HospitalInspections.org

Based on observation, review of facility policies, review of medical records (MR) and interview with staff (EMP), it was determined that the facility failed to ensure the safety and well-being of one patient identified with mental impairment for one of ten medical records reviewed (MR1).

Findings include:

Review of facility policy "Patient Rights and Responsibilities," effective June 13, 2013, revealed " 1. You have the right to safe, considerate and respectful care provided by competent personnel. ... 8. You have the right to high-quality care and high professional standards that are continually maintained and reviewed. ..."

Review of facility policy "Suicide Patient: Interdisciplinary Care of," effective June 20, 2013, revealed " I. Purpose: To assess all patients, 13 years of age and over, upon arrival to the Emergency Room, the Medical Clinic, and hospitalization for suicide. To provide a safe environment and protect the suicidal patient from self harm. II. Policy It is the goal of Aria Health to provide a safe environment for patients. Patients deemed at risk for suicide shall be continually observed to prevent self-harm. Suicide precautions involve a plan of care with intervention aimed at protecting a patient from self- harm. ... A risk assessment will be completed which includes identification of specific factors and environmental features that may increase or decrease the risk for suicide. ... Suicide Screening In The Emergency Department ... The initial suicide risk assessment will be initiated in triage and documented in the electronic medical record. ... Factors to be considered when screening for suicide risk includes: 3. Recent treatment of or presence of psychiatric illness, ... 4. History of alcohol and/or substance use and abuse. ... 10. Decreased social support ... Suicide Screening of Admitted Patients All patients who are admitted to Aria Health will have a suicide risk assessment repeated upon admission by the RN during the admission assessment regardless of their answer when assessed in the ED and any time during patient stay if the patient ... exhibits other clinical signs of potential self-harm. If deemed to be at risk at any point during the suicide screening, a Suicide Nursing Order Set will be entered into the electronic medical record, which includes a suicide 1:1 watch (keeping the patient at arms-length at all times), care management consult, and notification of the attending physician so that a psychiatry consult can be ordered. ... Initiation of 1:1 Suicide Watch ... 3. Patients are also screened for a history of substance abuse during the initial presentation and/or triage and again upon admission assessment. ... 5. Identification of Environmental Risks: ... b. Environmental risks should be identified ..."

Review of MR1 "Emergency Department (ED) Note," dated July 17, 2014, entered 04:53, revealed "Triage Information: ...History of Street/Recreational Drug Use: No ... stab wound to abdomen ... presented to ED via police secondary to stab wound. Per police, patient walked up to someone standing at a bus stop and the person at the bus stop called the police after noticing blood all over the patient. Patient admits to smoking PCP (Phencyclidine- a dissociative anesthetic than can cause individuals to be detached from reality, blank stare, rapid and involuntary eye movements, altered perceptions of pain and emotions) Unable to get full HPI (History of Present Illness) due to AMS (Altered Mental Status) from drug use. Additional HPI: Patient is high on PCP, not providing much history ... Patient with multiple stab wounds to ... abdominal area. ... Physical Exam General: ... Eyes: positive nystagmus (involuntary eye movements) ...Mental Status: oriented x1(self), ... not responding appropriately to questions. ..."

Review of MR1 "ED Re-Assessment/Intervention Flowsheet," dated July 17, 2014, entered 04:28 revealed " ... Suspected intoxication or medication overdose ... Suicide Risk Do you have any thoughts of hurting yourself at this time? : No "

Review of MR1 "Pre-Anesthesia Evaluation," dated July 17, 2014, timed 0730, revealed " ... 1. ? PCP use 2. Cognitive dysfunction secondary to chemical ingestion unknown Patient is cooperative but with obvious mental impairment. Possible self inflicted abdominal injury. ..."

Review of MR1 "Intraoperative Nursing Record", dated July 17, 2014, timed 08:47, revealed " ... Patient not answering questions appropriately. Keeps starring off and mumbling."

Review of MR1 "Post Anesthesia Care Nursing Report," dated July 17, 2014, timed 10:12, revealed " ... patient awake and alert refusing to answer questions patient responds to questions to determine orientation with blank stare trauma service and Dr ... notified ok to transfer patient to med surg. "

Review of MR1 "Nursing Admission Assessment," dated July 17, 2014, entered 15:27, revealed " ... Do you want your family member/representative notified of admission and can a message be left if they are not available? Patient declines ... Social History: Lives with: Alone ... Who is your primary support system: Unable to obtain information ... Substance Abuse: ... History of Street/Recreational Drug Use: No ... Changes in Mental Status: Unable to obtain information ... Source of information supplied: Patient Chart(s) Arrived from: Operating room ... Sensory Perception: No impairment. Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort ..."

Review of MR1 "Anesthesia Post Operative Note," dated July 17, 2014, entered 16:44, revealed "... Mental Status: At pre-op baseline Mental Status additional information: Patient appears to be psychiatrically impaired. ... Additional Comments: No adverse effects of general anesthesia ... "

Review of MR1 "Nursing Assessment," dated July 17, 2014, entered 17:27, revealed " ... Psycho-Social Assessment: Psychosocial observations: flat affect, quiet. ..."

Review of MR1" Nursing Assessment," dated July 17, 2014, entered 22:33, revealed "... alert and oriented x3. Speech clear, Memory intact ... Psychosocial Assessment Normal: interacts and communicates in an appropriate manner with others ... "

Review of MR1 "Progress Notes," dated July 17, 2014, timed 2306, revealed " Patient broke [patient's] hospital room window and jumped out of the fourth floor window and landed in grass. Patient found in fetal position, patient brought to trauma room by hospital staff ... 2318 Patient intubated, patient placed on Ventilator ... Musculoskeletal: B/L wrist fractures, B/L ankle fractures ..."

Review of MR1 "Trauma ICU Note," dated July 18, 2014, timed 0607, revealed " Events last 24 hours: Patient jumped out of window s/p ... for abdominal stab wounds. ... Problem List: Lumbar Fracture L2, L4 Burst Fracture with stenosis, Coccyx Fracture ..., Right Distal Radius Fracture, Left Distal Radius/Ulna Fracture, Right Bimalleolar Fracture, Left Calcaneus Fracture, Left Maxillary Sinus Fracture/Mandible ..."

Observation on July 24, 2014, at approximately 11:30AM, of 4B Nursing Unit revealed that the patient's room, at the time of the incident, was not directly visible from the nurses' station.

Interview on July 24, 2014, at 2:05 PM, with EMP4 indicated that the patient did not answer questions appropriately, the patient "was rambling and speaking about God, the devil and biblical projections." EMP4 revealed "my impression within 2-4 minutes was that [patient's] presentation was different than just exposure to drugs. The etiology was not the issue for anesthesiology. My concern was that [patient] was cleared for discharge from the OR. I was very clear with the PACU Nurse that [patient's] behavior was not from anesthesia and that [patient] had returned to his baseline."

Review of MR1 revealed no documented evidence that facility adequately addressed the patient's cognitive/psychiatric impairment or evaluated the "possible self-inflicted abdominal injury" as a potential suicide risk and/or a sign of self-injurious behavior in order to ensure the overall safety and well-being of this patient.