HospitalInspections.org

Based on a review of facility policy and information, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to provide a safe environment for two of ten patients (MR1 and MR2).
Findings include:
A review of facility "CONTRABAND LIST" Effective June 2022, revealed "...No Sharp Metal objects ...".

A review of facility policy, "Physical Aggression", revised December 20202, revealed "...PRINCIPLE A. To provide a safe environment for patients, visitors and staff B. To protect patients, visitors, and staff from harm C. To prevent property destruction...".

1. A review of MR1 revealed the patient was voluntarily admitted to inpatient treatment on June 1, 2023, for " ...Unstable mood with suicidal ideations ... " . Review of MR1 revealed the patient was able to obtain and utilize a pen to self harm/harm others on two separate occasions resulting in a chemical restraint on July 10, 2023, and physical and chemical restraints on July 14, 2023.
2. A review of MR2 revealed the patient was voluntarily admitted to inpatient treatment on July 8, 2023, for "suicidal ideation". Review of "RN Event Nursing Progress Note" within MR2 indicated "...[MR2] went behind the nurse's station @ 2046. ... [He/She] removed several pens from the drawer & staff removed [him/her] from nurse's station by direction ...".
3. A review of facility information revealed the patients to MR1 & MR2 were able to gain access to pens at the nurse's station and were threatening to self-harm and harm others. Further review of the information revealed the nurse's station was unsecured approximately 13 times on July 14, 2023, between approximately 6:50 PM and 10:00 PM.
4. A tour of the facility was conducted at approximately 10:20 AM on August 18, 2023. During the tour of unit G, two packs of ball point pens and a pair of scissors were found in an unlocked drawer at the nurses station.
5. A policy was requested for the supervision of the nursing station, however the facility indicated there was no policy related to the securing or supervison of the nursing station.
Interview, at approximately 1:15 PM on August 18, 2023, with EMP9 confirmed the above findings "...periods where it is not as far as imminent safety...", when asked if the nurse's station was secured at all times.
Interview, at approximately 1:45 PM on August 18, 2023, with EMP11 confirmed the above findings indicating "...nursing station should be supervised at all times...they were able to grab a pen. ..."

Based on review of medical records (MR), review of facility documents and interviews with staff (EMP), it was determined the facility failed to ensure telephone and verbal orders, were read back for accuracy and countersigned by the provider within 24 hours per facility policy for one of three restraint records reviewed (MR1).

Findings include:

Review, at 11:00 AM on August 24, 2023, of facility policy "Telephone and Verbal Orders" revised July 2023 revealed "It is the policy of Clarion Psychiatric Center that telephone and verbal orders may be obtained in situations where the provider is not readily available to write the order. The telephone or verbal order can only be obtained by an RN, LPN, or Pharmacist. All verbal and telephone orders must be Read Back and Verified (RBAV) to ensure order accuracy. ... PROCEDURES B. All Telephone and Verbal orders require verification. Once the RN, LPN, or Pharmacist has received the order they will repeat it back to the provider (RBAV) to ensure accuracy. C. Telephone and Verbal orders must be countersigned, dated, and timed by the provider within 24 hours. ...".

1. Review of MR1 revealed telephone orders for chemical restraints signed by an RN dated July 14, 2023, at 2300 and 2310. No documentation within the orders were found indicating the order was read back for accuracy per facility policy. The telephone orders were countersigned on July 17, 2023, not within 24 hours per facility policy.

2. Further review of MR1 revealed telephone orders for physical restraints signed by an RN dated July 14, 2023, at 2300 and 2315. No documentation within the orders were found indicating the order was read back for accuracy per facility policy. The telephone order was countersigned on July 17, 2023, not within 24 hours per facility policy.

Interview on August 17, 2023, at approximately 1:15 PM with EMP3 confirmed the above findings indicating "it probably won't be in there" when asked about restraint documentation within the medical record.