM identified at approximately 3:00PM a unit search was conducted and 6 pens were found, 2 of the pens were found under the floor tile in the patient's room.

Review of the hospital discharge summary dated 3/26/19 identified the patient presented with foreign body in urethra and was sent to the OR for a cystoscopy. Additionally, the patient was started on Keflex 500mg 3 times a day for 7 days.

Special observation orders dated 3/26/19 at 5:53PM directed the patient was to be on a one to one with 2 staff members at all times to prevent insertion of objects into the urethra, room search every shift for items patient can ingest and/or insert. Patient to use large toilet stall, patient to sit facing staff, no privacy, when finished going to bathroom may wipe self after showing staff hands, and when in bed hands are to be visible at all times.

Nurse's notes dated 3/26/19 at 9PM identified patient returned from ED, refused to wear sweatpants as ordered and was on a one to one with 2 staff members.

Interview with RN # 5 on 4/5/19 at 1:40PM stated that on 3/26/19 she overheard Patient # 17 say "it was already done." RN # 5 stated she spoke to the patient and asked what's going on and the patient stated that he/she inserted a pen into his/her urethra. RN # 5 stated that she assessed the patient and saw a pen sticking out from the patient's urethra, notified the MD and transported the patient to the ED. RN # 5 stated that a unit and room search were completed and found 6 pens, 4 on the unit and 2 pens under the tile floor in the patient's room. RN # 5 stated that she spoke to the MHA's prior to doing the CO and instructed them that the patients hands have to be visible at all times. RN # 5 further stated that during the investigation the MHA's reported that while the patient was in the bathroom they stood behind the patient and his/her hands were not visible.

Interview with MHA # 6 on 4/5/19 at 2:50PM stated she was doing the continuous observation on 3/26/19 between 11:15AM and 12:15PM. MHA # 6 stated that she took the patient to the bathroom and the patient squatted over the toilet and his/her hands were positioned on the inner thighs. MHA # 6 stated that she was standing at the doorway and MHA # 7 was behind her. MHA # 6 stated that she did not know why she told the nurse something different when asked but couldn't remember exactly how the patient was or where she stood while the patient was in the bathroom. Although MHA #6 identified that she was standing at the doorway while the patient was in the bathroom, she also reported to RN #5 that she stood behind the patient and the patient's hands were not visible.

Interview with MHA # 7 on 4/5/19 at 3:05PM stated that she did the environmental check prior to the patient going into the bathroom and observed the patient sit on the toilet. MHA # 7 stated that the patient was not visible to her because the door was half closed and when she questioned MHA # 6 about having the door open to watch the patient, MHA # 6 stated that "the patient needed privacy and couldn't go to the bathroom in front of us". MHA # 7 further stated that she told the nurse what happened and that she would not cover for MHA # 6. MHA # 6 and MHA #7 failed to ensure the environment was free of environmental hazards to avoid physical harm of the patient and/or failed to maintain visual contact with the patient's hands, face, and neck at all times in accordance with hospital policy.

Special observation orders dated 3/27/19 at 10:55AM directed one to one with 2 male staff, patient to have hands visible at all times, patient to wear sweatpants and if refuses check pockets before goes into bathroom and CO, room search room every shift for items patient can ingest/insert, while in bathroom patient is to sit on the toilet facing staff, no privacy and may wipe self after showing hands are empty, when in bed hands visible at all times and continue finger foods. Additionally at 2:40PM the order was updated to include when the patient was in blue room, one staff is to be at arm's length and one staff to sit in doorway, male staff only. Further review of the Special Observation orders from 3/27/19 through 3/30/19 at 11:30PM directed the orders continued as written.


d. Review of an incident report dated 3/31/19 at 8:10PM identified the nurse was called to evaluate the patient who was bleeding from the urethra. The note identified staff reported that the patient placed his/her hands in his/her pants for a moment and was immediately redirected by staff and when the patient's hands came out of his/her pants blood was observed on his/her hands and pants. The report stated that the patient identified placing a pen in the urethra. The area was assessed, pressure was applied to the site and the physician was notified and the patient was transferred to the ED. Physician progress noted dated 3/31/19 at 11:20PM identified patient inserted pen into the urethra and stated he/she got the pen from another patient who admitted to giving the patient the pen.

Nursing notes dated 3/31/19 at 12:35AM identified patient reported he/she inserted a pen into the urethra area between 9:30PM-10:30PM while making a phone call. The patient was assessed and the patient was trying to pull the pen out but was directed to stop and blood was noted in the patient's genital area. The physician was notified and the patient was transferred to the ED.

Review of the hospital report dated 3/31/19 identified the patient presented after ingesting a cartridge of a pen and was spitting up blood and had inserted a pen into the urethra and was having pain. The patient was taken to the OR and a endoscopy and cystoscopy were performed with foreign body removal.

Nurse's notes dated 3/31/19 at 10:15AM identified the patient returned from the ED and the unit and sleeping area were checked for any items. As a nursing intervention, the patient's bed was placed in the center of the room so staff could be on each side of the patient but the patient refused and pushed the bed against the wall.

Special Observation orders dated 3/31/19 at 10:40AM directed the patient to be a two to one male staff to prevent insertion of objects into genital area, patient to have hands visible at all times. Patient to wear sweatpants, no underwear, if patient refuses to have pockets checked before patient goes into bathroom and room search every shift for items the patient can ingest/insert. When the patient is in the bathroom use large toilet stall. Patient to sit facing staff when defecating or urinating, no privacy, patient may wipe self after showing hands are empty and hands to be visible at all times. Additional orders noted that patient is to eat away from peers and when in blue room one staff is to be at arm's length and the other to sit at doorway.

Interview with RN # 6 on 4/5/19 at 10:10AM stated that he was called to Patient # 17's room and upon entering the room saw the patient with blood on his/her hands and sweatpants. RN # 6 stated he assessed the patient and noted blood around the genital area and the physician was notified and the patient was transported to the ED. RN # 6 stated that they were not able to determine how the patient obtained a pen but identified that the patient had previously had an upsetting phone call and that when he/she was using the bathroom tried to close the stall door on staff.

Interview with MHA # 8 on 4/8/19 at 3:05PM stated that he was doing CO with RN #7 and sitting an arm's length away from the patient when the patient put his/her hands down the pants and when he/she pulled his/her hands out, there was blood on his/her hands. MHA # 8 stated that the patient reported that he/she inserted it earlier and at that time was pushing the object in further.

Interview with RN # 7 on 4/9/19 at 1:35PM stated he was providing CO and the patient was lying on the bed. RN # 7 stated that the patient had his/her fingers under the waistband of the pants and RN # 7 instructed the patient to take his/her hand out and when he/she finally did there was blood on his/her hand and at that time, he called the charge nurse. RN # 7 asked the patient how he/she obtained a pen and the patient would not divulge. MHA #8 and RN #7 failed to ensure the environment was free of environmental hazards to avoid physical harm by being able to insert foreign objects into the urethra and/or failed to maintain visual contact with the patient's hands, face, and neck at all times in accordance with hospital policy.

Observations on 4/4/19 at 9:45AM identified while entering Battell 4 North unit, Patient # 17 was observed in an observation room in front of the nursing station. The patient was noted standing on the side of the bed and 2 staff were observed seated in chairs on the other side of the bed with their heads down, not maintaining continuous observation. One staff member was observed holding a folder and the other stafff had his hands folded on his lap and looking down. Observation with the Program Manager on 4/4/19 at 11:57 AM, identified Patient # 17 was observed standing at the bedside and 2 staff members were observed with their heads down not looking at the patient in accordance with the CO policy. Interview with the Program Director at that time stated that staff are to be looking at the patient's hands, face and neck at all times for safety.


Interview with the Program Director of 4/5/19 at 2PM stated that as of 3/26/19, the hospital added a second staff member to do environmental rounds for Patient # 17, ensuring that staff would check the environment for hazards prior to the patient entering the area. The Program Director further stated that staff did not follow the hospital policy for CO regarding watching the patient's hands, face and neck at all times since he/she was able to obtain pens.

Review of the clinical record with the Program Director on 4/5/19 at 2PM identified although there was on order for room searches every shift effective 3/26/19 at 4:20PM the clinical record noted the only documented room search was completed on 3/26/19 at 8PM.


Interview with the Chief Nurse Executive on 4/5/19 at 9:30 AM stated that as of 4/4/19 on the second shift the hospital modified and/or implemented rounds to be completed by the charge nurse 4 times per shift at random times and 2 times by the RN Supervisor. The rounds are completed to ensure staff are adhering to hospital policy regarding observational status to ensure patient safety. The Chief Nursing Executive further stated that all staff are being re-educated on continuous observations and all staff will receive report from the charge nurse at the start of their shift regarding specific patient needs.

Immediate Jeopardy was identified under Patient Rights on 4/12/19. An onsite visit conducted on 4/12/19 verified that Immediate Jeopardy was corrected as of 4/4/19 when the hospital began educating staff regarding continuous observation (CO) and random nursing audits began to ensure staff were following the CO policy.

Based on clinical record reviews, review of facility documentation, observations, interviews and policy review 1 of 3 patients reviewed for positioning (Patient # 12), the facility failed to ensure the patient was positioned appropriately while out of bed and/or for 1 of 3 patients reviewed for personal grooming (Patient #1), the facility failed to ensure grooming was performed by the appropriate licensed professional and/or for 1 of 2 patients reviewed for self-harm behaviors (Patient #17), the facility failed to ensure the patient's room was searched as directed by the physician. The findings include:


1. Patient #12's diagnoses included Schizophrenia and Dementia. Observation on 3/27/19 at 3:55PM identified that Patient #12 was in his/her room, with the lights off, the door closed and the patients back was to the door. Patient #12 was observed to be reclined back in a Broda chair and his/her head suspended in the air without the benefit of a pillow behind it. Further observation noted the patient was slouched down in the chair. Interview with Chief of Patient Care services at that time stated that the patient should have a pillow or something for head support and needs to be pulled up in the chair. Subsequent to surveyor inquiry, the patient was repositioned in the Broda chair and a pillow was placed behind the residents head.



2. Patient #1 was admitted on 1/26/17 with diagnoses that included schizophrenia and personality disorder. A Nurse's Note dated 1/25/19 at 6:00 PM identified Patient #1's hair was cut by the day shift nurse. The Patient was assessed and no injury was identified.

An incident report dated 1/25/19 at 6:00 PM identified Patient #1's hair was cut by a Medication Nurse.

A Physician's Progress Noted dated 1/25/18 at 7:30 PM identified that Patient #1 asked for a haircut due to the length of the hair

A Physician's Orders dated 1/28/19 at 12:00 PM identified that the nurse was instructed to cut a matt out of the patient's hair per the patients request on the afternoon of 1/15/18.

Interview with RN#1 on 3/5/19 at 10:30 AM stated that RN#3 came to her regarding Patient #1's matted hair. RN#1 directed RN #3 to attempt to comb the patient's hair and/or wash it. RN#1 further stated that she did not assess the patient's hair nor did she know that the patient's hair was cut until the end of the shift.

Interview with MD #1 on 3/6/19 at 11:00 AM stated that RN#3 came to him regarding Patient #1's matted hair and the patient's request for a haircut. He directed the RN to cut the patients hair, not knowing that it was against facility policy.

Interview with RN#3 on 3/7/19 at 11:45 AM stated that Patient #1 came to him twice during his medication pass asking if there was anything that could be done with his/her hair. RN#3 stated Patient #1's hair was very matted on one side and reported this to the head nurse (RN#1). RN #3 stated he was directed to try and comb the patient's hair out and/or provide a shower to wash his/her hair. RN#3 stated he was unable to comb out the matted hair and when MD #1 came to the unit, MD #1 directed him to cut the patient's hair. RN #3 further stated that he was not aware of the facility's policy not allowing nurses to cut patient's hair.

Review of the facility's policy for Basic Needs identified only licensed hairdressers are permitted to cut patient's hair.


3. Patient #17 was admitted to facility on 2/6/19. Review of the hospital discharge summary dated 2/6/19 identified the patient was admitted to the emergency department (ED) for acts of self-harm. The report identified the patient ingested a nail, part of a razor, top of a beer can and while waiting to be evaluated the patient inserted a piece of plastic fork into the genital area. The summary further identified that the patient had suicidal ideation.

Review of the nursing admission assessment dated 2/6/19 identified recently the patient had thoughts of self-harm and/or self-mutilating behaviors. Review of the medical history dated 2/6/19 identified schizophrenia, history of bipolar disorder, anti-social disorder and PICA (eating items that are not food).

Review of the readmission psychosocial history and assessment dated 2/7/19 identified diagnoses including impulsive behaviors, intermittent anger, depression, anxiety and symptoms of post-traumatic stress disorder (PTSD). The note identified a long history of suicidal ideation and PICA. The note further identified to develop a therapeutic relationship with patient, work with family towards discharge and stabilize psychiatric symptoms by improving medication adherence and active involvement in treatment.

Review of the Treatment plan dated 2/16/19 identified a history of self-harm behaviors and PICA. Interventions included medications as ordered, stress management groups, coping skills, rapport building, and tools to recognize and cope with anxiety.

Physician orders dated 3/21/19 directed the patient to be a Level 4 with unescorted grounds passes daily betewwn 9:00 AM and 10:00 AM, 1:00 PM to 2:00 PM and 6:00 PM to 7:00 PM. May go to groups, activities and food carts on grounds.

a. Review of an incident report dated 3/24/19 at 11:50AM identified the patient reported he/she inserted a pen in the urethra and swallowed a paper clip. The physician was notified and assessed the patient and the patient was transferred to the ED for evaluation. The report further identified the patient had an increase in self-harming behaviors and that staff was to ensure they are viewing the resident from the front at all times, and a room search was to be completed.

A nurse's note dated 3/24/19 at 11:50AM identified patient requested to speak to writer and the patient reported that he/she inserted a pen into the urethra and swallowed a paper clip. The note further identified that the pen was visible in the urethra area, the patient was assessed by the physician and was transferred to the hospital.

A Psychiatry note dated 3/24/19 at 12:10PM identified that he/she was asked to see the patient after the patient inserted a foreign object (pen) into the urethra area and swallowing a paper clip. The note identified after a phone call, the patient was upset and became involved in self-injurious behaviors and was transported to the ED.

A Physician's order dated 3/24/19 at 5:20PM directed room searches for contraband including pens and items that can be swallowed.

Review of the hospital ED report dated 3/24/19 identified the patient arrived complaining about a pen that was inserted into the urethra and a paper clip the patient swallowed. The report identified a pen was palpated at the base of the penis and scrotum and a chest x-ray confirmed an uncoiled paper clip in the stomach. The report further identified the patient was taken to the operating room for removal of the foreign objects.

A nurse's note dated 3/24/19 at 9:40PM identified the patient returned from the hospital, the physician was notified and the patient was placed on continuous observation status.

Review of the clinical record with the Program Director on 4/5/19 at 2PM identified although there was on order for room searches every shift effective 3/26/19 at 4:20PM the clinical record noted the only documented room search was completed on 3/26/19 at 8PM. The Program Director stated that room searches are to be completed and documented each shift to ensure the patient does not have any objects he/she may use to insert in the urethra.

Review of the incident report dated 3/26/19 at 11:31AM identified that the patient was on continuous observation and the patient reported that he/she inserted a pen into the urethra around 11:30AM. The report noted that the bathroom door was half open and staff had full sight of patient and saw the patient adjust self but did not think anything of it.

Physician progress note dated 3/26/19 at 1:30PM identified the patient reported inserting a pen into the urethra when he/she went to the bathroom at 11:30AM. The patient was examined and the physician was able to palpate something at the base of the penis and the patient complained of pain and inability to urinate. The note further identified the patient stated he/she was inserting pens into his/her urethra out of anger and frustration. The patient was transferred to the ED for an evaluation.

The nurse's note dated 3/26/19 at 2:30PM identified that the patient remained on continuous observation for protection of self. The note identified the patient continued to make threats stating "I'm going back to the hospital", "I inserted a pen into my urethra and it hurts and I'm going back to the ED".

Nurse's notes dated 3/26/19 at 3:30PM identified at approximately 3PM a unit search was conducted and 6 pens were found, 2 of the pens were found under the floor tile in the patient's room.

Review of the hospital discharge summary dated 3/26/19 identified the patient presented with foreign body in urethra and was sent to the OR for a cystoscopy. Additionally, the patient was started on Keflex 500mg 3 times a day for 7 days.

Special observation orders dated 3/26/19 at 5:53PM directed the patient was to be on a one to one with 2 staff members at all times to prevent insertion of objects into the urethra, room search every shift for items patient can ingest and/or insert.

Interview with RN # 5 on 4/5/19 at 1:40PM stated that on 3/26/19 she overheard Patient # 17 say "it was already done." RN # 5 stated she spoke to the patient and asked what's going on and the patient stated that he/she inserted a pen into his/her urethra. RN # 5 stated that a unit and room search were completed after the patient was sent to the ED and found 6 pens, 4 on the unit and 2 pens under the tile floor in the patient's room.

Special observation orders dated 3/27/19 at 10:55AM directed one to one with 2 male staff, patient to have hands visible at all times, patient to wear sweatpants and if refuses check pockets before goes into bathroom and CO, room search room every shift for items patient can ingest/insert. Further review of the Special Observation orders from 3/27/19 through 3/30/19 at 11:30PM directed the orders continued as written.


b. Review of the incident report dated 3/31/19 at 8:10PM identified the nurse was called to evaluate the patient who was bleeding from the urethra. The note identified staff reported that the patient placed his/her hands in his/her pants for a moment and was immediately redirected by staff and when the patient's hands came out of his/her pants blood was observed on his/her hands and pants. The report stated that the patient identified placing a pen in the urethra. The area was assessed, pressure was applied to the site and the physician was notified and the patient was transferred to the ED. Physician progress noted dated 3/31/19 at 11:20PM identified the patient inserted pen into the urethra and stated he/she got the pen from another patient who admitted to giving the patient the pen.

A nursing note dated 3/31/19 at 12:35AM identified patient reported he/she inserted a pen into the urethra area between 9:30PM-10:30PM while making a phone call. The patient was assessed and the patient was trying to pull the pen out but was directed to stop and blood was noted in the patient's genital area. The physician was notified and the patient was transferred to the ED.

Review of the hospital report dated 3/31/19 identified the patient presented after ingesting a cartridge of a pen and was spitting up blood and had inserted a pen into the urethra and was having pain. The patient was taken to the OR and a endoscopy and cystoscopy were performed with foreign body removal.

A nurse's notes dated 3/31/19 at 10:15AM identified the patient returned from the ED, the unit and sleeping area were checked for any items.

Special Observation orders dated 3/31/19 at 10:40AM directed two male staff were to observed the patient to prevent insertion of objects into genital area and the patient was to have hands visible at all times. additionally, the patient was to wear sweatpants, no underwear, if patient refuses, check pockets before the patient goes into bathroom and room search every shift for items the patient can ingest/insert.

Interview with the Program Director of 4/5/19 at 2PM stated that as of 3/26/19, the hospital added a second staff member to do environmental rounds for Patient # 17, ensuring that staff would check the environment for hazards prior to the patient entering the area. The Program Director further stated that staff did not follow the hospital policy for CO regarding watching the patient's hands, face and neck at all times since he/she was able to obtain pens.

Review of the clinical record with the Program Director on 4/5/19 at 2PM identified although there was on order for room searches every shift effective 3/26/19 at 4:20PM the clinical record noted the only documented room search was completed on 3/26/19 at 8PM. The Program Director stated that room searches are to be completed and documented each shift to ensure the patient does not have any objects he/she may use to insert in the urethra.