HospitalInspections.org

Based on review of facility policy, medical record (MR), and staff interviews (EMP), it was determined the facility failed to ensure one patient that was involuntarily committed was provided a safe environment.

Findings include:

Review of facility documents Patient Rights and Responsibilities, Effective 11/30/2020, "I. Policy Statement: Crozer Health (CH) is committed to notifying and educating our patients about their rights and responsibilities in order to deliver the highest quality of care in a transparent, collaborative setting. ... II. Patient Rights and Responsibilities ... Your Rights ... As our patient, you have the right ... Receive kind, respectful, safe quality care delivered by skilled staff ... "

Review of Involuntary Mental Health Commitments and Voluntary Mental Health Admissions, Effective Date: 06/28/2021, "I. Policy: It is the policy of Crozer Health Hospitals that all patients receive the appropriate evaluation and determination for ongoing treatment. In this evaluation process, the hospitals will maintain a reliable system for insuring patients' safety and rights, as defined by the Mental Health Procedures Act of 1976 ..."
MR11 review revealed "ED Note 12/14/2022 [gender] 20s to ED complaining of stab wounds ... schizophrenic, stab wounds self-inflicted ... 12/14/2022 Trauma HP Assessment/Plan: 21 yo [gender] with stab wounds ... Intubated and taken to CT scanner in stable condition - will go to the OR for diagnostic ... 12/14/2022 Operative report ... Patient tolerated all procedures well and transported to the shock trauma unit in stable condition ..."
Further review of the medical record revealed "12/15/2022 ED Note-Physician @ 702 we are paged by the trauma ICU nurse that the patient was exhibiting violent behavior standing up ... and attempting to stab people and [gender] self with a sharp object. ... the patient began to grab ... with a sharp object and appeared to stab [gender] self ... I was paged by the resident that patient had stabbed [gender] self with the scissors ... "
Interview with EMP1 on December 19, 2022, at approximately 2:00 PM revealed that a nurse was providing care to the patient and when cleaning up, the nurse left the scissors within patient reach.