HospitalInspections.org

Based on a review of facility documents and medical records (MR), and staff interviews (EMP), it was determined the facility failed to ensure the protection and promotion of the rights of patients by failing to provide care in a safe setting (0142)(0144).

Cross reference with:
482.13(c) Patient Rights: Privacy and Safety: The hospital must ensure that the privacy and safety requirements are met.

482.13 Patient Rights (c)(2) The patient has the right to receive care in a safe setting.

Based on a review of facility policy and documents, and staff interviews (EMP), it was determined that the facility failed to provide a safe environment for one of ten medical records reviewed (MR1).


Findings include:

A review of the facility's Policy "Self-Harm Levels - Adult Inpatient Units" dated December 26, 2016, revealed "Policy: Each client admitted to Philhaven will be placed on a specific precaution level upon admission.... Procedure: 1. All Clients will be placed on Level A upon admission until seen by a physician. ... Level A Criteria: Admission Level and for moderate risk of harm to self or others. Client needs close monitoring and a locked bathroom. Protocol... a. Body search on admission. b. Room search and body search when Client is dropped from a higher level to this level. c. No belts, shoelaces, pants with drawstrings, or items which would be tied. d. Client may attend groups held on Unit. e. Bathroom door is locked on the Adult Unit. f. Client is observed while in the bathroom. g. Client may not leave the Unit (including courtyard). h. Client will receive meals on the unit. i. No access to sharps or other potentially harmful objects. j. May not shave. ... "

A review of the facility's Policy "Checks of Clients" dated December 26, 2016, revealed "... C. Routine Checks: 1. On admission a client will be placed on a minimum of 15-minute checks by a physician. A specific self-harm precaution level is ordered on admission by a physician. 2. All clients will be accounted for by staff at least every 15 minutes unless the physician orders more frequent checks for duration of their stay. 3. Staff will verify that the client is safe by doing a visual check. If the client is sleeping or appears to be sleeping, staff will either check to be sure that the client is breathing normally or obtain a verbal response from client... ."'

A review of MR1 revealed that the patient was admitted on December 29, 2016 at 1315, to The Adult Unit and placed on a Level A observiation, due to suicidal ideations and a plan to use a knife.

A telephone interview conducted with EMP3 on January 12, 2017, at 9:30 AM confirmed that EMP3 was on duty conducting patient checks at approximately 11:30 PM on the night the code was called. EMP3 did checks on the patient (MR1) by shining a flashlight on the patient, but did not see any movement and did not see the patient's face. EMP3 stated, "I finished the checks then I moved to the 30's (a different hallway)... I told [EMP4] to check on [MR1] ... he's sleeping funny." EMP3 confirmed she heard the code blue and grabbed the AED cart and EMP4 took the cart.

An interview conducted on January 12, 2017, at 9:44 AM with EMP4 confirmed being told by EMP3 to check MR1 in room 15 because the patient's arm was positioned in a funny way. EMP4 went to the room and did not see the patient breathing so EMP4 called a nurse. The nurse checked for a pulse and said to call a code. EMP4 stated they called "code blue adult unit room 15" three times over the walkie-talkie. EMP4 retrieved the crash cart and took it to the room.

During an interview with EMP3 it was confirmed that EMP3 failed to check MR1 to ensure normal breathing and failed to obtain a verbal response from MR1, as per facility policy.

Based on a review of facility policy and documents, and staff interview (EMP), it was determined that the facility failed to provide a safe environment for one of ten medical records reviewed (MR4).

Findings include:

A review of facility policy "Sharps/Contraband" date December 26, 2016, revealed "I Purpose: A. to ensure the safety of the inpatient unit's patient and staff by accounting for all sharps and harmful objects. B. To promote consistency among staff on the inpatient units in regards to the procedure for monitoring the use of sharps. C. To increase client responsibility in cooperating with the hospitals inpatient Units sharps policy...III Procedure: A. Sharps Check- designated times when staff will check to determine what items are signed out, minimally at the end of each shift...C. Client Items Sign Out/In Sheet- this is a sheet located into the Bin Closet, which is used to itemize each item being signed out. Note: Be sure to include the date, time, item signed out, client's name and staff member's initials... ."

A review of MR4 revealed the patient was admitted on March 9, 2016, with a "...Diagnosis:...Axis I Major Depressive Disorder, Recurrent, Severe without Psychotic Features...Cannabis Abuse...Axis II Borderline Personality Disorder..."

The medical record also revealed that MR4 expressed moderate anxiety and depression and thoughts of suicide without a plan. Further review revealed that MR4 ws admitted to the (EAU)Extended Acute Unit on the legal status of 304B precautions Level A.

A review of MR4's "Inpatient Multidisciplinary Note dated 01/04/17 22:24" revealed that MR4 inflicted self harm. RN found multiple small superficial scratches on MR4's left forearm. Patient admitted to using a broken piece of glass from her makeup compact that patient flushed down the toilet.

A review of the facility's "Client Items Sign Out/In Sheet" revealed that on January 4, 2017, MR4 signed out nine items of make-up at 1810 (6:10 PM) and returned (signed in) the nine items of make-up at 2145 (9:45 PM).

An interview conducted on January 11, 2017, at approximately 1:00 PM with EMP2 revealed that staff believe that MR4 signed out nine items of make-up but failed to return all nine items of make-up, instead hiding the contraband in her room or on person for when the patient wanted to self harm. The interview also confirmed that an RCA (Root Cause Analysis) was not done and that no education was conducted with staff regarding the facility's Sharps/Contraband policy.