HospitalInspections.org

Based on the review of medical records, the review of hospital policy, and interviews with hospital staff, it was determined that in one of one medical record, medical record # 1, the hospital failed to ensure the patient's right to receive care in a safe setting. Findings:

Although the hospital had developed and implemented a policy for personal property search for individuals admitted to the inpatient psychiatric unit, the policy and process failed to ensure that potentially dangerous objects were not available to patients on the unit. The personal property search of Patient # 1's personal belongings failed to establish with certainty the presence or the absence of dangerous objects. The presence of and the patient's possession of a dangerous object on the unit, broken tweezers, and the inability of hospital staff to establish how the tweezers came into Patient # 1's possession failed to ensure every patient's right to receive care in a safe setting on the inpatient psychiatric unit.

The Clinical Director of Behavioral Health Services was interviewed at 1010 hours on 05/06/2010 and reported the following incident had occurred on the inpatient psychiatric unit: Patient # 1 did not sleep all night between 2200 hours on 03/22/2010 and 0600 hours on 03/23/2010. The review of the unit's hourly sleep chart for that time period confirmed the report. Patient # 1 was awake and up and down in his/her room and the unit all night. The Director reported that Patient # 1 presented to the nurses station at about 0530 hours on 03/23/2010 and asked for medication. Patient # 1 was holding a broken tweezers in his/her hand and was observed to be bleeding from puncture wounds on his/her neck. The Director described the tweezers as about three and one half inches long with one tine broken off so that the tweezers looked like a spear.

The Director reported that nursing staff did not know how or where Patient # 1 obtained the tweezers.
Although the Clinical Director of Behavioral Health Services reported that unit staff did not know where the tweezers came from, documentation in the medical record focused on the makeup bag. The neuro stroke physician's progress note dated 03/24/2010 timed 1108 hours reflects the following: "The patient was hospitalized on the psych ward. Yesterday [s/he] asked for [his/her] make-up back and stabbed [him/herself ] in the neck with tweezers."

Although it is unknown how credible Patient # 1's statements were, the medical record contained the following entry by the attending psychiatrist in the progress note dated 03/31/2010 timed 1053 hours: "[S/He] [Patient # 1] states that [s/he] had the tweezers with [her/him] from the beginning but admitted that this was the first time [s/he] has ever self-injured like this."

Documentation in medical record # 1 reflects that Patient # 1 was admitted to the inpatient psychiatric unit from the Emergency Department (ED) at 1400 hours on 03/15/2010. The admitting psychiatrist's History and Physical dated 03/15/10 timed 1543 hours reflects Patient # 1 had a history of bipolar disorder, had stopped taking medications weeks ago, had signs of mania that included pressured speech, flight of ideas, increased activity, and delusional thinking and wanted to be admitted to the hospital voluntarily. The psychiatric examination identified "No" suicidal ideation. The principle diagnosis for admission was mania. The treatment plan included medications lithium and risperidone.

The ED RN completed a patient belongings list dated 03/14/2010 timed 2007. The belongings list identified clothes, two handbags, a makeup bag, two luggage bags, a cell phone, and valuables that included a wallet and money.

The following policy was reviewed: OHSU Health Care System Policy No:HC-ADM-PRS-P020 entitled Patient Personal Property, effective date 02/02/2004. The policy directed that "All patients admitted to the Psychiatric Units will have their personal possessions documented on a Patient Belongings Disposition Form. All patients and their belonging will be searched. Sharp or glass objects, belts, knives, medications, and other potentially dangerous items will be confiscated, labeled and stored in a locked area until discharge." Interview with Quality Management staff revealed that policy direction at the time of the incident was the same, although the hospital converted to an electronic patient belongings form since the policy inception.

Medical record # 1 contained a second patient belongings list generated on admission to the inpatient psychiatric unit. The belongings list was timed 1400 hours and dated 03/15/2010. The second patient belongings list differed from the first with respect to contents; clothing items, the luggage, handbags, and make up bag listed on the first belongings list were not listed on the second belongings list. The Clinical Director of Behavioral Health Services reported that the ED patient belongings list is not duplicated on admission to the inpatient psychiatric unit. Psychiatric Unit staff search the patient's personal belongings on admission to the unit and only document any differences between the initial belongings list and the search findings. The Director reported that the Behavioral Health Tech (BHT) searched Patient # 1's personal belongings according to hospital policy. The BHT was reported to be experienced in psychiatric care.

The Director reported that the BHT opened each of Patient # 1's bags, including the makeup bag, and inspected the contents. No sharp or glass objects were identified. The makeup bag was described as follows: about eight inches long, four inches high, and two inches wide. The Director reported that the BHT did not "dump out" the contents of the makeup bag. The Director reported that the BHT inspected the contents by visually looking through the contents in the bag and by handling the contents. Per unit practice, the BHT opened cosmetic containers like compacts and eye shadows and inspected the containers for glass or sharp edges. No sharp or glass objects were identified. No tweezers were identified. After Patient # 1's belongings were searched, all of Patient # 1's personal belongings were locked in his/her assigned personal belongings closet located on the unit.

The Director reported that nursing staff gave the makeup bag back to Patient # 1 at some time after admission to the inpatient psychiatric unit. The Director reported that staff checked the makeup bag contents prior to giving it back to Patient # 1. The Director reported that staff did not document either the search of the makeup bag prior to returning it to Patient # 1 and did not document the actual return of the makeup bag to Patient # 1. The Director reported that Patient # 1 had the makeup bag in his/her possession during his/her stay on the unit prior to 03/23/2010.

The psychiatrist's progress note dated 03/23/2010 timed 0638 hours reflects the following: "On my encounter [Patient # 1] ws (sic) calm, admits to having stabbed [him/herself] in the neck in an attempt to 'teke (sic) my own life' and explains this was because [s/he] fears 'people out there' will 'brutalize' [him/her]-[s/he] clarifies this to means (sic) people in the community. [S/he] is in pain and neck is very tender. [S/he] also requested medications that [s/he] could use to 'OD', and would like to sleep."
On examination the psychiatrist identified "multiple small shallow lacerations to neck-I can find 3 puncture wounds that have penetrated skin-these do not appear deep but continue to bleed in oozing fashion. Surrounding tissue appears inflamed".



-These findings also reflect noncompliance with the following Oregon Administrative Rule (OAR) for Hospitals:
333-505-0033 Patient Rights, A hospital shall comply with the requirements for patients' rights set out in 42 CFR 482.13 (71 FR 71426, December 8, 2006).

Based on the review of medical records and hospital policy, it was determined that in one of one medical record in which documentation reflects the use of restraint, medical record # 1, the hospital failed to ensure that the use of restraint or seclusion was in accordance with a written modification to the patient's plan of care. Findings:

1. The following hospital policy was reviewed: OHSU Health Care System policy No:HC-CLN-GPC-P046 entitled Restraint and Seclusion, Use of, Effective date: April 02, 2009. The policy failed to identify the hospital's obligation to ensure that the use of restraint or seclusion was in accordance with a written modification to the patient's plan of care. The policy lacked direction to staff to modify the patient's plan of care when restraint or seclusion was used in the provision of care.

2. Medical record # 1 was reviewed. Documentation on the Behavioral and Non-Behavioral Restraints data flowsheets in the medical record reflects the use of restraint on multiple occasions that included the following:
The use of restraint for behavioral management on 03/23/2010 from 0600 hours to 1029 hours;
The use of restraint for medical purposes on the following dates and times:
on 03/23/2010 from 2000 hours to 2300 hours;
on 03/24/2010 from 0000 hours to 2200 hours;
on 03/25/2010 from 0008 hours to 2226 hours;
on 03/26/2010 from 0025 hours to 1325 hours;
on 03/27/2010 from 0100 hours to 2100 hours;
on 04/24/2010 from 1900 hours to 2000 hours; and
on 04/25/2010 from 0000 hours to 0200 hours.

The medical record lacked written modification to the patient's plan of care to reflect the use of restraint.



-These findings also reflect noncompliance with the following Oregon Administrative Rule (OAR) for Hospitals:
333-505-0033 Patient Rights, A hospital shall comply with the requirements for patients' rights set out in 42 CFR 482.13 (71 FR 71426, December 8, 2006).

Based on the review of medical records, it was determined that in one of one medical record in which documentation reflects the use of restraint, medical record # 1, the hospital failed to ensure that the use of restraint was always in accordance with the order of a physician. Findings:

Medical record # 1 was reviewed. Documentation on the Behavioral and Non-Behavioral Restraints data flowsheets in the medical record reflects the use of restraint on multiple occasions that included the following:
The use of restraint for behavior management on 03/23/2010 from 0600 hours to 1029 hours;
The use of restraint for medical purposes on the following dates and times:
on 03/23/2010 from 2000 hours to 2300 hours;
on 03/24/2010 from 0000 hours to 2200 hours;
on 03/25/2010 from 0008 hours to 2226 hours;
on 03/26/2010 from 0025 hours to 1325 hours;
on 03/27/2010 from 0100 hours to 2100 hours;
on 04/24/2010 from 1900 hours to 2000 hours; and
on 04/25/2010 from 0000 hours to 0200 hours.

The medical record lacked documentation of a physician's order for the use of restraint on the following dates:
The medical record lacked a physician's order for use of restraint for behavior management and medical purposes on 03/23/2010 and on 03/24/2010.

The medical record lacked a physician's order for the use of restraint for medical purposes on 03/26/2010 between 0030 hours and 1325 hours.

The medical record lacked a physician's order for the use of restraint for medical purposes on 03/27/2010 between 0100 hours and 2100 hours.



-These findings also reflect noncompliance with the following Oregon Administrative Rule (OAR) for Hospitals:
333-505-0033 Patient Rights, A hospital shall comply with the requirements for patients' rights set out in 42 CFR 482.13 (71 FR 71426, December 8, 2006).