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Based on medical record review and staff interviews the hospital failed to promote the rights of one of fifteen patients (patient #1) whose medical records were reviewed, when they failed to provide a safe environment for patient #1. This failure places the condition of participation related to Patient Rights out of compliance.

See documentation at tag A144.

Based on interviews and documentation review, the facility failed to provide patient #1 with care in a safe setting to protect her from her own behavior while on the psychiatric unit. On two separate occasions she was able to obtain and swallow foreign objects, including batteries, staples (from a magazine binding), and game pieces, while on 1:1 supervision. Findings include:

Although the facility was aware that patient #1 was having behaviors of swallowing foreign objects while in the hospital, on 6/13/2010 patient #1 was able to obtain and swallow staples from a magazine binding and monopoly pieces while receiving 1:1 supervision. In addition, on 6/16/2010 she was able to obtain, remove, and swallow two batteries out of a remote control while on 1:1 supervision.

Patient #1 was admitted to the psychiatric unit on 6/4/2010 with diagnoses including schizoaffective disorder and borderline personality disorder. The patient was noted to have increased agitation and suicidal behaviors. While in the hospital she had behaviors including swallowing foreign objects. She received on-going interventions, including but not limited to, intermittent 1:1 supervision for safety, individual and group therapy, psychiatric medication adjustments, gastrointestinal medication interventions, and an upper gastrointestinal endoscopy (a procedure that uses a lighted, flexible endoscope to see inside the upper GI tract) to remove the foreign objects. In addition, all of her bowel movements were monitored by staff, her care was regularly reviewed and evaluated by the interdisciplinarily team, including physicians, psychiatrists, and nurses, and she received consultations from gastroenterology, Path Lab, and toxicology.

According to interviews with employees (C)/nurse on 9/2/2010 at 12:30 p.m. and (D)/Psychiatric Nursing Assistant on 9/2/2010 at 1:00 p.m. and documentation review, on 6/13/2010 during the day shift patient #1 was calm, pleasant, and cooperative with her medications and group therapy. She was on 1:1 supervision due to swallowing two batteries on 6/9/2010. The patient reported to staff that she was feeling better and not having impulses to swallow foreign objects. Employee (C) indicated that after a long discussion with patient #1 regarding her safety, she placed patient #1 on a "loose 1:1," as the patient's goal was to be off of 1:1 supervision on 6/14/2010. Employee (D) was the assigned staff for the 1:1 supervision and was instructed by employee (C) to do a "loose 1:1" and keep the patient in his line of sight, but was not required to have her within arms reach. A short time later, the patient reported that she swallowed 2 staples from the binding of a magazine and three monopoly pieces. Employee (D) indicated that she was out of sight for approximately 5 to 10 seconds when she walked around a corner. Employee (C) indicated that after the incident, she was instructed by employee (E)/administrative nurse that she did not follow hospital policy for 1:1 supervision as ordered by a physician and that there was no such thing as a "loose 1:1." She received an official written reprimand in relation to the incident. Employee (C) was interviewed on 9/2/2010 at 2:16 p.m. and indicated that the 1:1 supervision policy was not followed and there is no such thing as a "loose 1:1." She indicated that after that incident, the psychiatric staff were re-educated on 1:1 supervision policies and procedures.

On 6/16/2010 at approximately 10:00 a.m. the patient was noted to be calm and controlled sitting in the TV room with her assigned 1:1 staff. According to interviews and documentation review, a short time later, she suddenly ran and grabbed a remote from another patient, ran into the shower room, shut the door, removed the batteries, and swallowed them. The patient was immediately seen by gastroenterology. Employee (C) indicated that she was unsure how the remote control was out in the common area, as it had been kept behind the nursing station after patient #1's previous incident.