HospitalInspections.org

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ITEM #1 SECURITY PROCEDURES AND IDENTIFICATION OF HAZARDS

Based on observations, review of manufacturer's instructions for use, and review of hospital policy and procedures, hospital staff members failed to follow manufacturer's instructions when using the hand held metal detector.

Failure to ensure that staff are trained and skill competency verified to operate the hand-held metal detector correctly puts patients, staff, and visitors at risk for contraband and other dangerous hazards entering the facility posing a serious threat which may result in injury or death.

Reference: Garrett Metal Detector Super Scanner User Manual.

Findings:

1. The hospital's policy and procedure titled "Wanding - Use of Hand-Held Metal Detector Wand" (Reviewed/2017) stated in part, "All patients will be wanded prior to or immediately upon arriving on an inpatient unit". The section titled "Procedure" read in part: "Staff should not allow the scanee to influence them as to what is actually causing an alarm. For instance, if the detector denotes the presence of a suspicious item under a shirt sleeve, do not fail to completely investigate the source of the alarm even though the scannee assures you that [it] is just his/her watch." Page 4 of the hospital policy illustrates the proper technique and procedure to use when operating the wand; wanding from the front to the back and ending with the underfoot of the individual.

The user manual for the Garrett Metal Detector Super Scanner under the section titled "Components/Function" (pp 5-6) read in part: "Interface Elimination Button- The detector is factory set for maximum sensitivity to detect the smallest of items. The high level of sensitivity may produce alarms when approaching a floor containing rebar. Press and hold this button to decrease sensitivity to a level that does not respond to the rebar. Release button and detector returns to normal sensitivity."

2. On 3/7/2017 between 8:00 PM and 8:28 PM, Surveyor #1 requested a certified nurse's aide (CNA) (Staff Member #2) to demonstrate the use of the hand-held metal detector. During the observation, the CNA turned the metal detector on and the metal detector appeared to be malfunctioning with the surveyor noting that all LED lights were flashing on and off. Staff Member #2 pushed a button on the side of the metal detector and the flashing LED lights shut off except for a single green light. The CNA then proceeded to scan the surveyor while continuously holding (depressing) the side button.

Staff Member #2 acknowledged in a follow-up interview with Surveyor #1 that he/she was unaware of the side button's function or purpose.

3. On 3/8/2017 at 9:00 AM, Surveyor #1 interviewed the Director of Intake Personnel (Staff Member #4) about the use of hand-held metal detectors and training of personnel. S/he confirmed the metal detector used on 3/7/2017 by Staff Member #2 had malfunctioned and the battery had been replaced. The hospital did not have a system in place to check the battery status of the hospital's eight metal detectors.

4. On 3/10/2017 between 11:00 AM and 11:45 AM, Surveyor #1 observed an Intake Personnel staff member (Staff Member #3) demonstrate the use of the hand-held metal detector wand. During the observation, Staff Member #3 pushed the side button (interference elimination button) and proceeded to wand the front of the patient. The metal detector beeped and a red light flashed when the wand was located near the patient's feet. Staff Member #3 asked the patient (Patient #5) if they had anything in his/her socks. Patient #5 stated "no". Staff Member #3 continued the wanding procedure to include both sides of the patient (left and right). Staff Member #3 did not wand the backside (posterior aspect) of the patient as required by hospital policy. The staff member failed to wand the underside of the patient's feet or investigate further the source of the beeping as required by hospital policy.

5. On 3/10/2017 at 2:30 PM, Surveyor #1 reviewed eight medical records and the "Intake to Nursing Communication Hand-Off" forms and noted the following:

a. Four of eight records reviewed were not marked "Yes" or "No" to document and confirm the patient had been wanded.

b. One of eight records reviewed was marked "No" reflecting that the patient had not been wanded.

c. Three of the eight records reviewed were marked "Yes" indicating the patient had been wanded on admission. Upon further review, the surveyor found:

1. Patient #3 had a metal "X-Acto: blade" found after the patient had done harm to self by cutting themselves. The record indicated the patient acknowledged hiding the metal blade in his/her sock.

2. Patient #6 had a cellular phone found during the skin/clothing check by the nursing staff upon arrival on the unit.

3. Patient #7 had a cellular phone discovered on the day of discharge after a five day hospital stay.

ITEM #2 LINE OF SIGHT MONITORING

Based on record review and review of hospital policy and procedures, the hospital failed to ensure that patients on "Line of Sight" (LOS) observation were kept safe from self-harm or injury from other patients.

Failure to protect patients from self-harm and harm by other patients may lead to serious injury or death.

Findings:

1. The hospital's policy and procedure titled, "Patient Observation"(Policy # PC.P.300; Reviewed 1/2017) stated in part, ". . .III. Levels of Observation. . . B. Line of Sight. The patient will be kept within eyesight and accessible at all times, day and night. Tools or instruments that could be used to harm themselves or others should be removed. This level of observation is required when the patient could, at any time, make an attempt to harm themselves or others. Positive engagement with the patient is an essential aspect of this level of observation."

The hospital policy and procedure titled, "Patient Rights and Responsibilities" (Policy # ADM.P.300; Reviewed 1/2017) stated in part: ". . . Procedure . . . B. The list of patient rights shall include but are not limited to the following: . . . 5. The right to receive care in a safe setting."

2. Patient #3 was an 18 year-old admitted on 2/24/2017 for treatment of depression with suicidal ideation. The patient received a score of 40 on the Suicide Assessment scale which was completed on admission. A review of the overall risk level scoring tool indicated that medium risk is classified as a score between 25 and 41. Other than the routine every 15 minute checks that are completed for all patients on the unit, no special observation status was assigned until after the physician had examined the patient on the following day (2/25/2017) after which the patient was placed on line of sight (LOS).

3. On 2/27/2017 at 10:00 PM, a Registered Nurse (RN) (Staff Member #7) entered a note into the patient's medical record stating that the RN had examined the patient and found multiple cuts on her/his left wrist and arm. The RN notified the patient's physician. A telephone order documented by the RN on 2/27/2017 at 9:30 PM stated that the patient was on LOS observation status and that the patient was responsible for remaining in LOS of assigned staff. The patient's physician had ordered LOS observation status earlier in the day at 2:25 PM as well. The RN phone call to the physician about her/his concerns related to the patient's self-harm did not result in an order for increased monitoring of the patient.

4. Review of a physician (Staff Member #9) note dated 3/2/2017 at 1:00 PM showed the physician assessed the patient to have an increased suicide risk. The physician ordered increased staff monitoring of the patient. The physician's order dated 3/2/2017 at 10:45 AM stated "LOS Q [every] 5-minute checks for 24 hours."

5. According to documentation, on 3/2/2017 around 10:00 PM, a licensed nurse (Staff Member #8) found that Patient #3 was bleeding in the area of her/his left hand/wrist area. The patient was noted to be sitting on the floor with a blanket covering her/his arm. Initially, Patient #3 stated she/he cut themselves using a pencil. After further questioning, it was discovered that the patient had used a metal blade [X-Acto blade]. The patient reported that she/he kept the blade hidden in her/his sock.

6. Review of documentation dated 3/2/2017 at 11:00 PM, following the blade cutting incident, revealed that staff felt the patient should have been in 1:1 observation status because while the patient was in LOS of staff and on every 5 minute checks the incident still occurred.

7. An interview with a RN (Staff Member #7) on 3/8/2017 at 3:20 PM with Surveyor #2 showed that she/he felt that Patient #3 should have been on 1:1 observation status as the patient had a history of grabbing pencils and using them to harm herself/himself even though she/he was on LOS observation status. Staff Member #7 also reported that Patient #3 harmed themself with a metal blade while on LOS observation status with every 5 minute checks.

8. An interview with the Director of the Adult Psychiatric Unit (Staff Member #10) on 3/9/2017 at 10:40 AM confirmed the incident related to Patient #3. Staff Member #10 revealed that she/he was unsure how Patient #3 came to be in possession of such a dangerous object. Staff Member #10 stated that Patient #3 told staff that she/he brought the blade from home.

9. On 3/09/2017 at 10:00 AM, Surveyor #4 reviewed the inpatient record of Patient #4. S/he was admitted on 2/13/2017 due to concerns that the patient might harm themselves. Patient #4 was initially placed on 1:1 observation from 2/13/2017 to 2/18/2017, and then was placed on LOS observation for safety. The patient remained on LOS observation until 3/8/2017. An entry in the medical record by a registered nurse (Staff Member #5) dated 3/7/2017 at 5:37 PM documented "Pt. A&O (alert and oriented) x3. Mood is anxious and restless. Pacing about unit. Approached nurse with blood streaming down R (right) forearm from self-inflicted injury." The self-harm injury sustained by Patient #4 occurred while the patient was ordered for LOS. No other documentation in the medical record was found to indicate the hospital staff attempted to stop the patient from harming themselves prior to the patient presenting themselves to the nursing staff.

10. On 3/9/2017 at 9:15 AM, Surveyor #3 reviewed the medical records of three patients who were involved in a total of eight patient on patient assault incidents of which five occurred while on LOS monitoring. The surveyor noted the following:

a. On 2/25/2017 at 6:15 AM, Patient #8 while on LOS monitoring was noted in the record to be "exiting seeking, frequently trying to open doors . . .Pt [patient] is observed wandering into peers bedroom & taking their belongs. Staff stated that pt. was observed punching a much larger peer who assaulted him back. Staff was able to break up the argument & redirect pt's to different locations."

b. On 2/11/2017 at 9:45 PM, Patient #2 while on LOS monitoring was noted in the record as "Patient threw a punch and knocked . . . patient to the ground . . .Police officers arrived in unit [to] investigate the case. . .Patient medicated PRN [as needed] meds. Remain in room for a while until the second patient transferred for safety".

11. On 3/7/2017 at 9:15 AM, Surveyor #3 interviewed a registered nurse (Staff Member #6) about the different levels of observation and the difference between them. The nurse indicated that LOS is similar to the 15 minute checks with the entire staff and no one person responsible for the monitoring. Staff Member #6 acknowledged that only when a patient is ordered for 1:1 monitoring is a specific individual assigned to monitor the patient.

12. An interview with the Director of Quality and Risk (Staff Member #11) with Surveyor #2 revealed that the facility was not collecting data on the use and effectiveness of levels of observation (i.e. LOS, 1:1) of patients. He/she also stated that there were no current improvement projects concerning LOS and 1:1 patient monitoring.
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