HospitalInspections.org

The facility failed to protect patient's rights to a safe environment when,

- Items, considered contraband, were not safely secured, and were available for self-harming or suicidal patients.

- A suicidal patient was provided the means to self-harm two times before the facility conducted a contraband search of her room; the search resulted in the finding of additional contraband items.


These failures place suicidal or self-harming patients at risk of injury or death.

Cross Refer to A144 Care in a safe setting.

Based on observation, interview, and record review the facility failed to provide care in a safe setting when the staff neglected to ensure a safe environment for suicidal or self-harming patients.

a.) Items, considered contraband, were not safely secured, and were available for self-harming or suicidal patients.

b.) A suicidal patient was provided the means to self-harm two times before the facility conducted a contraband search of her room; the search resulted in the finding of additional contraband items.

These failures place suicidal or self-harming patients at risk of injury or death.

Findings include:

a.) An observation, on the afternoon of 7/19/23 on the adolescent unit, revealed a large dayroom with felt markers, crayons and papers on the tables and chairs; the patients had left the room and were going to lunch. A red ball point pen was found in one of the patient chairs.

Further observations revealed a plastic tub in a patient's room. The tub contained the following:
30.6 oz. (ounce) bottle of moisturizer
12 oz. bottle of hair lotion
3.8 oz. metal can of spray deodorant
8.5 oz. of shampoo
16 oz. of facial cleaner

During the tour, on the afternoon of 7/19/23 on the adolescent unit, Staff #4, Risk Manager, removed the personal hygiene items from the patient's room and stated, "Hygiene items need to be kept in the hygiene cart, they are considered a hazard." The room was assigned to Patient #19, review of the medical record reflected on 7/19/23 Patient #19 was on an every 5-minute watch for Suicidal Ideations and Self-harm. Patient #19 had been seen in the dayroom, prior to the finding of the ball point pen.

During an interview, on the afternoon of 7/19/23 on the adolescent unit, when asked if a ball point pen is allowed, Staff #9, BHA (Behavioral Health Associate) stated, "No, a staff member must have left it."

During an interview, on the afternoon of 7/19/23 on the administrative office, when informed the facility's contraband list did not include ball point pens, or the shampoos and lotions, Staff #2, CNO (Chief Nursing Officer) stated, "The staff can remove anything they think could harm a patient." When asked how the areas are checked for contraband items, Staff #2 stated, "They should check the areas before and after the patients go into the dayroom." When asked for the policy or procedure for the contraband checks, Staff #2 stated the facility did not have one.

Review of the patient's medical records of patients on the adolescent unit during the date of the tour, reflected the following:
#19 was admitted on 7/12/23 for self-harm, suicidal attempt
#21 was admitted on 7/12/23 for suicidal attempt
#22 was admitted on 7/12/23 for self-harm, suicidal attempt
#23 was admitted on 7/12/23 for self-harm, suicidal attempt
#24 was admitted on 7/12/23 for suicidal attempt
#25 was admitted on 7/12/23 for self-harm, suicidal thoughts

Review of the facility provided policy, "Contraband" (Last revision 12/2022) reflected,
"2. Staff will consider the following to be contraband:
a. General
i. Any item deemed unsafe by any staff member
ii. Any item with strings
iii. Any item with sharp edges
iii. Cans (aluminum, metal such as aerosol cans)"

b.) Review of Patient #1's admission records reflected a 15-year-old-female admitted on 05/06/23 for suicidal ideation and a history of cutting self.

Review of Patient #1's incident reports reflected the following:

- 05/25/2023 at 9:00 pm, "Pt came to staff and reported that she cut her arm (L inside) with a sharp object she found in her room. Nurse cleaned her arm and objects was disposed of properly."
- 06/05/2023 at 5:45 pm, "Patient #1 had an Ensure (nutritional supplement that comes in a can) peeled the metal off and self-harmed leaving superficial scratches to left forearm. MD notified more contraband removed from room inspection."

Review of the Patient #1's Nurse's note dated 6/05/23 reflected, "Room was searched for contraband per MD order. Mask and markers were removed from the room."

During a telephone interview, on the afternoon of 7/19/23, when asked what the patient had used to cut herself, Patient #1 stated, "I found a loose piece of metal on the bedframe. I wiggled it off." When asked if the facility staff had conducted a full room check for potential items, Patient #1 stated, "No, not until the third time."

Review of the facility provided policy, "PATIENT RIGHTS" (last revision 12/2022) reflected,
"f. Patients have the right to be treated with consideration, respect [sic] and full recognition of their dignity and individuality.
g. Patients have the right to be protected by the Hospital from neglect; from physical, verbal and emotional abuse (including corporal punishment); and from all forms of misappropriation and/or exploitation"

Based on record review and interview, the facility failed to properly assess patients' wounds for signs of infection (Patient #1 and #16). This failure places patients with wounds at risk of not receiving timely treatments, preventative interventions, and the patient of experiencing increased pain and infections.

Findings include:

Patient #1
Review of Patient #1's Cedar Crest's Nursing skin assessments reflected the following:
7/9/23-Nurses note: "Lfa (left forearm) with a circular area she states is a 'bite' with redness/pink 3x3 [sic] approx. surrounding sli [sic] warm to touch."
7/10/23- no issues
7/11/23- normal
7/12/23- normal, warm. Nurse's Note: "Patient #1 requires multiple attempts for redirection ...constantly touches wounds causing redness and edema. Wound has redness and increased temp to wound sight [sic] to touch."

Review of Patient #1's hospital emergency room history and physical, dated 7/12/23 reflected, "Patient #1 presents with a history of wound (-0.5 centimeters in diameter) that appeared suddenly
on her left forearm. Patient states that the wound had a little bit of pus draining and pain is 6/10 in severity. Quality of pain is sharp and stabbing. The wound appeared erythematous and was accompanied by swelling that had extended to her hand ... Skin: Skin is warm.
Erythema and tenderness of left arm localized between left wrist and left elbow. Evidence of erythema tracking upward to antecubital fossa concern for appearance of dirty wound."

During an interview, on the afternoon of 7/19/23 in the administrative office, Staff #4, Risk Manager stated, "Patient #1 had poor hygiene. She would pick at the wound."

During an interview, on the afternoon of 7/19/23 in the administrative office, when asked if interventions had been put into place, such as increased hand hygiene or covering the wound, Staff #2, CNO (Chief Nursing Officer) stated, "We focused on the treatment of the behavior, when Patient #1 goes home the behavior would continue."


Patient #16
Review of the facility provided incident report dated, 7/11/23 at 6:55 pm, reflected Patient #16 was punched on her left eye, by another patient, receiving a laceration to the left eyebrow. Patient #16 was sent to the emergency room for further medical treatment.
Review of the hospital emergency room discharge instructions dated 7/11/23 reflected, Patient #16 received 3 stitches and stated, "Check your wound area every day for signs of infection. Check for: More redness, swelling, or pain."
Review of Patient #16's Daily Nursing Skin assessments reflected the following:
7/12/23- Normal, warm
7/13/23- No issues
7/14/23- Normal warm
The skin assessments did not show the presence of the sutures to the left eyebrow and the nursing notes did not include a check of the wound for signs of infection.

Review of the facility provided policy, "SKIN ASSESSMENT" (last revision 8/22) reflected,
"POLICY
Upon admission, return from a pass, and ED visit, an elopement, or where there is
concern that patient has sustained an injury or engaged in self-harm activity, it may be
necessary to conduct a skin assessment or body and belonging search ... e) Document all skin assessment findings on the skin assessment in the nursing assessment. If the skin assessment/search occurs after admission, any changes in the skin condition are to be documented in the nursing reassessment in the skin assessment section or the alternative document that can be used for more involved wounds."

During an interview, on the afternoon of 7/19/23 in the administrative office, when asked if the patient goes to the hospital, what assessments need to be done on return. Staff #2, CNO (Chief Nursing Officer) stated, "They (the nurses) do another head-to-toe assessment. We don't have a wound care nurse; each nurse assesses the patient and will reach out to the provider if necessary." Staff #2 confirmed the missing and inconsistent skin assessments for patients #1 and #16.

Based on interview and record review, the facility's Director of Nursing failed to monitor and evaluate the nursing care furnished to ensure it met acceptable standards of nursing practice, when patient's wounds were not being monitored for signs of infection.

Findings include:

Patient #1
Review of Patient #1's Cedar Crest's Nursing skin assessments reflected the following:
7/9/23-Nurses note: "Lfa (left forearm) with a circular area she states is a 'bite' with redness/pink 3x3 [sic] approx. surrounding sli [sic] warm to touch."
7/10/23- no issues
7/11/23- normal
7/12/23- normal, warm. Nurse's Note: "Patient #1 requires multiple attempts for redirection ...constantly touches wounds causing redness and edema. Wound has redness and increased temp to wound sight [sic] to touch."

Review of Patient #1's hospital emergency room history and physical, dated 7/12/23 reflected, "Patient #1 presents with a history of wound (-0.5 centimeters in diameter) that appeared suddenly
on her left forearm. Patient states that the wound had a little bit of pus draining and pain is 6/10 in severity. Quality of pain is sharp and stabbing. The wound appeared erythematous and was accompanied by swelling that had extended to her hand ... Skin: Skin is warm. Erythema and tenderness of left arm localized between left wrist and left elbow. Evidence of erythema tracking upward to antecubital fossa concern for appearance of dirty wound."

During an interview, on the afternoon of 7/19/23 in the administrative office, Staff #4, Risk Manager stated, "Patient #1 had poor hygiene. She would pick at the wound."

During an interview, on the afternoon of 7/19/23 in the administrative office, when asked if interventions had been put into place, such as increased hand hygiene or covering the wound, Staff #2, CNO (Chief Nursing Officer) stated, "We focused on the treatment of the behavior, when Patient #1 goes home the behavior would continue."


Patient #16
Review of the facility provided incident report dated, 7/11/23 at 6:55 pm, reflected Patient #16 was punched on her left eye, by another patient, receiving a laceration to the left eyebrow. Patient #16 was sent to the emergency room for further medical treatment.
Review of the hospital emergency room discharge instructions dated 7/11/23 reflected, Patient #16 received 3 stitches and stated, "Check your wound area every day for signs of infection. Check for: More redness, swelling, or pain."
Review of Patient #16's Daily Nursing Skin assessments reflected the following:
7/12/23- Normal, warm
7/13/23- No issues
7/14/23- Normal warm
The skin assessments did not show the presence of the sutures to the left eyebrow and the nursing notes did not include a check of the wound for signs of infection.

Review of the facility provided policy, "SKIN ASSESSMENT" (last revision 8/22) reflected,
"POLICY
Upon admission, return from a pass, and ED visit, an elopement, or where there is
concern that patient has sustained an injury or engaged in self-harm activity, it may be
necessary to conduct a skin assessment or body and belonging search ... e) Document all skin assessment findings on the skin assessment in the nursing assessment. If the skin assessment/search occurs after admission, any changes in the skin condition are to be documented in the nursing reassessment in the skin assessment section or the alternative document that can be used for more involved wounds."

During an interview, on the afternoon of 7/19/23 in the administrative office, when asked if the patient goes to the hospital, what assessments need to be done on return. Staff #2, CNO (Chief Nursing Officer) stated, "They (the nurses) do another head-to-toe assessment. We don't have a wound care nurse; each nurse assesses the patient and will reach out to the provider if necessary." Staff #2 confirmed the missing and inconsistent skin assessments for patients #1 and #16. Staff #2, CNO stated, "We plan to re-educate the nurses."