HospitalInspections.org

Based on observation, staff interview, medical record review, and review of facility documents, it was determined the facility failed to ensure the rights of each patient is protected.

Findings include:

1. The facility failed to ensure that notices of patient rights are provided and explained in a language or manner the patient can understand. (Refer to Tag A-117)

2. The facility failed to provide all patients with the right to special communication devices appropriate to their condition and ability to understand. (Refer to Tag A-129)

3. The facility failed to ensure patients receive care in a safe setting. (Refer to Tag A-144)

Based on review of one (1) of one (1) medical record (Medical Record #1) of a patient with special communication needs, staff interview, and review of facility documents, it was determined the facility failed to ensure notices of patient rights are provided and explained in a language or manner the patient can understand.

Findings include:

Reference #1: Facility document, "PICU (Psychiatric Intensive Care Unit) Guidelines" states, "You have the right to the following while on [name of facility]'s Psychiatric Intensive Care Unit... To be provided with a reasonable explanation, in terms and language, appropriate to your condition and ability to understand."

Reference #2: Facility policy, "Interpreter Services: Patients with Special Needs: Hearing Impaired, Sign Language, Visually Impaired, and Language Interpretation" states, "[Name of facility] recognizes the special needs and concerns of individuals who... have physical and/or cognitive limitations. [Name of facility] will provide special communication devices... ."

1. Review of Medical Record #1 on 11/3/21, revealed that Patient #1 was non-verbal.

2. There was no evidence that special communication devices were used to inform Patient #1 of his/her patient rights.

3. There was no evidence that Patient #1's legal guardian was notified of his/her patient rights.

4. The above findings were confirmed with Staff #1, Staff #2, and Staff #16 on 11/3/21 at 3:00 PM.

Based on staff interview, review of one (1) of one (1) medical record (Medical Record #1) of a patient with special communication needs, and review of facility documents, it was determined the facility failed to provide all patients with the right to special communication devices appropriate to their condition and ability to understand.

Findings include:

Reference #1: Facility document, "PICU (Psychiatric Intensive Care Unit) Guidelines" states, "You have the right to the following while on [Name of facility]'s Psychiatric Intensive Care Unit... To be provided with a reasonable explanation, in terms and language, appropriate to your condition and ability to understand."

Reference #2: Facility policy, "Interpreter Services: Patients with Special Needs: Hearing Impaired, Sign Language, Visually Impaired, and Language Interpretation" states, "[Name of facility] recognizes the special needs and concerns of individuals who... have physical and/or cognitive limitations. [Name of facility] will provide special communication devices... ."

1. Review of Medical Record #1 on 11/3/21, revealed the following:

a. Patient #1 was admitted to the hospital on 8/6/21 at 10:45 PM.

b. On 8/7/21 at 12:18 AM, the Nursing Flowsheet states, "non verbal."

c. On 8/7/21 at 12:30 AM, the Nursing Note states, "Patient is unable to let needs be known."

d. On 8/7/21 at 2:23 AM, the Nursing Progress Note states, "Patient is unable to communicate."

e. On 8/7/21 at 2:30 AM, the Nursing Note states, "Patient is unable to let needs be known."

f. On 8/7/21 at 11:27 AM, the Nursing note states, "It is difficult to gage his thought process as he does not communicate in English... ."

g. On 8/7/21 at 1:19 PM, the Nursing Note states, "Patient has a red communication folder. The folder was discussed with staff today working with this patient." According to Staff #2, The Red Communication Folder contained pictures that identified patient needs, such as food and drinks. There was no documented evidence that the patient ever used the Red Communication Folder or had the ability to use it.

h. On 8/7/21 at 4:33 PM, the Activity Therapist Progress Note states, "Patient settled down in the unit slowly due to nonverbal, no language accessible to patient, or very limited language."

i. On 8/8/21 at 6:26 AM, the Psych (Psychiatric) Nurse Progress Note states, "The patient is non verbal. ... Anticipate the needs of the patient... ."

j. On 8/9/21 at 5:29 AM, the Plan of Care states, "Patient is unable to make his need known... ."

k. On 8/8/21 at 1:30 PM, the Activity Therapist Progress Note states, "No interview was conducted due to nonverbal."

l. On 8/9/21 at 10:12 AM, the Social Work Addendum states, "Mother reported patient's unable to verbalize need... Patient uses iPad... for communication... ."

m. On 8/10/21 at 10:40 AM, the Treatment Plan states, "Problem: Language Barriers: Goal: Patient uses a form of communication to get needs met and to relate effectively with people and his/her environment... Description: Assess the patient's preferred language and ensure the patient fully understands written words, pictures and gestures."

n. On 8/11/21 at 4:05 PM, the Nursing Progress Note states, "Patient is non verbal."

o. On 8/12/21 at 2:04 PM, the Treatment Plan states, "Problem: Language Barriers: Goal: Patient uses a form of communication to get needs met and to relate effectively with people and his/her environment... Description: Assess the patient's preferred language and ensure the patient fully understands written words, pictures and gestures."

p. On 8/13/21 at 2:34 PM, the Nursing Note states, "Patient being sent to the ED (Emergency Department) at 2:30 PM do [sic] to change in medical condition."

2. There is no documented evidence that staff used the red communication folder or the iPad to communicate with the patient during his/her entire hospital stay.

3. Upon interview, Staff #2 and Staff #16 stated that the staff should have documented the form of communication they used to communicate with the patient.

4. The above findings were confirmed with Staff #1 and Staff #2 on 11/3/21 at 3:00 PM.

A. Based on observation and staff interview, it was determined the facility failed to ensure ligature and safety risks are mitigated in environments where patients are at risk for self-harm.

Findings include:

1. During a tour of the Alcohol Chemical Dependence Unit on 11/1/21, the following was observed:

a. At 10:46 AM, in the Female Shower Room, a four (4) foot metal cord was attached to the shower head.

b. At 11:06 AM, in the Dining Room, a telephone with a three (3) foot phone cord was attached to the wall.

c. At 11:10 AM, in the Men's Lounge, a wall mounted television had several four (4) foot cords hanging from the back. The television was not mounted flush against the wall, making it easy to remove and use as a weapon.

d. At 11:11 AM, in the Women's Lounge, a wall mounted television had four (4) foot cords hanging from the back. The television was not mounted flush against the wall, making it easy to remove and use as a weapon.

2. Upon interview on 11/01/21 at 2:00 PM, Staff #1 indicated the identified ligature risks were mitigated. The phone cord was removed immediately. Staff were educated on the policy and procedure regarding supervision of patients in the handicapped shower room. The lounges will be locked and under staff supervision until the television and cords are secured behind an enclosure.

3. During a tour of the Adult Crisis Intervention Service Unit on 11/1/21, the following was observed:

a. At 11:53 AM, in the Entrance Corridor, a telephone with a six (6) foot phone cord was attached to the wall.

b. At 12:00 PM, in the Dining Room, a telephone with a six (6) foot phone cord was attached to the wall.

4. Upon interview on 11/01/21 at 2:00 PM, Staff #1 indicated the identified ligature risks were mitigated. The telephone cords were removed immediately.


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5. During a tour of the PICU on 11/1/21 at 2:08 PM, in the presence of Staff #2, electrical outlets that were not tamper proof, were found in the following patient areas: TV Room, Quiet Room, Dining Room and Art Therapy Room. The electrical outlets were easily accessible to patients.

6. On 11/1/21 at 2:40 PM, Staff #2 confirmed that the electrical outlets identified in the TV Room, Quiet Room, Dining Room and Art Therapy Room were not tamper proof.

B. Based on medical record review (#4), staff interview, and review of facility policy and procedure, it was determined the facility failed to ensure a higher level of observation is maintained for patient's at risk for self harm.

Findings include:

Reference: Facility policy, "Suicidal Ideation Risk Assessment - Behavioral Health" states, "... 1. Identify patients at risk for suicide. 1.1 A suicide risk screen, utilizing the Columbia-Suicide Severity Rating Scales (C-SSRS)... is completed on every patient who enters the behavioral health inpatient or outpatient department. ... 1.3 Once risk is determined, the patient is placed on the corresponding level of observation and appropriate Patient Safety Strategies... are implemented. ... Guidelines to Determine Level of Risk... Moderate Risk Patient Safety Precautions... Line of Sight Observation - Unless otherwise ordered by attending/admitting physician. ... ."

1. Review of Medical Record #4 on 11/3/21 at 12:03 PM revealed the following:

a. The patient was admitted to the facility on 10/29/21 at 12:33 PM. The Psychiatric Evaluation note dated 10/29/21 at 9:33 PM states, "... History of Present Illness... Patient is a 16-year-old female... that presented to the emergency room after a suicide attempt by overdose on approximately 300 mg of Prozac. Patient indicates that she had been planning the suicide for the day. Patient reports her mother was driving her to the emergency room and she was thinking about jumping out of the car. ... Patient reports a previous suicide attempt in August 2021 where she overdosed on Zofran and Lexapro and was hospitalized... Patient reports that she first experienced suicidal thoughts in eighth grade, and that over the last 3 months they have been increasing in intensity and frequency. Patient reports when there is the "slightest inconvenience" she automatically thinks of suicide now. ... Plan: Inpatient treatment is expected to improve the patient's condition. Inpatient level of care is necessary due to danger to self."

b. The patient's suicide risk assessment, completed during the patient's admission assessment, determined the patient was a moderate risk for suicide. There was no evidence the patient was placed on line of sight observation after being assessed as a moderate risk for suicide, as indicated in the facility's policy. There was no evidence a physician determined the patient did not require line of sight observation.

(i) Review of the Special Precautions/Observation Record indicated the patient was visually observed every fifteen (15) minutes.

c. The Special Precautions/Observation Record notes dated 10/29/21 at 9:15 PM states, "Patient placed on 1:1 observation following attempt to choke herself. 1:1 initiated and maintained."

d. Psych Nurse Progress Note dated 10/29/21 at 10:22 PM states, "... During 15 minute safety check patient asked staff to take sweatshirt away from her and stated she had tied it around neck to choke self. Patient states she had panic attack and impulsively did this. ... Patient placed on 1:1 observation and [name of staff member] notified. Doctor [name of physician] was notified of incident and patient condition. ... Patient reports while sweatshirt was around her neck she vomited and felt she was going to pass out. ... Patient is unable to state what her intentions were but states she likes the feeling of making herself pass out. ... Patient reports she has previously choked herself at home but has never told anyone. Patient is calm and cooperative at this time, denies SI [suicidal ideation] but is unable to contract for safety."

2. Upon interview on 11/3/21 at 2:20 PM, Staff #1 confirmed that Patient #4 should have been placed on line of sight observation after the admission assessment determined the patient was a moderate risk for suicide.

Based on staff interview, medical record review, and review of facility documents, it was determined the facility failed to ensure a nursing service that continually supervises and evaluates patient care to ensure patient needs are met, is maintained.

Findings include:

1. The facility failed to ensure registered nurses supervise and evaluate the nursing care of each patient. (Refer to Tag A-398)

A. Based on review of one (1) of three (3) medical records (Medical Record #1) of patients transferred to another facility, staff interview, and review of facility policies and procedures, it was determined the facility failed to ensure a change in a patient's status is identified and reported to the provider.

Findings include:

Reference #1: Facility policy, "Admission and Multidisciplinary Assessment and Reassessment" states, "... Assessment of patients is a continued process. When any change in status is noted a more therapeutic assessment is to be completed in order to determine treatment needs as indicated. Any change in status is directly reported to the physician. ... ."

Reference #2: Facility policy, "Communication: Handoff /SBAR (Situation Background Assessment Recommendation)" states, "... A communication approach (such as the SBAR format) to handoff patient information will occur under the following circumstances... Notification to providers... change in patient status... ."

1. Review of Medical Record #1 on 11/3/21 revealed the following:

a. Patient #1 was admitted to the facility on 8/6/21 at 10:45 PM. The Registered Nurse Progress Note on 8/9/21 at 5:10 PM states, "... Patient does not have an appetite. Ate just a few bites."

(i) The Social Worker Note on 8/10/21 at 6:18 PM states, "Collateral Contact... Mother stated patient usually has good walking posture, walking normally straight up (unlike currently when he would lean forward, drooling, unable to stand still without crouching forward)... ."

(ii) The Registered Dietician Note on 8/11/21 states, "... Patient sleeping. Not easily aroused. ... He is only able to take a few bites of food at a time due to lethargy."

(iii) The Mental Health Worker Progress Note dated 8/12/21 at 6:30 PM states, "... Patient appeared to be unstable on his feet, difficulty keeping his eyes open, and slight tremors."

b. The Bedside Intake/Output form dated 8/12/21 reports no Intake for a 24 hour period.

c. The Creative Art Therapy Progress Note on 8/13/21 at 9:43 AM states, "... Patient was catatonic like and unable to respond to simple inquiries."

d. The Social Work Progress Note dated 8/13/21 at 2:30 PM states, "... Appeared stiff... ."

e. The Registered Nurse Nursing Note on 8/13/21 at 2:34 PM states, "... Patient being sent to the ED (Emergency Department) at 14:30 (2:30 PM) due to change in condition. Patient is noted to be more lethargic, has not eaten in two days and now is unable to walk. He is still in bilateral upper extremities. Nystagmus is noted in both eyes. Patient is noted to be drooling. ... ."

2. When the above changes in status were noted, there was no evidence that a more therapeutic assessment was completed to determine treatment needs.

3. There was no evidence that the changes in patient status were directly reported to the physician.

4. The above findings were confirmed with Staff #2 and Staff #16 on 11/3/21 at 2 PM.


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B. Based on medical record review (Medical Record #4), staff interview, and review of facility policy and procedure, it was determined the facility failed to ensure nurses adhere to safety strategies utilized in the care of patients at risk for self harm.

Findings include:

Reference: Facility policy, "Suicidal Ideation Risk Assessment - Behavioral Health" states, "... 1. Identify patients at risk for suicide. 1.1 A suicide risk screen, utilizing the Columbia-Suicide Severity Rating Scales (C-SSRS)... is completed on every patient who enters the behavioral health inpatient or outpatient department. ... 1.3 Once risk is determined, the patient is placed on the corresponding level of observation and appropriate Patient Safety Strategies... are implemented. ... Guidelines to Determine Level of Risk... Moderate Risk Patient Safety Precautions... Line of Sight Observation - Unless otherwise ordered by attending/admitting physician. ... ."

1. Review of Medical Record #4 on 11/3/21 at 12:03 PM revealed the following:

a. The patient was admitted to the facility on 10/29/21 at 12:33 PM. The Psychiatric Evaluation note dated 10/29/21 at 9:33 PM states, "... History of Present Illness... Patient is a 16-year-old female... that presented to the emergency room after a suicide attempt by overdose on approximately 300 mg of Prozac. Patient indicates that she had been planning the suicide for the day. Patient reports her mother was driving her to the emergency room and she was thinking about jumping out of the car. ... Patient reports a previous suicide attempt in August 2021 where she overdosed on Zofran and Lexapro and was hospitalized... Patient reports that she first experienced suicidal thoughts in eighth grade, and that over the last 3 months they have been increasing in intensity and frequency. Patient reports when there is the "slightest inconvenience" she automatically thinks of suicide now. ... Plan: Inpatient treatment is expected to improve the patient's condition. Inpatient level of care is necessary due to danger to self."

b. The patient's suicide risk assessment, completed during the nursing admission assessment, indicated the patient was a moderate risk for suicide. There was no evidence the patient was placed on line of sight observation after being assessed as a moderate risk for suicide, as indicated in the facility's policy. There was no evidence a physician determined the patient did not require line of sight observation.

(i) Review of the Special Precautions/Observation Record indicated the patient was visually observed every fifteen (15) minutes.

c. The Special Precautions/Observation Record notes dated 10/29/21 at 9:15 PM states, "Patient placed on 1:1 observation following attempt to choke herself. 1:1 initiated and maintained."

d. Psych Nurse Progress Note dated 10/29/21 at 10:22 PM states, "... During 15 minute safety check patient asked staff to take sweatshirt away from her and stated she had tied it around neck to choke self. Patient states she had panic attack and impulsively did this. ... Patient placed on 1:1 observation and [name of staff member] notified. Doctor [name of physician] was notified of incident and patient condition. ... Patient reports while sweatshirt was around her neck she vomited and felt she was going to pass out. ... Patient is unable to state what her intentions were but states she likes the feeling of making herself pass out. ... Patient reports she has previously choked herself at home but has never told anyone. Patient is calm and cooperative at this time, denies SI [suicidal ideation] but is unable to contract for safety."

2. Upon interview on 11/3/21 at 2:20 PM, Staff #1 confirmed Patient #4 should have been placed on line of sight observation after the nurse's admission assessment determined the patient was a moderate risk for suicide.

A. Based on observation, staff interview, and review of facility policy and procedure, it was determined the facility failed to ensure all visitors are screened for COVID-19, in accordance with facility policy.

Findings include:

Reference: Facility policy, "COVID-19 Plan EH" states, "... 1. Individual Screening and Management... a. In settings where direct patient care is provided, [name of facility] will... ii. Screen and triage all clients, patients, residents, delivery people, visitors, and other non-employees entering the setting for symptoms of COVID-19. ... c. For visitors and non-employees conducting business at the facility (e.g., vendors and contractors)... ii. All non-employees, visitors, vendors, and delivery people will be asked about symptoms of and exposure to COVID-19. ... ."

1. Upon arrival to the facility on 11/1/21 at 9:40 AM, this surveyor was greeted by Staff #17, who notified administrative staff about the visit. Staff #17 then instructed this surveyor to proceed down the corridor to meet an awaiting administrative staff member.

a. Staff #17 did not ask this surveyor about the presence of symptoms or exposure to COVID-19.

2. Upon interview on 11/3/21 at 9:45 AM, Staff #17 confirmed he/she did not ask this surveyor about COVID-19 symptoms or exposure to COVID-19.

B. Based on staff interview, review of facility policies and procedures, and review of facility documents, it was determined the facility failed to ensure physicians and licensed independent practitioners (LIPs) receive fit testing for N95 masks.

Findings include:

Reference #1: Facility policy, "EH-Fit Testing" states, "... B. Fit testing is required prior to initial use of a specific brand, style or size of N95 respirator mask, and at least annually thereafter. Additional fit testing is required whenever the employee reports or the employer observes changes in the employee's physical condition that could impact fit... or if the fit is deemed to be unsatisfactory. C. Supervisors will be responsible for prohibiting their employees from wearing an N95 respiratory/mask unless they have satisfactorily completed a fit testing... ."

Reference #2: Facility policy, "COVID-19 Plan EH" states, "... h. For employees with exposure to people with suspected or confirmed COVID-19, [name of facility] will provide respirators and other PPE... [name of facility] will ensure respirators are used in accordance with the OSHA Respiratory Protection standard (29 CFR 1910.134)... ."

1. During the entrance conference on 11/1/21 at 9:58 AM, Staff #1 confirmed the facility accepts COVID-19 positive patients that are asymptomatic.

2. Upon interview on 11/3/21 at 10:15 AM, Staff #14 stated all employees are fit tested for N95 masks. Review of employee fit testing logs lacked evidence of fit testing for physicians or LIPs.

3. Upon interview on 11/3/21 at 1:50 PM, Staff #1 stated that physicians and LIPs are contractors and not employees of the facility. He/she stated, "I spoke with the Infection Prevention Department and they said that the physician's contract states that it is the physician's responsibility to get fit tested with our masks."

a. There was no evidence in the physician's contract indicating physicians and LIPs were responsible for conducting their own fit testing using the facility's N95 masks.

4. During a telephone interview on 11/3/21 at 2:07 PM, Staff #20 confirmed the facility does not conduct fit testing for physicians or LIPs. Staff #20 confirmed the facility does not verify physicians or LIPs have been fit tested elsewhere, utilizing the N95s provided by the facility.

5. Staff #1 confirmed the above findings on 11/3/21 at 3:05 PM.

Based on observation and staff interview, it was determined the facility failed to maintain a clean and sanitary environment.

Findings include:

1. During a tour of the Psychiatric Intensive Care Unit (PICU) on 11/1/21 at 2:08 PM, in the presence of Staff #2, the following was observed:

a. Brown and green colored stains were visible on the ceiling and in the light fixture of the shower room.

b. Dust and white debris were observed inside and around the toilet.

2. Staff #2 confirmed the above findings on 11/1/21 at 2:08 PM.