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Based on record review, and review of the hospital policy entitled "Patient Safety Observation Frequency", it was determined that the hospital failed to ensure that the nursing care plan was implemented related to safety and in accordance with hospital policy, for relevant sample patient ID #13.

Findings are as follows:

A review of the hospital policy entitled "Patient Safety Observation Frequency" under "Explanation of the different categories of observation" states:

Under b) Level ITU (Intensive Treatment Unit), bullet 4: "A staff member keeps the patient(s) within his or her visual field at all times."

A review of the clinical record for patient ID # 13 revealed a psychiatric admission on 1/31/11. The patient was placed on every 5 minute observation checks. The "Mental Health Unit Treatment Plan" identified a "Psychosis" problem with hallucinations, and nursing interventions included "Maintain safe milieu by performing safety checks as ordered". The patient was transferred to the ITU on 2/1/11 after irritable, anxious, and agitated behavior, with intrusiveness towards staff and other patients. A Mental Health Worker (MHW) was assigned to observe this patient in the ITU, as well as another psychiatric patient per hospital policy. Although the 5 minute observation checks were done as ordered for the patient, at approximately 7:30 PM on 2/1/11 the patient was able to climb out a window in the ITU lounge, resulting in injury. It was determined that the MHW did not keep the patient within his/her visual field at all times while in the ITU per the hospital policy, resulting in an unsafe milieu.

Based on surveyor observations, record review, and staff interviews, it was determined that the hospital failed to ensure that the physical condition of the psychiatric unit was maintained in a manner to assure the safety and well being of patients.

Findings are as follows:

Clinical record review for patient ID # 13 revealed an admission to the hospital on 1/31/11 under emergency certification for delusional and disorganized behavior. The patient has a history of multiple psychiatric hospitalizations. The "Diagnostic Impression" was "schizoaffective disorder, bipolar type, most recently hypomanic, cocaine dependence in partial remission". The goal of treatment was "stabilization of delusional and hypomanic symptoms, with establishment of compliance and outpatient care in the community".

The patient was admitted to the general psychiatric unit, and placed on every 5 minute observation status. He was refusing medications, and was noted to be "isolated to his room". On 2/1/11, the patient was noted to be anxious and agitated. He was "intrusively responding to internal stimuli by touching staff and other patients on the unit". The Psychiatrist was notified, and at 1920 an order was received for Haldol and Ativan po (by mouth). This medication was documented by the nurse as administered in the MAR (Medication Administration Record) at 1930.

A nursing note revealed that "barely 2 minutes after the medications were administered the patient slipped open one of the ITU (Intensive Treatment Unit) tv (television) lounge windows and jumped out." The patient fell approximately 10 feet to the ground, and was taken to the Emergency Department with diffuse tenderness of the left ankle. An X-ray revealed a comminuted fracture of the left calcaneus. He was transferred to Rhode Island Hospital for further treatment at 2200.

During an interview on 2/3/11 at approximately 8:45 AM with the Chief of Medicine, it was reported that the patient had been nonviolent and not suicidal. Because this patient's behavior had been escalating on the general psychiatric unit, he had been moved to the ITU on 2/1/11. The last 5 minute observation check had been documented at 7:25 PM, with the patient noted to be in the ITU lounge. The patient went out the ITU lounge window at approximately 7:30 PM. The ITU Mental Health Worker (MHW) who had been assigned to keep this patient within his/her visual field at all times, was also assigned to another ITU patient for observation per the ITU protocol. When the patient had been in a "blind spot" at the end of the ITU lounge and proceeded out the window, the MHW heard a "noise" and witnessed the patient climbing out the window.

During an interview on 2/4/11 at approximately 11:00 AM with the Facilities Manager/Safety Officer, he reported that during a State Fire Marshall inspection at the hospital in December of 2010, an old smoking booth no longer in use in the ITU lounge was cited for "no smoke alarm". The hospital decided to remove this booth. A maintenance worker removed the walls and doors to this booth on 12/16/10, and then alleged that an inspection of the area had been done after completion of the work. It had been reported by the worker after the occurrence that there were no safety issues identified, which included the checking of windows that had been enclosed by the booth. However, the safety inspection had not been documented by the worker after completion of the work.

During a tour of the psychiatric unit on 2/3/11 at 1:45 PM with the Risk Manager and Psychiatric Clinical Nurse Manager, all windows were noted with metal screws securing the windows shut. The Facilities Manager had reported that machine screws had previously been used to secure the windows shut, however these screws have all been changed to sheet metal screws as a result of the occurrence, "because the machine screws are easier to remove". The Facilities Manager also reported that preventive maintenance checks are computer generated monthly, and are completed by the Maintenance staff. This includes the checking of windows and safety screws. The last preventive maintenance window inspection was done on 12/19/10. The hospital determined that the 1/24/11 preventive maintanence check had not been done by the staff as scheduled due to the maintanence staff being "busy with snow removal" at that time.

During a tour of the psychiatric unit on 2/7/11 at approximately 1:00 PM with the Risk Manager, Psychiatric Clinical Nurse Manager, and the Facilities Manager, the following conditions were observed that pose potential hazards for patients at risk of harming themselves:

Crank beds in all patient rooms on the general psychiatric unit
Lever door handles on all doors with the exception of patient rooms
Standard round door knob on the Seclusion Room
Cut door hinges on all doors
Elongated faucet on the sink in the general psychiatric unit lounge/dining room

In addition, exposed sink hardware was observed in the public bathroom in the ITU area, next to the nurse's station. Although the Psychiatric Clinical Nurse Manager revealed that this public bathroom "is never used by patients without staff in attendance", it was determined that there remains the concern for a potential hazard to patients at risk of harming themselves.