HospitalInspections.org

29707

Based on observation, interview, medical record and document review, the facility failed to ensure that ligatures were removed from a Gero-Psychiatric (psychiatry of old age) Unit.

In addition, the facility failed to ensure the area around the secured bed in the seclusion room could provide for safe care if needed.

As a result, there was a minimal potential risk of suicide, and a potentially unsafe bed in the seclusion room for 11 of 11 sampled patients housed in the unit.

1. A tour of the GPU was conducted on 4/18/17 at 9:33 A.M. The unit consisted of 12 private patient rooms, in an "L" shaped hallway, with a day room near the end of one hallway and a locked door at the other end. There was a staff member observed seated at the bend of the "L" with direct view of each hallway. Curved mirrors were positioned on the walls at ceiling level and provided additional viewing of the "L" shaped hallway. The handrails on the walls in the hallways posed a ligature risk (something that could be used for tying or binding tightly). The day room had a storage cabinet with 8 cupboard doors that had handles which posed a ligature risks. All 11 patients were in the day room with staff present.

Each patient room had the same and/or similar type ligatures such as bed headboards and footboards with holes in the design, faucets, handles and grab bars in the bathrooms, exposed plumbing on the toilets and under multiple sinks, handles on cupboard doors, and dropped down ceilings, magnetic door handles to keep doors in open position etc...

In addition, the seclusion room's (the isolation of a patient in a special room to decrease stimuli that might be causing or exacerbating the patient's distress and should be free from objects that the patient might use to cause self-harm or to harm others) bathroom area had similar ligatures.

An interview with MD 1, the Medical Director of Psychiatry, was conducted on 4/20/17 at 8:20 A.M. MD 1 stated she had worked at the facility and has had oversight of the GPU since February 2012 and is a hospitalist psychiatrist. MD 1 also stated she rounded on all patients in the GPU and spent several hours interacting daily with the patients. MD 1 stated the GPU provides a much needed service to the community for patients with moderate to severe dementia (memory loss). MD 1 stated the GPU is the only such unit in the community and it is very difficult to find placement for these types of patients.

MD 1 stated that the types of patients that are admitted to the GPU are diagnosed with severe neurocognitive impairment (memory and functional problems), dementia, have a high fall risk, short attention span and are mobility impaired. MD 1 stated that the patients in GPU are very impaired to the point that they are not capable of carrying out simple tasks, understanding or even carrying out something such as a suicide plan. MD 1 stated in early 2017, a request was submitted to remove the ligature risk points.

MD 1 further stated that the Unit has decreased the amount of patients and ensured a higher nurse to patient ratio. MD 1 stated that she was confident that patients were at minimum to no risk of suicide due to the admission criteria to the GPU, direct line of site, and constant monitoring, MD 1 further stated the patients are so physically and cognitively impaired that they require 1 to 2 staff for assistance for mobility and were physically unlikely to carry out or comprehend a suicide. MD 1 stated the Unit had already removed and replaced door hinges and had already started closing off some rooms to begin the removal of ligatures.

The census of the unit on 4/20/17 was 7, with 4 residents discharged from the facility since 4/18/17.

An interview with the FM and concurrent review of the hospital's capital renovation request, dated 3/19/17, was conducted on 4/19/17 at 1 P.M. The records indicated that a request was submitted for removal of ligatures in the GPU on 3/19/17. The FM stated that the request was made as a result of a risk assessment that identified the ligatures in the GPU and the request had been approved by the governing board. The FM stated that some physical plant changes had been made immediately such as replacing the door hinges and installing anti-ligature door handles. The GPU had initiated safety measures in the interim, as the construction needed would require OSHPD (Office of Statewide Health Planning and Development) approval. The FM indicated that the GPU ensured that patients with suicidal ideation would not be admitted to the GPU, the staff were trained on suicide prevention, the process of admission to GPU, and that patients were under constant supervision.

A Quality Assessment Performance Improvement (QAPI) interview was conducted on 4/19/17 at 1 P.M. with the VPCC. The VPCC stated that the ligatures in GPU had been identified and a request for removal had been submitted in early 2017. The GPU had initiated changes such as replaced the door hinges, removed the plastic bags in the trash cans, removed the window blinds, changed the gowns to snaps, removed the call cords, removed the fitted sheets with elastic, and mirrors were replaced with polished metals. The VPCC further stated windows were bolted shut, had tempered glass, door hinges were removed and anti-ligature handles were installed. The VPCC also stated that the staff were trained on suicide prevention and assessment of patients for suicidal ideation. The VPCC stated the GPU does not admit any patient with suicidal ideation and had increased the nursing ratio to ensure patients have increased supervision and direct line of site.

A review of a memorandum directed to the BOD dated 4/12/17 and concurrent interview with the CEO was conducted on 4/19/17 at 1:30 P.M. The memo indicated that the BOD was informed of the suicide risk prevention in the physical environment of the GPU with details of the planned physical alterations to occur. The CEO stated the BOD was also informed that the policies and procedures and care delivery systems would ensure patient safety on the unit during implementation of the physical modifications.

An interview with the Executive Vice President of Operations (EVPO) was conducted on 4/20/17 at 10:30 A.M. The EVPO stated the GPU's renovation and removal of ligature plan had been elevated to emergent and the Unit will remain open in a limited capacity of 4 beds while sections of the unit will be closed to permit construction.

A review of all GPU patient's records was conducted 4/18/17 through 4/20/17.

a. Per the physician H & P dated 3/23/17, Patient 11 was admitted with a diagnosis of severe neurocognitive impairment with behavioral disturbance and denied suicidal ideation. According to the FAST assessment, Patient 11 had moderately severe dementia and had the mental age of 3 to 4 years. Per the nursing Flowsheets dated 3/23/17 through 4/19/17, Patient 11 required 1 to 2 staff for assistance with most ADLs.

Per the admission nursing Suicide Assessment dated 3/23/17, Patient 11 was documented as low risk for suicide. Per the ongoing Q shift suicide risk assessments dated 3/23/17 through 4/19/17, Patient 11 had no thoughts, intent, or plan for suicide.

On 4/20/17 at 9:20 A.M., Patient 11 and was observed seated in a Geri-chair (large padded chair with wheeled bases, designed to assist seniors with limited mobility), with a flannel sheet on top of the table positioned in front of the patient. Patient 13 was occupied moving and flattening the sheet and moved it around the table top. Patient 11 was seated next to Patient 13 and Patient 11, without saying any words joined in and assisted Patient 13 to straighten out the sheet until it covered the table.

After the sheet was straightened by Patient 11 and 13, the activity leader (AL) said to the group, "today is the 19th (wrong current date), what day is tomorrow?" No one responded to the prompt. The AL restated the question four times, and Patient 11 eventually answered, "the 20th."

Another observation of Patient 11 was conducted on 4/20/17 at 9:34 A.M. in the day room. Patient 11 sat in a Geri-chair with staff who demonstrated for Patient 11, how to tie a shoe lace. Patient 11 was observed to fumble and weave the shoe lace, and after 22 minutes the patient was eventually able to tie a loose bow.

b. Patient 12 was admitted to the facility on 3/31/17, per the face sheet. According to the H & P, dated 4/1/17, Patient 12 was admitted for being gravely disabled, had a major neurocognitive impairment, most likely Alzheimer's type and had no suicidal ideation.

According to the nursing admission Suicide Assessment, Patient 12 was low risk for suicide attempt. Per the ongoing Q shift suicide risk assessments, dated 3/31/17 through 4/19/17, Patient 12 had no thoughts, intent, or plan for suicide.

According to the nursing Flowsheets, Patient 12 was independent for some ADLs, but required either supervision or 1 person assistance for others.

c. Per the physician H & P dated 3/23/17, Patient 13 was admitted on 3/22/17, with a diagnosis of major neurocognitive impairment likely secondary to Alzheimer's disease and had no suicidal ideations. According to the FAST assessment, Patient 13 had moderately severe dementia and had the mental age of 3 to 4 years.

Per the nursing Flowsheet dated 3/22/17 through 4/19/17, Patient 13 required 2 to 3 staff for assistance with ambulation, bathroom assistance, getting in and out of bed and 1 person assist with all other ADLs. Per the admission nursing Suicide Assessment dated 3/22/17, Patient 13 was negative for suicide risk. Per the ongoing Q shift suicide risk assessments dated 3/22/17 through 4/19/17, Patient 13 had no thoughts, intent, or plan for suicide.

An observation of Patient 13 was conducted on 4/20/17 at 9:30 A.M. Patient 13 was observed sitting in a Geri-chair with the activities staff who instructed and demonstrated to Patient 13 how to tie a bow with an activity blanket (a fabric mat with shoe laces, zippers and buttons). Patient 13 was observed fumbling with the shoe lace, was unable to tie the bow and quickly lost interest.

d. Patient 14 was admitted to the facility on 4/3/17, with diagnoses which included severe neurocognitive impairment with behavioral disturbances, and had no thoughts of self harm, per the H & P. According to the FAST assessment, Patient 14 had moderately severe dementia and the mental age of 3 to 4 years. Per the nursing Flowsheets, dated 4/3/17 through 4/20/17, Patient 14 required 1 to 2 person assistance for ADLs.

According to the nursing admission Suicide Assessment, Patient 14 was low risk for suicide attempt. Per the ongoing Q shift suicide risk assessments, dated 4/3/17 through 4/19/17, Patient 14 had no thoughts, intent, or plan for suicide.

On 4/18/17 at 9:31 A.M, Patient 14 was observed. Patient 14 was seated in the day room during a group activity. The AL asked Patient 14 to tell the group about the "places" you have traveled. The patient did not respond verbally or non verbally.

e. Patient 15 was admitted to the facility on 3/31/17, per the face sheet.

According to the admission H & P, dated 4/1/17, Patient 15 had a neurocognitive impairment, secondary to Alzheimer's disease and had no thoughts of self harm. According to the FAST assessment, Patient 15 had moderately severe dementia and the mental age of a 2 to 3 year old. Per the nursing Flowsheets, dated 3/31/17 through 4/20/17, Patient 15 required 1 to 3 staff assistance with ADLs.

Per the admission nursing Suicide Assessment, dated 3/31/17, Patient 15 was negative for suicide risk and per the ongoing Q shift suicide risk assessments, dated 3/31/17 through 4/19/17, Patient 15 had no thoughts, intent, or plan for suicide.

On 4/20/17 at 9:20 A.M., Patient 15 was observed seated next to staff in a chair in the day room. Patient 15 was non verbal but appeared comfortable in the seated position next to staff. Occasionally Patient 15's attention was on the activity and others in the room. At 9:30 A.M. Patient 15 became restless and 2 staff assisted the patient to ambulate out of the room. Patient 15 was observed with spastic uncoordinated movements of trunk, arms, legs, and required physical support of 2 staff for ambulation to maintain an upright position.

f. Patient 16 was admitted to the facility on 3/25/17, and demonstrated neurocognitive impairment with behavior disturbance but denied suicidal ideation, per the admission H & P.

According to the nursing admission Suicide Assessment, dated 3/25/17, Patient 16 was low risk for suicide attempt and according to the ongoing Q shift suicide risk assessments, dated 3/25/17 through 4/19/17, Patient 16 had no thoughts, intent, or plan for suicide.

According to the nursing Flowsheets, dated 3/25/17 through 4/19/17, Patient 16 required 1 to 2 staff assistance with ADLs.

g. Patient 21 was admitted to the facility on 4/6/17, per the face sheet.

According to the admission H & P, dated 4/7/17, Patient 21 had major neurocognitive impairment, secondary to Alzheimer's, and had no thoughts of self harm. Per the FAST assessment, Patient 21 had moderately severe dementia and had the mental age of a 2 to 3 year old.

According to the nursing admission Suicide Assessment, dated 4/6/17, Patient 21 was low risk for suicide attempt, and according to the Q shift suicide risk assessments, dated 4/6/17 through 4/19/17, Patient 21 had no thoughts, intent, or plan for suicide.

The nursing Flowsheets, dated 4/6/17 through 4/20/17, reflected Patient 21 required 1 to 2 staff for assistance with ADLs.

On 4/19/17 at 10:25 A.M. Patient 21 was interviewed. Patient 21 said he had no thoughts related to self harm.

On 4/20/17 at 9:20 A.M Patient 21 was observed in the day room during a group activity. Patient 21 sat with his eyes closed throughout the activity until 9:45 A.M. and when he opened his eyes the AL attempted to engage him in the group. Patient 21 appeared to listen to the AL's spoken words and gestures, however it took multiple prompts and cues for Patient 21 speak.

h. Patient 22 was admitted to the facility on 4/3/17, per the face sheet.

According to the H & P, dated 4/4/17, Patient 22 had major neurocognitive impairment, Alzheimer's type, denied any prior suicide attempts and had no current thoughts of self harm. Per the FAST assessment, Patient 22 had moderately severe dementia and the mental age of a 4 year old.

According to the nursing admission Suicide Assessment, dated 4/3/17, Patient 22 was low risk for suicide attempt and per the ongoing Q shift suicide risk assessments, dated 4/3/17 through 4/19/17, Patient 22 had no thoughts, intent, or plan for suicide.

The nursing Flowsheets, dated 4/3/17 through 4/20/17, reflected Patient 22 required 1 staff member assistance, and rarely supervision, for ADLs.

On 4/19/17 at 9:43 A.M., Patient 22 agreed to an interview and 1 staff physically assisted Patient 22 to ambulate from the day room to her room. Patient 22 was observed with abnormal swaying trunk movements and some spasticity in upper and lower extremities. Patient 22 said she was at the facility because of "fear"...and said she "never" had thoughts or intention of self harm.

i. Patient 23 was admitted to the facility on 3/18/17, per the face sheet.

According to the H & P, dated 3/19/17, Patient 23 had severe neurocognitive impairment, secondary to Alzheimer's disease with behavioral disturbance, speech was nonsensical/disorganized and did not answer when asked about suicidal ideations. Per the FAST assessment, Patient 23 had moderately severe dementia and the mental age of a 3 to 4 year old.

According to nursing admission Suicide Assessment, dated 3/18/17, Patient 23 was low risk for suicide attempt and per the ongoing Q shift suicide risk assessments, dated 3/18/17 through 4/19/17, Patient 23 had no thoughts, intent, or plan for suicide.

Per the nursing Flowsheets, dated 3/18/17 through 4/20/17, Patient 23 required the assistance of 1 to 2 staff for ADLs.

On 4/20/17 at 9:31A.M., Patient 23 was observed for 30 minutes seated in a geri-chair in the reclined position. Patient 23 occasionally responded with non verbal facial smiles to the group activity, and the only verbal statement made was "my daughter." Patient 23 rarely moved any part of her body, she had an approximately 12 inch cloth wrapped baby doll in her lap. When Patient 23 did move her arms and hands she was observed to make minimal movements with significant tremors, and her attention was focused on the baby doll.

j. Patient 24 was admitted to the facility on 4/8/17, per the face sheet.

According to the H & P, dated 4/9/17, Patient 24 had a history of dementia, unspecified major neurocognitive impairment, and no suicidal ideation or thoughts to harm self.

According to the nursing admission Suicide Assessment, dated 4/8/17, Patient 24 was low risk for suicide and per the ongoing Q shift suicide risk assessments, dated 4/8/17 through 4/19/17, Patient 24 had no thoughts, intent, or plan for suicide.

According to the nursing Flowsheets, dated 4/8/17 through 4/20/17, Patient 24 was independent with some ADLs and others required one to one verbal instruction, supervision or 1 staff assistance.

k. Per Patient 25's H & P dated 4/13/17, the patient was admitted with a diagnosis of major neurocognitive impairment secondary to Alzheimer's disease with behavioral disturbance. Per the H & P Patient 25 had no suicidal ideations and had never made a suicide attempt. According to the FAST assessment, Patient 25 had moderately severe dementia and had the mental age of a 2 to 3 year old.

Per the admission nursing Suicide Assessment dated 4/12/17, Patient 25 was low risk for suicide. Per the ongoing Q shift suicide risk assessments dated 4/12/17 through 4/19/17, Patient had no thoughts, intent, or plan for suicide.

Per the nursing Flowsheets dated 4/12/17 through 4/19/17, Patient 25 required 1 to 2 staff with assistance with ADLs.

On 4/20/17 at 9:31 A.M., Patient 25 was observed in the day room. Patient 25 was asked by the AL to tell the group "something important about your self." The AL re-worded and prompted the patient several times and Patient 25 never verbally responded.

An observation of Patient 25 was conducted on 4/20/17 at 9:54 A.M. in the day room. Patient 25 was sitting in a Geri-chair with the AL who demonstrated, twice, to patient 25 how to tie a shoe lace. Patient 25 was unable to complete the task and quickly lost interest.

Each of these patients had similar care plans in place which included such interventions as Q 15 minute observations and Q shift reassessment of suicide risk etc.

According to the facility policy, entitled, Admission Criteria for the Gero-Psyciatric Unit (GPU), last revised 3/8/17, criteria that would exclude a patient admission was, "A patient at threat of harm to self, suicide intention or gesture, self mutilation (actual or threatened), A patient with a neurocognitive disorder at risk for suicide."

According to the facility policy, entitled, Assessment and Reassessment of Psychiatric Inpatients, approved 2/1/17, "All patients are assessed for suicide risk upon admission and will be reassessed at least once per shift...For the Gero-Psychiatric Unit (GPU), if a patient becomes suicidal or expresses intent of self-harm, he/she will be under the constant observation until assessed by a physician. If the physician deems the patient at risk for suicide, the patient will be transferred to an inpatient behavioral health unit."

2. A tour of the seclusion room in GPU was conducted on 4/18/17 at 10:20 A.M. with the IDBH and the DPSQ. The seclusion room had a twin sized bed secured to the floor. There was a 6 inch gap between the bed and the wall which would not allow staff to provide assistance from both sides of the bed in the event of an emergency, such as the need for 4 limb restraint, and a patient could potentially get an arm, leg or body part stuck in the 6 inch gap.

At that time the DPSQ attempted to move between the bed and wall up from the foot of the bed to the head of the bed and was unsuccessful. The DPSQ said it would be difficult to get in and out next to the bed and wall.

The IDBH stated at that time, the seclusion room was rarely used.

During a subsequent observation of the seclusion room on 4/18/17 at 11:20 A.M. conducted with the DDR, and the PM, the DDR was unsuccessful in an attempt to move between the wall and bed from the foot of the bed to the head of the bed. The DDR was successfully able to place an arm and partial leg between the bed and the wall.