HospitalInspections.org

The Hospital was out of compliance for the Condition of Participation for Patient Rights.

Findings included:

The Hospital failed to ensure for one (Patient #2) of 10 sampled patients that the Hospital provided care in a safe setting.

Refer to TAG: A-0144.

Based on interviews and record review, the Hospital failed to provide care in a safe setting for 1 Patient (#2) out of 10 sampled Patients. Patient #2 was admitted to the inpatient psychiatric unit where he/she was able to ingest a golf pencil in a suicide attempt.

Findings include:






40928

Review of Hospital document 'Your Patient Bill of Rights', rev. 6/08/2019, indicated patients have the right to receive care in a safe setting free from all forms of abuse and harassment.

Patient #2 presented to the Emergency Department 4/12/22 after attempting to swallow a pen in a suicide attempt and reporting that he/she wanted to die.

Record review indicated that Patient #2 was admitted to the inpatient Psychiatric Treatment and Recovery Center (PTRC) on 4/14/22 for further assessment and treatment, due to feeling depressed and wanting to die. On 4/15/22, Patient #2 reported to Nurse #1 that he/she swallowed a pencil and a CT scan indicated a pencil in his/her duodenum (first section of the small intestine). On 4/16/23, Patient #2 had the pencil surgically removed.

During an interview on 4/26/23 at 2:03 P.M., Nurse Manager #1 said patients use golf pencils on the PTRC. Nurse Manager #1 said that for a patient with a history of swallowing pens and pencils, like Patient #2, some potential interventions to maintain safety could be to ask the patient to use a crayon for writing, or not allowing any writing utensils at all without direct supervision. There was no evidence that the Hospital provided these interventions for Patient #2.

During an in interview on 4/28/23 at 9:45 A.M., Nurse #1 said patients have access to golf pencils on the unit and that the staff try to keep track of the pencils. Nurse #1 was unaware if Patient #2 had any special recommendations from the provider to keep him/her safe based on his/her suicide attempt by trying to swallow a pen prior to admission. Nurse #1 said that Patient #2 told her that he/she found the pencil on the unit and swallowed it in an attempt to kill him/herself.

The hospital failed to provide a safe setting for Patient #2 who was admitted after attempting to swallow a pen in a suicide attempt and who then again attempted suicide by swallowing a pencil as an inpatient.

The Condition of Participation of Quality Assessment & Performance Improvement Program was not met.

Findings included:

The Hospital failed to identify opportunities for improvement, consider the incidence, prevalence, and severity of problems and implement changes that will lead to improvement for 1 (Patient #2) of 10 patient records reviewed.

Refer to Tag: A-0286.

Based on interviews and record reviews, the Hospital failed for 1 Patient (#2) out of a sample of 10 patients, to investigate, analyze and provide system wide implementation of preventative actions after Patient #2 was admitted to the inpatient psychiatric unit where he/she was able to ingest a golf pencil in a suicide attempt.

Findings include:







40928

Review of Hospital Policy '1090 Root Cause Analysis and Regulatory Reporting Guidelines', effective date 8/16/2021, indicated the following:

*Policy: Members of the Risk Management, Quality, Patient Safety and Regulatory (QPS) departments will conduct a thorough assessment and quality of care review for adverse events. When an adverse event occurs, a timely, systematic, and case appropriate level of review of the event will occur and required reports will be submitted.

In addition to entering a safety event report, workforce members must also do the following:
-Nurses must also report the event to their manager/ supervisor/ director as per department procedure.

Patient #2 presented to the Emergency Department 4/12/22 after attempting to swallow a pen in a suicide attempt and reporting that he/she wanted to die.

Record review indicated that Patient #2 was admitted to the inpatient Psychiatric Treatment and Recovery Center (PTRC) on 4/14/22 for further assessment and treatment, due to feeling depressed and wanting to die and was placed on 15 minute checks. Patient #2 presented back to the ED from the PTRC on 4/15/22 after swallowing a pencil in a suicide attempt while inpatient and required surgery to remove the foreign body.

During an interview on 4/26/23 at 12:25 P.M., the Associate Vice President of Regulatory said that the nurse never filed an incident report related to Patient #2 swallowing a pencil as required. The Associate Vice President of Regulatory acknowledged that the Hospital failed to evaluate or investigate this incident.

During an in interview on 4/28/23 at 9:45 A.M., Nurse #1 said she did not complete an incident report for this event nor notify the Nursing Supervisor of Patient #2's suicide attempt. Nurse #1 said events like this get reported shift to shift and that generally the Nurse Manager is aware of what is going on in the unit because there is a 24-hour event huddle

The hospital failed to review a suicide attempt that occurred in the Hospital, and no corrective actions were taken as a result of this incident to prevent a like occurrence from happening in the future.