HospitalInspections.org

Based on record review, interviews, and observation, the hospital failed to provide care to patients in a safe environment for 4 of 4 patients (Patient #1, Patient #3, Patient #7, Patient #9) in that,

1) Shortly after receiving an emergency administration of a sedating medication mixture, Patient #3 eloped through the window in his assigned room by prying the expanded metal away from the window and forcing the window open.

2) 3 of 3 patients (Patient #1, #7, #9) were observed with their room doors closed on 04/30/15. Although identified as a ligature in 03/2015, the gaps observed in the expanded metal in front of windows of 3 patients on suicide precautions (Patients #1, #7, #9) provided potential for self harm.

Findings included

1. Patient #3's "Coding Summary" dated 02/12/15 reflected Patient #3's diagnoses included, Psychosis, Cannabis Dependence, and Attention Deficient with Hyper-Activity.

Patient #3's "Clinical Documentation Record" dated 02/07/15 reflected, Patient #3 eloped through the window in his assigned room, by prying the expanded metal away from the window and forcing the window open. Patient #3 received a "cocktail" (medication administration of Haldol, Ativan, Benadryl) prior to his elopement. Patient #3 jumped out of the second story to the ground level. He left the hospital grounds and was located by the police on the opposite side of the Expressway. Patient #3 was returned to the hospital by the Police Department within 30 minutes of his elopement. Patient #3 was noted to have an abrasion to the left leg, and bruise to his right face by the eye upon returning to the unit.


During an interview at 9:25 AM on 04/29/15, Personnel #6 was asked how long it would take for the "cocktail" to effect Patient #3. Personnel #6 responded, "It is a sedative drug, and it would take effect within 15 to 30 minutes. It has a possibility to be dangerous."


During an interview with Personnel #4 at 9:30 AM on 04/29/15, Personnel #4 was asked if she was aware when the incident took place. Personnel #4 indicated, "The event took place in the middle of the night...I think it was between rounds, and he was kicking the window open."


During an Interview with Personnel #1 at 9:35 AM on 04/29/15, Personnel #1 stated expandable metal covers were identified as an issue during the hospital facility quality assurance meeting on 12/12/14.

During an interview on 04/29/15 at 01:10 PM, Personnel #7 stated the windows had been replaced only on the 5th floor.

During two separate tours of the hospital's second floor on 04/29/15 at 9:35 AM and 04/30/15 at 10:40 AM, the following was observed: All of the windows in patient rooms were bolted down with the expanded metal in front of the windows bolted to the walls, ceilings, and window base. There were openings where fingers could force the expanded metal away from the window so that the window was accessible for elopement.

2) The hospital's "Daily Census/Bed Board" dated 04/30/15 indicated 3 patients (Patient #1, #7 and #9) were on suicidal precautions.

During a tour of the hospital's second floor on 04/30/15 at 9:25 AM, Patient #1 was in her room with the door closed. The window had an expanded metal screen cover.

On 04/30/15 at 9:30 AM, Patient #7 was observed in his room with the door closed. The patient stated he was depressed. The window had an expanded metal screen cover.

On 04/30/15 at 09:32 AM Patient #9 was observed in his room with the door closed. The room for Patient #9 had a window with expanded metal screens.

During observations 04/30/15 at 12:15, personnel #11 had three patient rounds sheets with 15 minute observational checks updated at 11:45 AM. Personnel #11 stated there was a medical emergency on the unit, and she was "doing them [the round sheets] now."

During an interview on 04/29/15 at 9:30 AM, Personnel #4 was asked, how patients on suicide precautions were kept safe and stated, "Patients are kept safe by continuously monitoring the floor and keeping patients out of their rooms until bedtime at 10:00 PM."

During an interview on 04/29/15 at 12:55 PM, Personnel #4 stated patients on suicide precaution had to be "out of their rooms on all waking hours."

During an interview on 04/29/15 at 1:10 PM, Personnel #7 stated the windows were first identified as a risk in the hospital on 12/12/14.

Record review of the hospital's risk assessment dated 03/26/15 noted "...cage protecting the windows is ligature risk..."

The hospital's policy "Special Precautions" approved 10/2014 included, "Patient should remain in the day area during daytime hours..."

The hospital's policy "General Safety of the Psychiatric Units" revised 10/2014 noted the policy "to provide a safe physical environment for patients..."