HospitalInspections.org

I. Based on review of a medical record, policies and associated documents, and staff interviews, the hospital's Administrative staff failed to:

1. Ensure 1 of 1 patient received care in a safe setting (Patient #1), and to have direct observation by staff member throughout hospitalization. Refer to A-0144.

2. Implement immediate action to ensure the safety of the IBH (Inpatient Behavioral Health) patients to prevent the reoccurrence of self hanging attempts.

The cumulative effect of these failures and deficient practices resulted in the hospital's inability to ensure patients in the IBH were continuously monitored, to prevent self harm, and receive care in a safe setting.

II. During the complaint investigation (61540-I), the surveyor identified an Immediate Jeopardy (IJ) situation, a situation that placed the patient at risk for harm, related to Condition of Participation, Patient Rights 42 CFR 482.13.

1. The Administrative staff, Chief Medical Officer, and Director of IBH failed to develop and implement a corrective action plan to ensure the immediate safety of IBH patients in B hall, following the unsuccessful self hanging attempt of Patient #1 on 7/16/16.

2. After the Administrative staff were informed of the IJ, the Administrative staff took action and put a corrective action plan in place and removed the Immediate Jeopardy prior to the exit date of the complaint investigation. A condition level deficiency remained for the Condition Patient Rights.

The corrective action plan included in summary:

The IBH policy, Patient Assessment was modified to include: Patients will be assessed for suicide risk upon admission and daily for a minimum of 5 days and then PRN (as needed) based on assessment of the patient.

The IBH policy, Safety/Equipment/Alarms, was modified to include: Safety Monitoring
Video Monitoring.
a. The video monitor for observing patients will be located at the nursing station.
b. The determination of the staff monitoring video activity will be determined by the charge nurse on every shift, is assigned in one hour increments and is documented on the shift assignment sheet.
c. The video monitor will be watched continuously 24 hours per day, 365 days per year.
d. The assigned staff member obtains relief for breaks and ensures direct hand-off before leaving to ensure there are no interruptions of continuous video monitoring.
e. Note - the area immediately adjacent to the hinge edge of the outer door (inside of room) for B hall rooms is an area of decreased visualization. If visualization of the patient is lost for any reason, a staff member is immediately requested to go to the area to physically check on the patient.
f. Patients, visitor, and staff will be informed that video monitoring is occurring.

Heavy, rip and roll-resistant blankets will be the only bed linens utilized in the B hallway. A count of towels and washcloths will be conducted and logged when handing out and then collecting used towels and washcloths. A maximum of two towels and one washcloth will be counted, logged in and out, and provided at each patient request.

Staffing for the IBH unit was increased by one staff member/shift over usual levels for acuity of patients to allow one person to be at the monitors at all times. Additionally, coverage for breaks is provided to ensure continuous monitoring occurs at all times. the charge nurse of each shift is responsible to ensure that breaks are able to be taken and are covered.

The perimeter of each patient room in the B hall was walked off and assessed as to the visibility of all areas of the room. An area approximately 1 foot wide by 1 foot deep next to the hinge side of the outer door (on the inside of the room) was found to have decreased visualization. Camera angles are not able to be changed without then creating additional/different areas of decreased visualization. Bids are actively in process for additional cameras. Until such time as these additional cameras are installed, the staff member watching the monitors has been instructed to immediately call the staff in the B hall to report to the room and check on the patient if the patient is noted to be entering the 1 x 1 foot areas not entirely visualized. Staff at the monitors and staff in the B hall have walkie talkies in hand for this communication.

Staff Education
IBH staff will be educated via written and face-to-face communication and competency completion by department supervisors on the above policy and process changes. Education will be completed with each staff member at the beginning of their next shift scheduled (Staff will not work on the floor until the education has been completed.)

Compliance monitoring
Chart audits will be conducted daily for 4 weeks by supervisors to ensure that suicide assessments and 15 minute checks are documented per policy. If 100% compliance at the end of 4 weeks, charts audits will be conducted weekly for 8 weeks. If 100% compliance at the end of 8 weeks, chart audits will conducted monthly on an ongoing basis. Results of the audits will be reported to the CNO (Chief Nursing Officer) weekly and then monthly, unless concerning trends are noted, in which case results will be reported immediately.
Observational audits will be conducted by supervisors every shift every day for 4 weeks to ensure that monitors are being watched continuously, that 15 minute checks are completed per policy, and that patients in the security (B) hall are using the tear and roll resistant bedding (once it arrives). If 100% compliance at the end of 4 weeks, observational audits will be conducted weekly for 8 weeks. If 100% compliance at the end of 8 weeks, observational audits will conducted monthly on an ongoing basis. Results of the audits will be reported to the CNO weekly and then monthly, unless concerning trends are noted, in which case results will be reported immediately.
The schedule will be audited daily for 4 weeks by supervisors to ensure that someone is continuously assigned in the role of monitor tech as well as to provide breaks to the monitor tech. If 100% compliance at the end of 4 weeks, audits will be conducted.
weekly for 8 weeks. If 100% compliance at the end of 8 weeks, audits will conducted monthly on an ongoing basis. Results of the audits will be reported to the CNO weekly and then monthly, unless concerning trends are noted, in which case results will be reported immediately.
Linen tracking logs used for the security hall will be audited daily for 4 weeks by supervisors to ensure that towels and washcloths have been tracked appropriately. If 100% compliance at the end of 4 weeks, audits will be conducted weekly for 8 weeks. If 100% compliance at the end of 8 weeks, audits will conducted monthly on an ongoing basis. Results of the audits will be reported to the CNO weekly and then monthly, unless concerning trends are noted, in which case results will be reported immediately.
Education and competency completion will be monitored via tracking logs on a daily basis by the IBH Director until all staff have completed the education. Results will reported to the CNO weekly until all staff have completed the education.
Results of compliance monitoring will be reported by the CNO to the medical staff, senior leaders, and governing body members at the Quality Council meetings each quarter.

The hospital submitted a Facility Investigation Report Form to the SA (State Agency) on 7/19/16, that explained the incident (7/16/16) and what took place with no major physical injury, to Patient #1, only some redness in the neck area. The investigation included interviews from staff involved and a root cause analysis with a plan of correction that included:
1. Obtain supply of different blankets designed to be unable to be ripped or rolled up. Trial use in patients admitted with suicide attempts or ideation.
2. Discuss with architect metal inner door modifications, if any possible-still need to be able to latch and lock door for seclusion, however.
3. Explore possibility of some type of pressure sensors on tops of doors that would alarm if something were hung over the top of them.
4. Explore options for assigning dedicated staff to watch monitors at all times.
5. Add more formal suicide assessment every day throughout entire stay for any patient who came in with suicide intent.
The plan of correction submitted with the Facility Investigation Report Form failed to identify what actions or corrections would be taken immediately to ensure patients were provided care in a safe setting. Refer to A-0144.

Based on observations, review Patient #1 medical record, policies, and documents the hospital failed to ensure Patient #1 received care in a safe setting when placed in B Hall (Seclusion/Quiet area) of IBH Unit(Inpatient Behavioral Health). B Hall has 5 patient beds, all beds were occupied at time of entrance.

Failure of the IBH staff to provide patient care in a safe setting resulted in 1 of 1 patients in B Hall to non-successfully attempt self hanging, with torn bed linens, provided by the hospital, on 7/16/16.

Findings include:

1. Patient #1 was brought into the ED (Emergency Department) by EMS (Emergency Medical System, ambulance) on 7/10/16, for suicide attempt by overdose. Patient #1 was last seen in the ED on 7/9/16, and could not contract for safety, was discharged to a crisis center, by cab. Patient #1 diverted the cab to his home. When things got bad at home he took 1 weeks worth of his medication, told his friends and returned to the ED on 7/10/16, for a drug overdose, suicide attempt.
Review of Patient #1 medical record revealed he was admitted on 7/10/16, to the ICU as a court committal. Patient #1 was transferred to Medical/Surgical unit on 7/11/16, with 1:1 observation, a sitter is in constant observation of his activities. On 7/12/16 Patient #1,was medically cleared and transferred to IBH and discharged on 7/22/16.
Patient #1 acuity level on admission to IBH was a level 4, an admission standard level of acuity. Level 4 definitions, according to policy titled Patient Observational Categories, reviewed on 1/16; staff must be aware of patient's whereabouts at all times with 15 minute documentation of whereabouts, and the patient may not leave the unit. Multiple entries into the nurses notes establish Patient #1 contracted for safety when he experienced depressed feelings, suicidal ideation's, or issues with self safety.
Nurses notes reveal on 7/16/16 at 12:23 PM, Patient #1 threw a roll from his lunch tray, he was upset since he did not get to fill out his menu. Five minutes later Patient #1 was found hitting the walls and windows in his room. Patient #1 was redirected to use coping skills. Five minutes later Patient #1, ran out of his room, hitting the walls, he tore the electrical fixture from the wall (Public Safety and Maintenance were notified). Patient #1 was asked to go to B hall (quiet/seclusion). Staff encouraged Patient #1 to enter B hall. B hall is a locked hall, within the IBH; it allows patients privacy, or seclusion to act out and not disrupt the milieu of the IBH. The patient rooms in B hall have 2 entry doors into the patient rooms. The door from B Hall is solid, that enters into a small area that contains the bathroom, this area is connected to the patient room with a windowed door. Patient #1 was placed in a camera monitored room in B hall with 15 minute checks. At 5:15 PM, Staff A, HCT (Health Care Technician), opened the first door of Patient #1 room and found Patient #1 with a piece of torn blanket knotted at both ends, around his neck. One knotted end between the closed windowed door and the frame and other end knotted into a noose and wrapped tightly around his neck. Patient #1 was trying to pull himself down toward the floor in order to asphyxiate himself, but his feet never left the ground and he never lost consciousness. Staff B, HCT; got Staff C, Primary Care RN (Registered Nurse) for Patient #1. Staff C and Staff D, Public Safety Officer attempted to remove the noose from Patient #1 neck, with Staff C opened the inner windowed door to release the knot. Patient #1 resisted the removal of the noose and finally removed the noose himself. Additional Public Safety officers arrived for show of force, and additional assistance if needed. Patient #1 entered his room and pulled the cabinet door off the wall and handed it to a Public Safety officer. Patient #1 was placed on 1:1 monitoring and placed in a paper gown. Patient #1 stated he "Did this because he could and it doesn't fucking matter why he did it." All linen except for 1 blanket was removed from Patient #1 room immediately after the incident.
Practitioner E, Psychiatrist,was notified at 5:35 PM, new medication orders were obtained along with orders for examination by a medical doctor. Practitioner F, Family Practice Resident, was notified and ordered a C-collar be applied until a physical exam could be completed. 7/16/16 at 6:30 PM, Practitioner F examined Patient #1, cervical collar was removed, no injuries noted and Patient #1 denied any complaints associated with the hanging attempt.

2. During an interview on 7/28/16 at 9:32 AM, with Staff A, HCT, per phone revealed he/she was assigned to 15 minute rounds in B hall at the time of the incident. At 5:15, the outside brown door was shut and I heard feet scuffling and metal clanging, I opened the door and saw Patient #1 between the 2 doors with a torn blanket over the second door (inner door with window), the door was closed, and the patient had a noose around his neck. I tried to talk him down, I shouted for help another HCT, RN, and Public Safety came. At 4:30 PM rounds Patient #1 was lying down asleep, at 5:00 PM Patient #1 refused dinner.

During an interview on 7/25/16 at 4:00 PM, with Staff B, HCT revealed he/she was working the day of the incident on B hall. I took Patient #1 dinner tray into the room, the patient was in bed with head covered, I tried to wake the patient, I left the tray, and went on to other patients. Staff A and myself heard something hitting and making an unusual noise, we opened the brown outer door and found Patient #1 with a blanket noose around his neck and trying to shut the inside windowed door. A blanket with a knot tied in the end was over the windowed door, the blanket was too thick, and the windowed door was unable to shut completely. Nurses came along with others and convinced Patient #1 to remove the noose. Public Safety was called, Patient #1 was threatening, got violent and ripped off a cabinet door inside of the room.

During an interview on 7/25/16 at 4:30 PM, with Staff C, Primary Care RN for Patient #1, revealed at 5:15 PM a HCT came to the nurses station and informed us that Patient #1 was trying to self hang, on the windowed door with a thick blanket that was torn and knotted at both ends, with one knot over the top of the windowed door. It some encouragement to get Patient #1 to remove the noose from neck.

During an interview on 7/27/16 at 9:46 AM, with Staff D, Public Safety Officer, revealed reporting to B hall of the IBH unit for the incident. Patient #1 had attempted self hanging with a torn blanket. After the incident Patient #1 slammed the brown door went into the room and ripped the cabinet door off of the wall.

During an interview on 7/27/16 at 2:00 PM, with Psychiatrist Practitioner I, who was covering for vacationing Psychiatrist Practitioner E, revealed Patient #1 was admitted due to an overdose suicide attempt, several past admits to IBH. Patient #1 was low functioning and acts out impulsively, and stated he wasn't trying to kill himself.

During an interview on 7/27/16 at 9:53 AM, with Practitioner F, Family Practice Resident, revealed being asked to medically evaluate Patient #1 after a self hanging attempt. I requested a C-collar be applied until I could exam the patient. At the time of the examination Patient #1 had no pain, was in no respiratory distress, and had no other complaints. I cleared the C-spine, there was no tenderness, some mild redness to the front of the neck, no bruising, and I removed the C-collar. Patient #1 was compliant answered yes and no questions.

3. Observations on 7/25/16 at 1:45 PM, during the initial tour of IBH with Staff G, Chief Nursing Officer, and Staff H, Director of Inpatient Behavioral Health revealed: There were
5 patient rooms in B hall, all patient rooms had 2 doors from the patient room to B hall. The outside door of each room provided direct exit to the hall, was solid and brown in color. The inner door was attached to the room, contained a window, was white in color. The area between the 2 doors contained the bathroom, and a small ante area. The doors lacked sensor monitors on the top edge. Camera monitors were mounted on the ceiling in back left corner. Bed linen, towels , wash cloths were in each patient room. Interview at this time with Staff G and H revealed that they had encouraged more active monitoring of patients by staff assigned to B hall and staff to be more mindful of camera monitors at the nursing station, and there was no monitoring of linens used by the patients. At this time there were no staff assigned to monitor the cameras in the nursing station.
Observation on 7/25/16 at 2:30 PM revealed no staff sitting at the camera monitors in the nursing station. A lap top computer was open with the screen obstructing the view of one monitor.

4. Review of the Patient Handbook, dated 6/11/15, page 8. Rights related to Safety
To receive care in a safe and secure setting. This handbook is presented to patients at admission to the hospital.

Review of the policy titled, Safety/Equipment/Alarms from IBH Nursing Governing Policies, dated 7/16, reads in part...F. Safe Patient Management 1. All patients admitted to the Inpatient Behavioral Health unit will be assessed by nursing staff upon admission and every shift for potential safety risks to the patient or others...All patients will have direct observation by staff members throughout the hospitalization. Camera monitoring is used as an additional safety measure. Safety rounds will consist of direct visualization a minimum of every 15 minutes. Patients may be directly visualized more often as determined by nursing assessment or provider recommendation.

Review of B Hall Safety Rounds, dated 7/16/16 from 5:00 PM to 11:15 PM , revealed Staff A, HCT, doing 15 minute rounding for B hall. Patient #1 at 3:30 PM to 4:45 PM was in his room asleep, at 5:00 PM to 5:30 PM he was in his room awake.



Refer to A- 0115 for further details.