HospitalInspections.org

Based on observation, interview and record review the facility failed to ensure patients receive care in a safe setting when they failed to prevent repeated ingestion of non-food items for 2 of 3 patients (#1 and #2) who were at risk for self-injury and required emergent transport to an acute care hospital for removal of ingested foreign bodies, from a total of 3, resulting in the potential for serious harm for all 123 patients serviced by the facility. Findings Include:

A0144 - The facility failed to prevent repeated ingestion of non-food items for 2 of 3 patients (#1 and #2) who were at risk for self injury.

Based on observation, interview and record review the facility failed to protect the patient's right to receive care in a safe setting when they failed to prevent repeated ingestion of non-food items for 2 of 3 patients (#1 and #2) who were at risk for self-injury and required emergent transport to an acute care hospital for removal of ingested foreign bodies, from a total of 3, resulting in the potential for serious harm for all 123 patients serviced by the facility. Findings Include:

Patient #1

On 6/15/17 at 1115 a tour of the first floor with Staff E revealed the TV cabinet in the day/dining room on the developmentally disabled (DD) unit was locked and 3 TV remote controls were visible on the shelf below the TV screen. The glass front of the cabinet had 2 oval openings approximately 8 inches long and 3 inches wide. The surveyor was able to easily reach in through the openings and remove a TV remote control.

At 1140 patient #1 was observed on the DD unit in her room lying on the bed with 1:1 Staff L sitting in a chair within approximately 3 feet of the patient. When introduced to the surveyor patient #1 stated "You are from the State? They don't believe me that I swallowed a battery this morning." When queried as to where she got the battery she asked for the first floor manager (Staff G). Staff G entered the room and patient #1 repeated that she had swallowed a battery adding "at 0630 my 1:1 was in my room sleeping I went into the TV room and all the staff were sleeping even the nurse. I took the battery out of the remote. The cabinet was unlocked. I told them and no one believes me."

At 1210 in the presence of Staff G and Staff E the TV cabinet was unlocked and the 3 TV remote controls were opened to reveal a missing battery in one of the remotes.

Staff G stated the missing battery was the one patient #1 had swallowed last week and asked Staff J, the lead mental health assistant for the unit about the missing battery. Staff J stated that it has been missing since last Thursday (6/8/17) when (patient #1) was sent to the hospital after stating she swallowed a battery. Staff J stated it is documented on the maintenance log for 6/8/17 that the battery is missing. Review of the maintenance log with Staff J did not reveal any documentation related to the missing battery. Staff G stated the remotes are kept locked in the cabinet for safety. When queried Staff G denied there was any documentation of monitoring to ensure the TV remotes were locked in the cabinet and/or batteries were accounted for.

A review of the medical record for patient #1 revealed that she was a 28 year old female admitted to the facility on 2/8/17 at 1600 for auditory hallucinations and acute psychosis. Admission diagnoses included bipolar, diabetes and hypothyroidism. Patient #1's initial Interdisciplinary Treatment Plan (IDTP) dated 2/7/17 documented psychiatric diagnosis of schizoaffective disorder, with the active psychiatric problems documented as suicidal ideation and homicidal ideation.

During medical record review it was revealed that patient #1 had reported ingestion of foreign bodies on 5 different dates between 5/12/17 and 6/8/17. Further review of patient #1's medical record revealed the following:

Review of medical record documentation for 5/12/17 included a physician progress note that documented, patient #1 was angered, depressed, intrusive, focused on discharge with poor limits and boundaries. Patient appeared disheveled, had poor attention, delusions and was anxious, and angry. Patient unstable. . . harm to self and others.
A nurse's note at 1400 documented patient #1 was constantly at the nurse's station, very manipulative and attention seeking. It documented patient #1 was released from 1:1 supervision (staff within arms-length distance and eyes on the patient at all times) at 0700. A nurse's note at 1847 documented patient #1 was agitated and reported ingestion of the cap from a pen. The physician was notified and an abdominal x-ray was ordered. The x-ray noted, "No definitive radiopaque ingested foreign body."

Review of medical record documentation from 5/17/17 included a physician progress note that documented, patient #1 presented unpredictable behavior, impulsive control, hallucinations and anxiety. Patient unstable. . . harm to self and others. The IDTP dated 5/12/17 documented patient #1 refused treatment plan and appears guarded and withdrawn. The problem check list included suicidal ideation, anger/aggression and noted minimal progress made.
A nurse's note at 2230 documented patient #1 could not be redirected, was argumentative and would not leave the nurse's station demanding to speak to a supervisor and her doctor. Patient #1 reported swallowing two marker caps during the day shift. The physician was contacted and an x-ray was ordered. The x-ray revealed "a single metallic density overlying the left mid abdomen which could represent ingested foreign body. . ."

No incident reports were provided for the 5/12/17 or the 5/17/17 events. Staff D, Director of Quality and Risk Management confirmed she had provided all of the incident reports for April, May and June 2017. No incident report, investigation or action plan was provided.

Review of the medical record documentation from 5/24/17 included a physician progress note that documented, patient continues impulsive, aggressive behavior. Asking for personal items removed from her due to swallow threat. Patient unstable. . . harm to self and others. An Interdisciplinary behavioral modification plan documented patient #1 with negative behavior: Maladaptive behavior including aggression towards others, verbal threats. . .self-harm. The IDTP from dated 5/19/17 revealed patient #1 was attention seeking, anxious and restless. The problem check list included suicidal ideation, anger/aggression and noted minimal progress made.
A nurse's note on 5/25/17 at 0040 documented patient reported she swallowed a battery given to her by a friend and a screw from the door. Physician was contacted and ordered patient sent to emergency department for abdominal x-ray.

An Incident Report dated 5/24/17 at 2202 documented Patient claimed to have swallowed a battery and a screw from her door frame. Screw is missing from the door frame. Patient transferred to emergency room for evaluation. The "Report of Investigation" dated 5/30/17 and signed by Staff D, the Director of Quality and risk Management, documented: "Team met to review incident of 5/24/17 involving (patient #1). Patient stated she swallowed a screw and a battery. (Patient's physician) was contacted and patient was sent to (hospital) for evaluation. Patient had no complaints of pain and no signs of distress. We received report from (hospital) that the abdominal x-ray was + (positive) for screw but no battery. (Patient #1) was kept there for observation. Risk Manager (Staff D) spoke with nurse who stated that (patient #1) told her that since (name of patient, identified as patient #2) swallowed something, that she (patient #1) wanted to swallow something. Maintenance staff went to 1 South to see if anything was out of place, or if there were any breaches from construction. Nothing was found to be out of place. Discussion held with (patient #1's physician), patient attention seeking. (Patient #1) was returned to (facility name)."
The documentation did not include an action plan to prevent reoccurrence.

Review of the 1 south maintenance request log documented a screw missing from the door plates for rooms 104 and 112 on 5/24/17 at 2232.
Record review revealed patient #1 resided in room 104 (1 south) on 5/24/17.

On 6/17/17 at 1516 Staff O, the mental health assistant assigned to patient #1 on 5/24/17 was interviewed via phone regarding the incident. Staff O stated patient #1 had been on 1:1 observation in the past for trying to injure herself. That day (5/24/17) she (patient#1) told me a friend brought her a battery and she swallowed it and a screw from the lock on her door. A screw was missing from her door. She said she was going to get and swallow another screw. I heard she had swallowed something a week or so earlier, but I wasn't there. Another patient (identified as patient #2) had swallowed a battery and I think that is where (patient #1) got the idea. Staff O stated that patients #1 and #2 were at times sociable with one another on 1south. Staff O was asked if she had been provided with any education on patient safety or new interventions for patient #1 related to swallowing items. Staff O stated she had not. She stated the TV remote controls are usually locked in the TV cabinet or kept behind the nurse's station. She added "the remotes are often just on the desk top in the nurse's station on 1 south and the patients can reach over and get the remote or reach in because the doors are often left open. Staff O stated even when they are locked in the TV cabinet there are holes in the cabinet. I am not sure if you could reach in and get the remote out the holes."

An incident report dated 5/29/17 at 0215 documented patient was put in restraints for harming self (scratching) and threatening staff. "Pt. (patient) refused redirection threatened staff, spit at 1:1 staff, and stated she swallowed 2 screws and a paper clip. (Physician name) notified, for evaluation in AM. 4 point restraints for an hour. Will continue 1:1 observation.

On 5/15/17 at 1900 the Assistant Director of Nursing (Staff H) was asked if an x-ray had been ordered. Staff H stated she did not find an x-ray for 5/29/17 in the medical record.

Patient 1#'s medical record revealed a "Behavior Analyst Consult" dated 5/31/17 that documented, Reason for consult "Pt. has had multiple hospital admissions over the past year. Pt. has been engaging in aggressive and self-injurious behavior frequently since readmission on 5/28/17. . .Pt. has been engaging in high rates (daily occurrence with variable duration) of maladaptive behavior. Pt. aggressive, self-injurious and non-compliant with treatment. Pt. aggression includes: verbal threats, hitting, kicking, biting, spitting and throwing items at staff. Pt. self-injury includes: verbal threats, cutting, digging into skin with nails and ingesting non-food items." The bottom of the form revealed an added note written in under "Review/Addendum" dated 6/8/17 at 1430 that documented "Pt. to step down to close observation for 12 hours and review treatment observation with physician after 12 hours to determine continue 1:1 staffing or close observation."
A "Functional Behavioral Assessment" form dated 6/1/17 for maladaptive behavior included diagnoses of schizoaffective disorder, anxiety disorder, PTSD (post-traumatic stress disorder) and mild mental retardation.
The depressed mood without psychosis care plan documented patient purposely swallowed a screw.
A "Behavioral Recommendation" form included with the above consult and assessment documented (Patient #1) is currently 1:1 but the goal is to get her independent as soon as possible.

Review of the documentation from 6/8/17 included a mental health assistant (MHA) note at 1400 that documented Pt. 1:1 was discontinued at 1230 P and monitor closely for harm or behavior to see outcome.
A MHA note at 1700 documented, "Pt. stated that she swallowed a battery at 1645 during dinner. Staff was present in the dayroom with close observation but staff did not see her get the battery, but battery is missing. Pt. continues to be monitored for safety. Pt. seeking attention from staff. Pt. encouraged to follow treatment plan. Pt. monitor 1:1 for safety." Both notes were signed by Staff M.

An incident report dated 6/8/17 at 1800 documented Pt. stated I swallowed a battery. Pt. denies pain. Physician order to send to hospital. The attached "Report of Investigation" dated 6/13/17 and signed by Staff D, the Director of Quality and Risk Management, documented: "Team met to review incident of 6/8/17 involving (patient #1). (Patient #1) had been on 1:1 observation and was taken off after behavior modification meeting held earlier that day. The 1:1 observation was removed with the approval of (patient #1's physician). Staff were told to continue to watch her closely even though she was officially off 1:1. Risk Manager (Staff D) spoke with nurse (name) who stated that (patient #1) ate dinner and was fine, then approached her to tell her she had swallowed a battery. A battery was noted to be missing, from the TV remote. The patient was very happy when she learned she would be transferred out for evaluation. Immediately after the event, the TV remote was locked in the TV cabinet so that it would not be accessible. The facility began to explore other alternatives for storing remotes (gluing back of remote, "battery-less" remotes etc.). (Patient #1) returned to (facility) on 6/12/17. A behavior modification meeting was held on 6/13/17 to review her plan. (Patient #1) will stay on 1:1 observation, no items will be allowed in her room, staff were told to be aware of items at nursing station and in other areas and that soap and shampoo would be poured for her and she will not (be) given any bottles."

On 6/17/17 at 1335 Staff M who was assigned 1:1 for patient #1 was interviewed via phone in regard to the 6/8/17 incident. Staff M stated (patient #1) had been on 1:1 observation after she swallowed a screw on 1 south. She was then moved to DD unit. On the day she swallowed the battery she was taken off 1:1 and just under close observation. Close observation means just keeping an eye on her at all times. We had 3 MHA that day and split the ten patients after the 1:1 was removed. I don't know how she got the battery, but one was missing from the TV remote and she said she swallowed it. After she swallowed it they locked all the TV remotes in the cabinet, but the front of the glass has two holes in it that you could reach in. Maybe that is how she got it. She had been in the dining room most of the afternoon and for dinner. I am only aware of her swallowing the screw and the battery. A patient (identified as patient #2) on 1 south where Patient #1 used to be, swallowed a battery too. When queried as to management providing education on safety following the incidents Staff M stated she had not received any new training.

Review of the hospital final report dated 6/8/17 documented patient presents after swallowing batteries and screws out of a TV remote, "has been admitted several times for the same." Patient required EGD (upper endoscopy-thin scope with light and camera inserted into the upper digestive tract and stomach) to remove foreign objects.

A review of the IDTP dated 6/12/17 documented "Pt. purposely swallowed batteries. Long term goal: (patient #1) will not harm self or others. Short term goals: 1. approach staff when having feelings or thoughts of self-harm/suicide. 2. List 2 stressors that contribute to depressed thoughts. New interventions included, monitor patient 1:1 for safety. . .
The accompanying interdisciplinary behavioral modification plan listed goals of "Pt. will remain safe at the hospital. Pt. will use functional communication to get needs met. Pt. Will tolerate delays/denials. . ."
The plan listed the following safety precautions:
1:1 Staff must remain within 3 feet of patient and must go to bathroom with patient.
During shower 1:1 staff must dispense the shampoo/conditioner/soap. . .
Ensure all remote controls are locked up and only handled by staff. (TV remotes were observed to be accessible by survey team on 6/15/17).
Always be on the look-out for items she can use to harm herself. When possible remove them from her environment. . .

On 6/15/17 at 1630 Staff B, the Chief Nursing Officer stated patient #1 was only 1:1 at times related to behaviors. Staff B provided a print out of the patients who were on 1:1 observation which included start and stop dates and times. It documented the following:

Patient #1 was under 1:1 observation:
5/11/17 at 1800 to 5/12/17 at 0700.
5/28/17 at 1542 to 6/8/17 at 1820 (per nurses note 1:1 was discontinued at 1230).
6/12/17 at 1600 (per treatment plan pt. continues on 1:1 observation).

Staff B stated when (patients #1 and #2) were on 1 south (patient #1) started copy-cat swallowing of items after (patient #2) swallowed an item. (Patient #1) learned she could get attention by swallowing items. (Patient #1) was then moved to another unit and then she swallowed a battery. She is not allowed to have any personal items in her room.

On 6/15/17 at 1725 Staff D, the Director of Quality and Risk Management with Staff A, the CEO was asked what had been done to prevent reoccurrence of the swallowing incidents. Staff D stated the remotes were locked in the cabinet and a discussion occurred about gluing the remotes closed or removing them from the unit's altogether. Staff D stated we have not come up with a resolution yet. We are locking them in the cabinet on DD, on 1 south they are kept at the nurse's station. When asked if logs or audits or any documentation is being done related to locking the remotes in the cabinet or regularly checking for missing batteries. Staff D stated no, we just talked to the lead MHA. Staff D was asked if staff had received any new or additional education related to safety, locking of the remotes or monitoring for batteries and other small objects following the swallowing incidents by patients #1 and #2. Staff D stated "To my knowledge no formal education for staff on safety related to patients swallowing items has been provided or documented."

Staff A the CEO and Staff D were asked if the concerns of patients swallowing items had been addressed in quality. Staff A stated no, the last meeting was May 18 and the next meeting was scheduled for today but cancelled when you (survey team) arrived. It would have been discussed at that meeting.

On 6/15/17 at 1900 the facility Incident reporting program policy dated 1/1/16 was reviewed. The policy documented: "Policy: It is the policy of (name of facility) to utilize the Risk Management Program techniques to promote safety, pro-actively focus on loss prevention, and detection of hazardous events and circumstances. It must provide a systematic, multidisciplinary approach to managing and reporting incidents of injury, damages, and loss. Purpose: The incident report is a risk management tool that raises awareness of potential exposures to perils that may/did cause harm. It enables the facility to manage risks, increase safety, and improve the quality of health care provided in the facility through risk control intervention and monitoring the effectiveness of the interventions and corrective action plan. An 'incident' is an unanticipated event which was not consistent with the standard of care and/or operation of the facility and may have occurred due to a violation of policy and procedure. The incident report will help the various facility communities and administration in identifying potential areas of risk and implementing measures to improve overall quality of care throughout the facility. Procedure: Any facility staff member who witnesses, discovers or has direct knowledge of an incident must complete an incident report before the end of the shift/work day. . . Responsibility: All staff must be trained in the importance of incident reporting required under our facility Risk Management Program. . ."







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Patient #2

On 6/15/17 at 1200 a review of the medical record for patient #2 was conducted.
Patient #2 was a 24 year old female admitted to the facility on 4/24/17.
A review of the nursing admission assessment dated 4/24/17 at 2242 documented the patient had homicidal ideations.

A review of a psychiatric/psychological evaluation dated 4/25/17 documented the patient was at risk of violence to self, had seizure disorder, was in imminent danger to self secondary to mental incapacity, not able to take care of herself and exhibited severe neuro-vegetative symptoms.

Physician's orders included 1:1 female only staff monitoring for patient safety dated 4/25/17 through 6/5/17.

A review of incidents and accidents (I&A's) reports dated 4/27/17 through 6/5/17 documented the following:

On 4/27/17 at 1000 the patient was observed while on 1:1 monitoring as she walked over to a cleaning cart and grabbed 2 chemical spray bottles and proceeded with ingesting 2 sprays of cleaning products. On the same day at 1500 while on 1:1 monitoring the patient was observed as she grabbed a key chain and attempted to strangle herself.

On 5/4/17 (no time listed) while on 1:1 monitoring during meal time the patient was observed as she took a plastic knife to her neck in attempt toward self injury.

On 5/11/17 at 1550 while on 1:1 monitoring during a group activity the patient was observed as she removed 2 batteries from a television remote control and swallowed both batteries.

On 6/5/17 at 1715 while on 1:1 monitoring the patient was observed after she had ingested a tampon that she had obtained from her roommates belongings.

On 6/15/17 at approximately 1135 an interview was conducted with Mental Health Associate Staff I. Staff I explained she had worked at the facility for approximately 8 years in her current role. When asked to explain 1:1 patient to staff monitoring she (Staff I) said it's close monitoring. The patient is never left alone. Staff must be able to touch the patient at all times. Staff I then demonstrated to the surveyor the distance for 1:1 monitoring as she extended her left arm to touch the surveyor. Staff I said we have to remain with the patient when he/she has to use the bathroom and when they shower as well. We (facility staff) have to hand them products for personal use. Staff I was asked if she was aware of a patient(s) swallowing batteries. She said (Staff I) I did hear that it's happened. When asked if anything had changed in regards to the incident such as patients not having access to remote controls or reeducation on the requirements of 1:1 patient monitoring, Staff I stated, "No. Nothing that I am aware of."

On 6/15/17 at 1430 further review of the medical record revealed the following:

A review of a patient transfer emergency care form dated 5/11/17 at 1605 documented the patient was transferred to a local community hospital (B) via ambulance following the ingestion of 2 batteries.
A review of a nursing progress note dated 5/12/17 at 1800 documented the patient remained hospitalized at a local community hospital. According to the progress note one battery had been retrieved and the second battery was located in the patient's small intestine.

A review of a physician discharge summary form dated 5/12/17 documented the patient had been originally admitted to hospital (A) on 4/24/17 following petition due to suicidal ideations, homicidal ideations and aggressive behavior. The patient had experienced worsening auditory hallucinations and reported hearing voices telling her to kill herself and others prior to her admission to hospital (A). The patient became medication compliant during her stay but required 1:1 supervision for the her safety and the safety of others due to her suicidal and homicidal ideations. On 5/11/17 the patient complained of having experienced nightmares and was started on trazodone (antidepressant). Also, on 5/11/17 the patient swallowed batteries, "despite continued 1:1 supervision". The patient was transported to the hospital (B) and admitted.

On 6/15/17 at approximately 1500 the Assistant Director of Nursing explained Mental Health Associate Staff R was assigned for 1:1 monitoring for patient #2 on 5/11/17 (the day that the patient swallowed the 2 batteries). A review of the investigation following the incident revealed there were no corrective measures taken to decrease the risk of reoccurrence.
There were 2 unsuccessful attempts to reach Staff R by telephone with messages left to contact the surveyor.

On 6/15/17 at approximately 1515 the Director of Quality and Risk Management Staff D was queried regarding the lack of investigation for the incident that occurred on 5/11/17. Staff D offered no explanation when asked to explain why there were no corrective measures that documented Staff R was interviewed and/or counseled regarding patient #2's ingestion of 2 batteries while on 1:1 supervision.

Additionally, Staff D was further queried regarding the incident that occurred on 6/5/17 at 1715 (ingestion of a tampon). When asked to explain how patient #2 that was on 1:1 monitoring was able to ingest a tampon and who was the staff member assigned Staff D confirmed the incident report did not identify the team member that was assigned. When asked to provide evidence that documented the corrective measure that had been implemented to decrease the potential for reoccurrence Staff D said, I've looked. I don't have anything else.

Based on interview and record review the facility failed to ensure nursing staff 1) the facilty failed to update the care plans for "disturbed thoughts and depressed mood" for 1 patient (#2) that was at risk for self injury, 2) nursing staff failed to develop a care plan that addressed seizure disorder for 1 patient (#2), and 3) followed the at risk for harm plan of care for 1 patient (#1) that was at risk for self harm, out of a total of 3 sampled patients reviewed for care plans, resulting in the potential for less than optimal outcomes for all patient's with behaviors and seizure disorder served by the facility. Findings include:

Patient #2

On 6/15/17 at 1215 a review of the medical record for patient #2 was conducted.
Patient #2 was a 24 year old female readmitted to the facility on 4/24/17.
A review of the nursing admission assessment dated 4/24/17 at 2242 documented the patient had homicidal ideations and no Neurological manifestations.

A review of a psychiatric/psychological evaluation dated 4/25/17 documented the patient was at risk of violence to self, had seizure disorder, was in imminent danger to self secondary to mental incapacity and was not able to take care of herself and exhibited severe neuro-vegetative symptoms.

A review of physician medication orders dated 4/24/17 for patient #2 included included Keppra 750 milligrams daily (anticonvulsant) and Depakote (anticonvulsant) 500 milligrams twice by mouth per day.
Additionally, there were physician's orders for 1:1 female only staff monitoring for patient safety dated 4/25/17 through 6/6/17.

A review of the patient's "disturbed thoughts" care plan initiated on 4/24/17 revealed the patient had experienced auditory hallucinations that told her to hurt herself. Short term goals included improved mood through use of psychotropic medications, improved reality testing and decreased auditory hallucination by the target date of 05/12/17.
Interventions included:
Nursing staff to monitor medication compliance with observation of therapeutic side effects.
Therapy to help patient determine triggers of psychosis and address hallucinations through reality orientation.
Activity/Recreation Therapy to offer activities to promote reality orientation and decrease auditory hallucinations and altered thoughts.
There were no updates to the plan of care documented after 4/25/17 for 1:1 monitoring for patient safety.

A review of the patient's "depressed mood" care plan initiated on 4/27/17 revealed the patient had experienced hearing voices and persistent thoughts of self injury. Short term goals included the patient would verbalize coping skills instead of self injury within 1 week and the patient would comply with the treatment plan aimed at eliminating mechanisms upon by discharged with target dates of 5/3/17.
Interventions included:
Nursing staff to encourage the patient to participate in activities and to educate the patient on medications daily and as needed.
Therapy to provide groups to help the patient to determine cognitions and behaviors that lead to depression and find alternate cognitions daily and as needed.
Activity/Recreation Therapy to provide interventions to help the patient with 2 coping skills 5-6 times per week.
There were no updates to the plan of care documented after 4/27/17 for 1:1 monitoring for patient safety.

A review of incidents and accidents (I&A's) reports dated 4/27/17 through 6/5/17 documented the following:

On 4/27/17 at 1000 the patient was observed while on 1:1 monitoring as she walked over to a cleaning cart and grabbed 2 chemical spray bottles and proceeded with ingesting 2 sprays of cleaning products. On the same day at 1500 while on 1:1 monitoring the patient was observed as she grabbed a key chain and attempted to strangle herself.

On 5/4/17 at 1025 the patient was observed having a seizure following a fall.

On 5/4/17 while on 1:1 monitoring during meal time the patient was observed as she took a plastic knife to her neck in attempt toward self injury.

On 5/11/17 at 1550 while on 1:1 monitoring during a group activity the patient was observed as she removed 2 batteries from a television remote control and swallowed both batteries.

On 5/22/17 at 1315 the patient was observed having a seizure.

On 6/5/17 at 1715 while on 1:1 monitoring the patient was observed after she had ingested a tampon that she had obtained from her roommates belongings.

On 6/15/17 at approximately 1630 the Assistant Director of Nursing (ADON) was queried regarding the aforementioned (I&A's) and patient behavior care plans. When asked to explain 1:1 monitoring for patient safety, the ADON said our staff would be required to be within arm's reach of the patient at all times. When further queried the ADON offered no further explanation as to how if the patient was within arms reach of staff where they were not able to intervene to facilitate patient safety.

When asked to explain why the patient's behavior care plans for disturbed thoughts and depressed mood had not been updated since 4/27/17 in lieu of continued exhibition of self harm/injury the ADON confirmed the care plans should have been.

When asked to explain why there was no care plan to direct the care of nursing staff for patient #2 who had seizure disorder, was on anticonvulsant medications and staff had witnessed the patient suffer 2 seizures. The ADON explained the admitting nurse should have initiated the seizure care plan or any other nurse after the seizure occurrences.



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Patient #1

On 6/15/17 at 1115 a tour of the first floor with Staff E, revealed that the TV cabinet in the day/dining room on the developmentally disabled (DD) unit was locked and 3 TV remote controls were visible on the shelf below the TV screen. The glass front of the cabinet had 2 oval openings approximately 8 inches long and 3 inches wide. The surveyor was able to easily reach in through the openings and remove a TV remote control.

On 6/15/17 at 1140 patient #1 reported swallowing a battery to Staff G, the first floor manager and the surveyor.

At 1210 in the presence of Staff G and Staff E the TV cabinet was unlocked and the 3 TV remote controls were opened to reveal a missing battery in one of the remotes.

Staff G stated the remotes are kept locked in the cabinet for safety. When queried Staff G denied there was any documentation of monitoring to ensure the TV remotes were locked in the cabinet and/or batteries were accounted for.

A review of the medical record for patient #1 revealed that she was a 28 year old female admitted to the facility on 2/8/17 at 1600 for auditory hallucinations and acute psychosis. Admission diagnoses included bipolar, diabetes and hypothyroidism. Patient #1's initial Interdisciplinary Treatment Plan (IDTP) dated 2/7/17 documented psychiatric diagnosis of schizoaffective disorder, with the active psychiatric problems documented as suicidal ideation and homicidal ideation.

During medical record review it was revealed that patient #1 had reported ingestion of foreign bodies (pen caps, marker caps, screws, paper clips, and batteries) on 5 different dates between 5/12/17 and 6/8/17. Further review of patient #1's medical record revealed the following:

Medical record review from 5/12/17 to 6/15/17 included physician and IDTP notes that documented patient #1 was at risk of self injury.

On 6/17/17 at 1516 Staff O, the mental health assistant assigned to patient #1 on 5/24/17 was interviewed via phone. Staff O was asked if she had been provided with any education on patient safety or new interventions for patient #1 related to swallowing items. Staff O stated she had not. She stated the TV remote controls are usually locked in the TV cabinet or kept behind the nurse's station. She added "the remotes are often just on the desk top in the nurse's station on 1 south and the patients can reach over and get the remote or reach in because the doors are often left open. Staff O stated even when they are locked in the TV cabinet there are holes in the cabinet. I am not sure if you could reach in and get the remote out the holes."

Patient 1#'s medical record revealed a "Behavior Analyst Consult" dated 5/31/17 that documented, Reason for consult "Pt. has had multiple hospital admissions over the past year. Pt. has been engaging in aggressive and self-injurious behavior frequently since readmission on 5/28/17. . .Pt. has been engaging in high rates (daily occurrence with variable duration) of maladaptive behavior. Pt. aggressive, self-injurious and non-compliant with treatment. . . Pt. self-injury includes: verbal threats, cutting, digging into skin with nails and ingesting non-food items." The bottom of the form revealed an added note written in under "Review/Addendum" dated 6/8/17 at 1430 that documented
A "Functional Behavioral Assessment" form dated 6/1/17 for maladaptive behavior included diagnoses of schizoaffective disorder, anxiety disorder, PTSD (post-traumatic stress disorder) and mild mental retardation.

On 6/17/17 at 1335 Staff M who was assigned 1:1 for patient #1 was interviewed via phone. Staff M stated (patient #1) has been on 1:1 observation after she swallowed a screw on 1 south. She was then moved to DD unit. On 6/8/17 patient #1 stated she swallowed a battery. After she swallowed it they locked all the TV remotes in the cabinet, but the front of the glass has two holes in it that you could reach in. Maybe that is how she got it. . .Another patient (identified as patient #2) on 1 south where Patient #1 used to be, swallowed a battery too. When queried as to management providing education on safety following the incidents Staff M stated she had not received any new training.

A review of the IDTP dated 6/12/17 documented "Pt. purposely swallowed batteries. Long term goal: (patient #1) will not harm self or others. Short term goals: 1. approach staff when having feelings or thoughts of self-harm/suicide. 2. List 2 stressors that contribute to depressed thoughts. New interventions included, monitor patient 1:1 for safety. . .
The accompanying interdisciplinary behavioral modification plan listed goals of "Pt. will remain safe at the hospital. Pt. will use functional communication to get needs met. Pt. Will tolerate delays/denials. . ."
The plan listed several new interventions including:
1:1 Staff must remain within 3 feet of patient and must go to bathroom with patient. . .
Ensure all remote controls are locked up and only handled by staff.
Always be on the look-out for items she can use to harm herself. When possible remove them from her environment. . .

The facility did not follow the plan of care, by ensuring the remote controls were locked up and only handled by staff. The survey team found the remote controls to be accessible to patients through the openings in the glass during the investigation on 6/15/17.