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Based on medical record review, hospital policy review, hospital document review, review of incident reports, and staff interview, it was determined the hospital failed to ensure adverse patient events were identified, analyzed, and actions were taken to prevent further incidents for 4 of 7 patients (#1, #2, #3, and #4) whose records and/or incident reports were reviewed. The hospital also failed to provide meaningful analysis of medication variances. This resulted in lack of analysis and evaluation of safe patient care and impeded the hospital from taking corrective action. Findings include:

1. Patient #1 was a 67 year old male, who was admitted to the hospital on 1/26/19 and was discharged on 1/28/19. His admitting diagnoses were bipolar disorder and suicidal ideation.

An incident report, dated 1/27/19, stated Patient #1 burned the base of his bed with a lighter on that date. Another incident report, dated 1/28/19, stated Patient #1 started another fire with a lighter on that date.

A timeline of events stated Patient #1 was admitted voluntarily to a unit for patients with medical issues on 1/26/19. The timeline stated he became belligerent and threatened staff on the morning of 1/27/19, and was transferred to the psychiatric intensive care unit at that time. The timeline stated Patient #1 was then evaluated by an NP. The patient requested discharge and the NP wrote those orders. The timeline stated Patient #1 was given his belongings in anticipation of discharge. The timeline stated Patient #1 was then determined to be a risk to himself and his wife. Staff rescinded the discharge. Patient #1 was examined by a physician and placed on an involuntary hold. The timeline stated Patient #1 then became volatile and threatening. The timeline stated Patient #1 used a lighter on 1/27/19 at 5:30 PM to burn his bed frame. The timeline stated, on 1/28/19 at 5:00 AM, Patient #1 was placed in seclusion for threatening behavior. The timeline stated he then used a second lighter to start his pillow and bedding on fire. The timeline stated the nursing unit was evacuated and police and fire fighters responded. Patient #1 was arrested and taken to jail.

A patient inventory form, dated 1/26/19, stated Patient #1's belongings included one cigarette lighter.

Patient #1"s "PSYCHIATRIC EVALUATION," written by an NP and dated 1/27/19, stated he complained of suicidal ideation on admission. It stated Patient #1 recently was released from jail for violating a restraining order against his wife. It stated he spent 123 days in jail for this offense. The evaluation stated Patient #1's plan of care was to discharge him today, 1/27/19. The evaluation stated "...despite the protective order, his wife is supportive of him and he knows that he can call her if there is an emergency.

Subsequent nursing and social service notes stated Patient #1 was a threat to himself and his wife and she did not want to participate in his discharge plan. These notes also stated the on-call physician examined Patient #1 before placing him on a hold. Sections of the hold request were completed by the physician, but no progress note by the physician was present in the medical record.

The hospital began an RCA of the event, but it was not complete. The RCA did not include an analysis of the hospital's process for searching patients and their belongings. The RCA did not include a peer review of the medical decisions made by the NP and the physician. The RCA did not include an analysis of the hospital's discharge process and Patient #1's discharge. The RCA did not include an analysis of how staff decisions contributed to Patient #1's behaviors and ultimately to his arrest. A handwritten note on a timeline stated, on 1/27/19 at 1:45 PM, "Noticed cig. in both jacket pocket - [Patient #1] very upset with me." (Cigarettes are not allowed on the unit.) No analysis of how Patient #1 obtained cigarettes or how many he had was documented. The same note stated Patient #1 was upset on the medical unit because of a problem with his oxygen. He then threatened violence to the nursing staff. No analysis of factors leading to Patient #1's threatening behaviors was documented. No analysis of overall supervision and monitoring of Patient #1 was documented.

The hospital made changes to the contraband policy and provided training for staff. However, an analysis of contraband procedures was not documented.

The Risk Manager was interviewed on 2/12/19 beginning at 12:10 PM. He stated the hospital's investigation did not include analysis of the discharge process, the process for collecting patient belongings and identifying contraband, staff decisions related to Patient #1's treatment, steps that were taken after the first fire, how the patient obtained a second lighter, and how he obtained cigarettes. The Risk Manager also stated the NP and the physician were not involved in the investigation and peer review of the case had not been conducted.

While the hospital had taken some steps after the incidents, a comprehensive analysis of the events leading to 2 fires and the arrest of a patient was not conducted.



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2. The hospital's incident reports for the month of January 2019 were reviewed. Three of the completed forms documented incidents on 1/21/19, on the adolescent unit, for Patients #2, #3, and #4. The 3 incidents were identified as "Medication Variance," and each included a handwritten note that stated "cheeking meds [medications]," meaning the patients were holding their medications in their mouths instead of swallowing them. This allowed patients to accumulate medications and take a dose that was higher than ordered, or to take medications that were not prescribed for them.

Patient #3's "NURSING FLOW SHEET" dated 1/21/19, had an entry at 4:00 PM, that stated, "Pt on LOS [line of sight] 30 min [minutes] after meds due to crushing and snorting meds, white residue found on window sill. Pt irritable with information [and] denied he did this. Staff found a white pill, [possibly] Trazadone [antidepressant], in a med cup in his room. He came forward [and] told staff of other 2 peers who asked him to save his meds. He didn't feel good about this and says he flushed the meds in toilet, knowing peers where [sic] crushing [and] snorting meds."

Patient #2's "NURSING FLOW SHEET" dated 1/21/19, had an entry at 4:00 PM, that stated "Pt asked about crushing and snorting his meds, He was irritated [and] denied. White powder residue found on window sill, peer also confirmed the snorting and him asking peers to cheek meds for him to use."

Patient #4's "NURSING FLOW SHEET" dated 1/21/19, had an entry at 4:00 PM, that stated "Pt placed on LOS [after] meds for 30 min for crushing and snorting meds of his own [and] peers. White powder residue found on windowsill. He was irritated and denied he participated in the crushing and snorting."

No documentation of an investigation into the medication variance was provided. There was no documentation that other adolescents on the unit were interviewed to determine if more than 3 patients were involved in saving medications. There was no analysis of how the adolescents were able to avoid swallowing medications without staff knowledge. The was no documentation of preventive actions implemented to prevent this situation from happening again.

During an interview on 2/12/19 at 1:25 PM, the Risk Manager confirmed the 3 documented incidents of male adolescents "cheeking" medications. He stated he did not implement an investigation into the situation as he felt it was an isolated incident. He stated the Program Manager for the unit was responsible for following up on the incidents.

The Program Manager for the adolescent male unit was interviewed on 2/12/19 at 2:30 PM. She stated 2 of the patients involved shared a room. The Program Manager stated that room and the room of the third patient were searched and a half pill was found in one room, that looked as though it was partially dissolved. Additionally, white powder residue was found on the windowsills in both rooms. She stated precautions were initiated for the 3 patients, to ensure they were not able to hold pills in their mouths. The Program Manager stated interviews were not conducted with other patients on the unit and she was not able to state how it was determined the situation was limited to the 3 patients. She confirmed there was no documentation of an investigation, surveillance, or implementation of changes in process to prevent future occurrence of this problem.

3. The hospital's QAPI documents were reviewed. One of the hospital's performance projects was medication variances. A "Nursing Performance Improvement Report" titled "Medication Variances" was reviewed for the months of November 2018, December 2018, and January 2019. Each of the reports stated the number of medication variances on each unit, and the type of variance, as follows:

November 2018:
Wrong Med: 2
Wrong Dose: 1
Omitted: 1
Wrong Patient: 1
Duplicate: 1
Wrong time: 1

December 2018:
Wrong Med: 5
Wrong Dose: 2
Not ordered: 2
Wrong time: 1
Other: 1

January 2019:
Wrong Med: 3
Wrong Dose: 1
Wrong time: 2
Other: 4

There was no documentation of the reasons patients received the wrong medication or dose, to allow the hospital to develop a plan to address the medication variances.

Each of the 3 reports included the following:

"Problems Identified: Nurses need to have time to pass meds and note orders without interruptions."

"Plan of Action:
- Increased supervision and change in management structure.
- Nurses have been followed up with and doctors notified as required.
- Review of double checking orders and 24 hour chart checks.
- Continue to have one-on-one education time with medication nurses."

There was no documentation to show the plan of action was implemented or whether improvement was achieved as a result of the plan of action.

The hospital's incident reports for December 2018 and January 2019 were requested and reviewed. Four incidents reported in December 2018, and 3 incidents reported in January 2019 were medication variances that resulted from errors in transcribing from the physicians' orders to the medication administration records.

During an interview on 2/12/18 at 2:30 PM, the hospital's pharmacist stated medication variances were reported and discussed in a weekly meeting. She stated she did not receive a copy of incident reports related to medication variances. She stated she was not aware of the transcription errors in December and January.

During an interview on 2/12/18 at 3:00 PM, the DON stated he received incident reports related to medication variances. He stated the problem was due to the lack of an electronic medical record at the hospital. The DON stated when a medication variance occurred, he spoke individually with the nurse involved. He stated he had instructed the nurses to transcribe medication orders correctly.

The hospital failed to thoroughly investigate and implement preventive measures in response to identified medication variances.