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Based on interview, record review, and review of facility policies, it was determined the facility failed to provide one (1) of ten (10) sampled patients (Patient #1) care in a safe setting and supervision by a trained staff. Patient #1 was admitted to the facility with a history of self-harming behaviors such as attempts to ingest non-food items and placing items in her vaginal cavity. Prior to this admission, Patient #1 had threatened to burn her vagina and had put razors in her vagina. While on one to one (1:1) supervision, the patient was able to ingest a third (3rd) screw and place broken pieces of plastic into her vagina.
Refer to A-144

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure patients at risk for self-harm were properly and adequately supervised for one (1) of ten (10) sampled patients (Patient #1). Patient #1 had a history of self destructive behaviors, such as swallowing non-food items and placing items in her vagina.

The findings include:

Review of the One to One (1:1) supervision policy, with a revision date of 02/14, revealed Patients placed by a physician's order on 1:1 supervision are monitored constantly to provide them safety and security. All patients on 1:1 supervision must be observed on a one to one (1:1) staff to patient basis at all times. This included accompanying the patient to the bathroom, shower room or bedroom. Staff will be able to view the patient at all times. Staff will be approximately three (3) feet from the patient unless otherwise specified by the physician/nurse practitioner.

Review of the Close Observation supervision policy, with a revision date of 07/08, revealed patients placed on close observation by a physician's order are monitored by staff every fifteen (15) minutes to provide a safe and secure environment.

Review of Patient #1's clinical record revealed she was admitted on 11/23/14 on a seventy-two (72) hour court order, with diagnoses which included Schizoaffective Disorder, Bipolar type, Borderline Personality Disorder, Hiatal Hernia and Chronic Nausea and Vomiting, no etiology. Further review revealed this was Patient #1's fourteenth (14th) admission to the hospital. Review of a physician's progress note, dated 11/24/14, revealed Patient #1 had a longstanding history of swallowing foreign bodies as well as putting foreign bodies in her vagina. Per the same progress note on admission, the physician removed a cigarette lighter and three (3) large balls of toilet paper from Patient #1's vagina.

Review of Patient #1's Physician Progress Note, dated 01/12/15, revealed Patient #1 had a one (1) by one (1) inch triangle shaped plastic shard, a two (2) inch by one (1) inch triangle shaped plastic shard, three (3) one (1) by three (3) centimeters (cm) plastic shards and a spring, one (1) inch long and one (1) cm diameter removed from the vagina. Patient #1 had been on close observation and was put on 1:1 supervision until 01/13/15.

Review of Patient #1's Interdisciplinary Progress Note, dated 01/14/15, revealed Patient #1 was sent to a local emergency department for ingesting contents of an ink pen. Review of the Interdisciplinary Progress note, dated 01/15/15, revealed there was no change to the treatment plan.

Review of Patient #1's Interdisciplinary Progress note, dated 01/15/15, revealed Patient #1 reported to staff that there was plastic in her vagina, but later came back and gave the plastic to the staff. Patient #1 was ordered to be on 1:1 supervision when in the bathroom and shower.

Review of Patient #1's Treatment Plan, dated 01/20/15, revealed Patient #1 told the team the only thing that would help was cutting her vagina off and once that happened she would no longer have nightmares, then stated she will cut it off. Patient #1 continued on close observation with 1:1 supervision when in the bathroom and shower, until 01/21/15, when she reported the ingested screws.

Review of Patient #1's Physician's Progress Note, dated 01/21/15, revealed Patient #1 reported to the staff she had ingested two (2) screws, which was verified by an abdominal x-ray. Patient #1 was ordered to be on 1:1 supervision.

Review of Patient #1's Physician's Progress Note, dated 01/23/15, revealed the repeat abdominal x-ray revealed a third (3rd) screw had been ingested. Patient #1 had been on 1:1 supervision.

Review of Patient #1's Interdisciplinary Progress Note, dated 01/28/15, while on 1:1 supervision, revealed Patient #1 went into the bathroom, obtained a piece of plastic and inserted it into her vagina.

Interview with Risk Manager #1, on 01/30/15 at 11:40 AM, revealed when Patient #1 had made it known to the staff, on 01/21/15, that she had ingested the two (2) screws, the investigation had been a Class ll in-house investigation. However, on 01/23/15, when it was discovered she had swallowed another screw, the investigation was then increased to a Class lll investigation due to failure of the 1:1 supervision. Risk Manager #1 stated the two (2) screws ingested were two and three fourths (2 ?) inches in length with blunt heads and the third (3rd) screw was one and a half (1 ?) inches long and pointed.

Interview with Patient Aide (PA) #1, on 01/30/15 at 1:45 PM, revealed she had supervised Patient #1 after she had reported she had ingested the screws. She stated she had followed all the rules for monitoring a patient on 1:1 supervision. PA #1 stated when monitoring the patient, the patient was to be no farther than three (3) feet away, and staff must have eye contact with the patient at all times and the head, neck, and hands must be seen at all times even when sleeping. PA #1 stated the staff monitor in one (1) hour intervals. She stated for Patient #1 to swallow another screw while on 1:1 supervision; apparently, someone was not paying attention.

Interview with PA #3, on 02/03/15 at 1:00 PM, revealed she had been one of the PA's assigned to supervise Patient #1 during the time Patient #1 had ingested the third (3rd) screw. PA #3 stated she did not see Patient #1 swallow anything or pick up anything. PA #3 stated when supervising, staff could be no further than ten (10) feet away from the patient. She stated while she was on one to one (1:1) with Patient #1, either they were in the television room or Patient #1 was asleep. PA #3 stated she was also supervising Patient #1 on 01/28/15, when Patient #1 had put the plastic pieces in her vagina. She stated when she took over at 5:30 PM, Patient #1 was screaming, and stated Patient #1 then walked to the shower room, climbed on a bench, pushed a ceiling tile away, pulled something out, and while walking put something in her vagina. PA #3 stated she then went to the door and yelled for help.

Interview with PA #4, on 02/03/15 at 12:45 PM, revealed she had heard PA #3 yell for help and she had gone into the shower room and noticed Patient #1 kneeling in the shower. She stated the nurses came in and called a code because the patient wanted to fight. PA #3 stated a piece of hard plastic with rugged edges was removed by staff from Patient #1's vagina.

Interview with Registered Nurse (RN) #3, on 01/30/15 at 3:55 PM, revealed she had worked 01/28/15 when Patient #1 had put the plastic in her vagina. She stated she responded to a code and Patient #1 was standing on a bench with her pants up. She stated she asked Patient #1 what happened and Patient #1 had stated she had put plastic in her vagina. RN #3 stated after Patient #1 had calmed down, she had performed the vaginal exam. RN #3 stated there was a plastic piece eleven (11) by three (3) cms protruding from Patient #1's vagina. She stated Patient #1 had complained of pain during the removal of the item. RN #1 stated Patient #1 had broken a light cover about three (3) weeks ago and had hidden it in the ceiling.

Observation of Patient #1, on 02/03/15 at 4:35 PM, revealed she was lying on a wooden bench on one side of the hallway, with PA #5 sitting on a chair on the other side of the hall. Further observation of Patient #1 revealed a large raised area on the back of the right hand.

Interview with RN #3, on 02/03/15 at 4:45 PM, revealed Patient #1 had met with the treatment team that morning and she was upset, and at 2:05 PM had started to hit her hand against the wall. RN #3 stated Patient #1 could move the hand; and there was no order for an x-ray at this time.

Interview with PA #5, on 02/04/15 at 10:46 AM, revealed she had been one (1) of the staff members to monitor Patient #1 during the period of time when she ingested the third (3rd) screw. She stated Patient #1 paced a lot when on 1:1 supervision because she does not like it and it makes her agitated. She stated she did not know how many feet away the staff could be from the patient when monitoring 1:1, but stated you are supposed to be up on them.

Interview with RN #4, on 02/03/15 at 3:15 PM, revealed she was the Continuity of Care nurse, who is the nurse who develops the treatment plans. She stated there were interventions ordered in an attempt to keep Patient #1 safe. She stated, that on 01/09/15, when Patient #1 put the plastic pieces in her vagina she had been on close observation, and was then put on 1:1 supervision until 01/13/15 when she was ordered back on close observation. She stated, that on 01/12/15, the physician ordered Patient #1's room be searched every shift. She also stated, that on 01/14/15, when Patient #1 ingested contents of the ink pen, Patient #1 was on close observation and there had been no change to the treatment plan. She stated Patient #1 had a long history of ingesting foreign objects, and she stated she does not know what else they could have done. She stated Patient #1 was restricted from so much in an attempt to keep her safe.

During the Interview with the Director of Nursing (DON), on 02/04/15 at 2:15 PM, she stated the Nurse Practitioner, as well as the physician, had been very involved in Patient #1's care. She stated there were numerous safety measures in place, from the least restrictive and has progressed over time to more restrictive as things happened. The DON stated the staff was trained on 1:1 supervision annually.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure the delivery of nursing services to one (1) of ten (10) sampled patients (Patient #1). Patient #1 was admitted to the hospital exhibiting self-harming behaviors such as attempts to ingest non-food items and placing foreign objects in her vagina. While on one to one (1:1) supervision, Patient #1 was able to continue to place sharp objects in her vagina and ingest non-food items.

Refer to A-395

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure one (1) of ten (10) sampled patients (Patient #1) at risk for self-harm was properly and adequately supervised. Patient #1 while on Close Observation and One to One (1:1) supervision continued to obtain objects to ingest and place in her vagina.

The findings include:

Review of the One to One (1:1) supervision policy, with a revision date of 02/14, revealed Patients placed by a physician's order on 1:1 supervision are monitored constantly to provide them safety and security. All patients on 1:1 supervision must be observed on a one to one (1:1) staff to patient basis at all times. This included accompanying the patient to the bathroom, shower room or bedroom. Staff will be able to view the patient at all times. Staff will be approximately three (3) feet from the patient unless otherwise specified by the physician/nurse practitioner.

Review of the Close Observation supervision policy, with a revision date of 07/08, revealed patients placed on close observation by a physician's order are monitored by staff every fifteen (15) minutes to provide a safe and secure environment.

Review of the Twenty-Four Hour (24) Patient Monitoring policy, with a revision date of 01/13, revealed Patient safety and health will be maintained by the provision of twenty-four (24) hour nursing supervision on every shift.

Review of Patient #1's clinical record revealed he/she was admitted on 11/23/14 on a seventy-two (72) hour court order, with diagnoses which included Schizoaffective Disorder, Bipolar type, Borderline Personality Disorder, Hiatal Hernia and Chronic Nausea and Vomiting, no etiology. Further review revealed this was Patient #1's fourteenth (14th) admission to the hospital. Review of a Physician's Progress Note, dated 11/24/14, revealed Patient #1 had a longstanding history of swallowing foreign bodies as well as putting foreign bodies in her vagina. Per the same progress note, on admission, the physician removed a cigarette lighter and three (3) large balls of toilet paper from Patient #1's vagina. Prior to this admission Patient #1 had put razors in her vagina.

Review of Patient #1's Physician Progress Note, dated 01/12/15, revealed Patient #1 had a one (1) by one (1) inch triangle shaped plastic shard, a two (2) inch by one (1) inch triangle shaped plastic shard, three (3) one (1) by three (3) centimeter (cm) plastic shards and a spring, one (1) inch long and one (1) cm in diameter removed from the vagina. Patient #1 had been on close observation and was put on 1:1 supervision until 01/13/15. A room search every shift was ordered on 01/12/15.

Review of Patient #1's Interdisciplinary Progress note, dated 01/14/15, revealed Patient #1 was sent to a local hospital emergency department for ingesting contents of an ink pen. Review of the Interdisciplinary Progress note, dated 01/15/15, revealed there was no change to the treatment plan.

Review of Patient #1's Interdisciplinary Progress note, dated 01/15/15, revealed Patient #1 reported to staff that there was plastic in her vagina, but later came back and gave the plastic to the staff. Patient #1 was ordered to be on 1:1 supervision when in the bathroom and shower.

Review of Patient #1's Physician's Progress note, dated 01/21/15, revealed, on 01/21/15, Patient #1 reported to the staff, that on 01/14/15, she had ingested two (2) screws, and the presence of the screws was verified by an abdominal x-ray. Patient #1 was ordered to be on 1:1 supervision.

Review of Patient #1's Physician's Progress note, dated 01/23/15, revealed Patient #1's repeat abdominal x-ray revealed a third (3rd) screw had been ingested. Patient #1 had been on 1:1 supervision from the time the x-ray revealed the two (2) screws on 01/21/15, until the third (3rd) screw was seen.

Review of Patient #1's Interdisciplinary Progress Note, dated 01/28/15, revealed while on 1:1 supervision, Patient #1 went into the bathroom, obtained a piece of plastic and then inserted it into her vagina.

Review of Patient #1's Treatment Plan, dated 01/20/15, revealed Patient #1 told the treatment team the only thing that would help was cutting her vagina off and once that happened she would no longer have nightmares, then she stated she will cut it off. Per a Physician's order, Patient #1 continued on close observation, until 01/21/15, when she reported the ingested screws.

Interview with Risk Manager #1, on 01/30/15 at 11:40 AM, revealed when Patient #1 had made it known to the staff on 01/21/15 that she had ingested the two (2) screws, the investigation had been a Class ll in-house investigation. However, on 01/23/15, when it was discovered she had swallowed another screw, the investigation was then increased to a Class lll investigation due to failure of the 1:1 supervision. Risk Manager #1 stated the two (2) screws ingested were two and three fourths (2 ?) inches in length with blunt heads and the third (3rd) screw was one and a half (1 ?) inches long and pointed.

Interview with Patient Aide (PA) #1, on 01/30/15 at 1:45 PM, revealed she had supervised Patient #1 after she had reported she had ingested the two (2) screws. PA #1 stated she had followed all the rules for monitoring a patient on 1:1 supervision. She stated when monitoring the patient, the patient was to be no farther than three (3) feet away, and staff must have eye contact with the patient at all times and the head, neck, and hands must be seen at all times even when sleeping. PA #1 stated the staff monitor in one-hour intervals. She stated for Patient #1 to swallow another screw while on 1:1 supervision; apparently, someone was not paying attention.

Interview with PA #3, on 02/03/15 at 1:00 PM, revealed she had been one of the PA's assigned to supervise Patient #1 during the time Patient #1 had ingested the third (3rd) screw. PA #3 stated she did not see Patient #1 swallow anything or pick up anything. PA #3 stated when supervising, staff could be no further than ten (10) feet away from the patient. She stated while she was on one to one (1:1) with Patient #1, either they were in the television room or Patient #1 was asleep. PA #3 stated she was also supervising Patient #1 on 01/28/15 when Patient #1 had put the plastic pieces in her vagina. She stated when she took over at 5:30 PM, Patient #1 was screaming, and Patient #1 then walked to the shower room, climbed on a bench, pushed a ceiling tile away, pulled something out, and while walking put something in her vagina. PA #3 stated she then went to the door and yelled for help.

Interview with PA #4, on 02/03/15 at 12:45 PM, revealed she had heard PA #3 yell for help and she had gone into the shower room and noticed Patient #1 kneeling in the shower. She stated the nurses came in and called a code because the patient wanted to fight. PA #3 stated a piece of hard plastic with rugged edges was removed from Patient #1's vagina.

Interview with Registered Nurse (RN) #3, on 01/30/15 at 3:55 PM, revealed she had worked 01/28/15 when Patient #1 had put the plastic in her vagina. She stated she responded to a code and Patient #1 was standing on a bench with her pants up. She stated she asked Patient #1 what happened and Patient #1 had stated she had put plastic in her vagina. RN #3 stated after Patient #1 had calmed down she had performed the vaginal exam, she stated there was a plastic piece eleven (11) by three (3) centimeters protruding from Patient #1's vagina. She stated Patient #1 had complained of pain during the removal of the item. RN #1 stated Resident #1 had broken a light cover about three (3) weeks ago and had hidden it in the ceiling.

Observation of Patient #1, on 02/03/15 at 4:35 PM, revealed she was lying on a wooden bench on one side of the hallway, with PA #5 sitting on a chair on the other side of the hall. Further observation of Patient #1 revealed a large raised area on the back of the right hand.

Interview with RN #3, on 02/03/15 at 4:45 PM, revealed Patient #1 had met with the treatment team that morning and she was upset, and at 2:05 PM had started to hit her hand against the wall. RN #3 stated Patient #1 could move the hand; however, there was no order for an x-ray at this time.

Interview with PA #5, on 02/04/15 at 10:46 AM, revealed she had been one (1) of the staff members to monitor Patient #1 during the period of time when she ingested the third (3rd) screw. She stated Patient #1 paced a lot when on 1:1 supervision because she does not like it and it makes her agitated. She stated she did not know how many feet away the staff could be from the patient when monitoring 1:1, but stated you are supposed to be up on them.

Interview with RN #4, on 02/03/15 at 3:15 PM, revealed she was the Continuity of Care nurse, who is the nurse who develops the treatment plans. She stated interventions were ordered in an attempt to keep Patient #1 safe. She stated, that on 01/09/15, when Patient #1 put the plastic pieces in her vagina, she had been on close observation and was then put on 1:1 supervision, until 01/13/15, when she was ordered back on close observation. She stated, that on 01/12/15, the physician ordered Patient #1's room be searched every shift. She also stated, that on 01/14/15, when Patient #1 ingested contents of the ink pen, Patient #1 was on close observation and there had been no change to the treatment plan. RN #4 stated Patient #1 had a long history of ingesting foreign objects, and she stated she does not know what else they could have done. She stated Patient #1 was restricted from so much in an attempt to keep her safe.

During the Interview with the Director of Nursing (DON), on 02/04/15 at 2:15 PM, she stated the Nurse Practitioner, as well as the physician, had been very involved in Patient #1's care. She stated there were numerous safety measures in place, from the least restrictive and has progressed over time to more restrictive interventions. The DON stated room checks are on the assignment sheet to be done, and if no contraband was found, there might not be any documentation that the room check was completed. The DON stated Patient #1 had no history of aggression and, on 01/28/15, when Patient #1 inserted the piece of plastic in her vagina, there had been no reason to think Patient #1 would push the staff member away in an effort to retrieve the plastic and insert into her vagina. The DON stated the staff was trained on 1:1 supervision annually.