HospitalInspections.org

The Psychiatric Hospital reported a census of 9 inpatients. Based on observations, staff interview and policy reviewed the hospital failed to ensure to protect and promote each patient's rights. The hospital failed to ensure patients receive care in a safe setting due to ligature (hanging) hazards. This deficient practice placed all suicidal patients at risk for harming or even killing themselves.

Findings Include:

The hospital failed to ensure the safety of their patients from ligature risks from one of one water fountain, three of three fire doors exit signs with large round eyes, three of three fire doors with large open hinges, one of two exit doors with unsmooth beveled hinges, one of two exit doors with push arm not flush to the door, one of three fire doors with interior push arm not flush to door/exterior with door handles, three of three fire doors with unsmooth beveled hinges and one of one electric box with combination lock which are all examples of ligature points which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation (Refer to A-0144 for further details).

Based on medical staff credentialing review, interview, and document review, the facility failed to ensure 2 of 5 medical staff members (Nurse Practitioner Staff G and H) had appointment signatures from the medical staff and board of directors, failure to ensure 1 of 5 medical staff members (Nurse Practitioner Staff G) included a sponsoring physician signature for appointment for privileges, failed to ensure 1 of 5 medical staff members (Nurse Practitioner Staff H) had a current Drug Enforcement Agency (DEA) license and a completed National Practitioner Data Bank is (NPDB - a United States Government program that the collects and discloses, only to authorized users, negative information on health care practitioners, including malpractice awards, loss of license or exclusion from participation in Medicare or Medicaid) report on file. This deficient practice has the potential to effect the quality of care, and place all patients at risk for harm due to lack of diligence in appointing and re-appointing providers by not ensuring a review of the practitioners' license history related to abuse, poor practice, or outstanding settlements and by not ensuring that they have a license to administer controlled substances.

Findings include:

- Medical Staff Credentialing, clinical privileges and NPDB inquiry review on 7/31/2017 at 1:00 PM revealed Nurse Practitioner Staff G's request for initial hospital privileges submitted 2/1/2017 lacked signatures for approval by the sponsoring physician, the medical staff, and the board of directors.

- Medical Staff Credentialing, clinical privileges and NPDB review on 7/31/2017 at 1:40 PM revealed Nurse Practitioner Staff H's credential file lacked a current DEA license and a NPDB inquiry. Staff H's request for initial hospital privileges submitted 1/27/2017 lacked signatures for approval by medical staff, and the board of directors.

- Chief Executive Officer (CEO) Staff A on 8/2/2017 at 4:40 PM upon facility exit, presented faxed documentation of Nurse Practitioner H's DEA license number, however the document lacked an expiration date.

CEO Staff A interviewed on 7/31/2017 at 2:00 PM acknowledged the items were missing and shared the reappointments were made in another physician's meeting. During credentialing review, the documents were not signed for Staff H or Staff G.

Document titled, "Medical and Professional Staff organization Bylaws" reviewed on 8/3/2017 at 8:57 AM directed, "...All nurse practitioners must have a supervising physician who is a member of Freedom Behavioral Hospital's active medical staff..."and "...The board shall be ultimately responsible for granting membership and responsibilities ..."and "... Any application, whether for initial appointment or reappointment will not be deemed to be complete and therefore ready for transmission to the credentials committee or other applicable Medical Staff (PAW) Committee until all information and attachments requested in the application are provided..."


Document titled, "Medical and Professional Staff organization Bylaws" reviewed on 8/3/2017 at 8:57 AM directed, "... Any licensed practitioner that serve in the psychiatric and medical field may apply with the hospital for privileges ...The applicant will be asked to supply documentation of the following threshold requirements: ...current, unrestricted DEA registration..." and "... DEA certificate: A temporary suspension of a practitioner's responsibilities to prescribe or obtain controlled substances or other medications at or through the hospital or any of its facilities shall be immediately imposed by the administrator upon the receipt by the hospital that such practitioner's light or license to prescribe or obtain controlled substances or medications has been suspended, revoked, or otherwise restricted by the applicable governmental agency. Such automatic suspension shall include only those controlled substances or medications suspended or revoked by the governmental agency and shall be effective until the governmental agency reinstates the practitioner's right or license in question..."

Based on medical record review, interview, and document review, the facility failed to follow the Medical and Professional Staff Organization Bylaws by failing to ensure 3 of 10 (Patient 1, 9 and 10) medical records were complete within 30-days of patient discharge. Failure to ensure medical record are complete has the potential to place all patients at risk for incomplete medical data, resulting in poor continuity of care or patient harm.

Findings include:

- Patient 1's medical record review on 7/31/2017 revealed the patient was admitted on 5/31/2017 with a diagnosis of psychosis (a severe mental disorder where the patient loses contact with reality) and bipolar disorder (episodes of depression and mania) and was discharged on 6/1/2017 to a local hospital with a medical emergency. The medical record review revealed the record lacked evidence of a discharge summary for this patient stay, 60 days post discharge, which exceeds the 30 day requirement.

- Patient 9's medical record review on 8/1/2017 revealed the patient was admitted on 4/13/2017 with a diagnosis of acute adjustment (temporary condition caused by stress) and psychosocial dysfunction (difficulty functioning normally in social situations) and was discharged on 4/27/2017 to their home. The medical record review revealed the record lacked evidence of a discharge summary for this patient stay, 95 days post discharge, which exceeds the 30 day requirement.

- Patient 10's medical record review on 8/1/2017 revealed the patient was admitted on 6/8/2017 with a diagnosis of depressive neurosis (depression in an emotionally unstable person) and was discharged on 6/12/2017 back to the institution where he/she resides. Medical record review revealed the psychiatric evaluation lacked physician's signature, 50 days post discharge, which exceeds the 30 day requirement.

Interview on 08/01/17 at 2:30 PM, Chief Executive Officer (CEO), Staff A acknowledged that the documentation was missing and indicated he would have medical records department locate the documents.

- Document titled, "Medical and Professional Staff Organization Bylaws," directed, Practitioners must complete their patients' medical records within 30-days of each patient's discharge and medical records that the practitioner fails to complete with in the 30-day (or other) period will be considered delinquent.

Based on observations, staff interviews and policy review the hospital failed to ensure the safety of their patients from ligature (hanging) hazards from one of one water fountain, three of three fire doors exit signs with large round lights on either side (bug eyes), three of three fire doors with large open hinges, one of two exit doors with unsmooth beveled hinges, one of two exit doors with push arm not flush to the door, one of three fire doors with interior push arm not flush to door/exterior with door handles, three of three fire doors with unsmooth beveled hinges and one of one electric box with combination lock. This deficient practice has the potential to cause harm and even death to any of the patients receiving care at the hospital.

Findings Include:

Review of the hospital's website under the tab "Signs and Symptoms", related, Who May Be Appropriate for an Initial Review (for admission to the hospital)? Someone who poses an actual or imminent danger to self or others due to behavioral manifestations of a mental disorder.

Observation of the patient unit on 07/31/17 and 08/01/17 revealed the following ligature (hanging) hazards:

1) One water fountain between the oxygen room and shower room with a spout at the top of the fountain (an example of a ligature point which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation).

2) Three exit signs with large round lights above the three fire doors have a separation that could easily be a ligature point used to attach a cord, rope or other material for the purpose of hanging or strangulation.

3) The three fire doors on the interior side have large hinges at the top side of door near the wall with adequate space to be a ligature point used to attach a cord, rope or other material for the purpose of hanging or strangulation.

4) The back Exit door next to room 112 and room 111 had two side beveled (sloping edge) hinges that could easily be a ligature point used to attach a cord, rope or other material for the purpose of hanging or strangulation. Demonstration with a cell phone cord placed on top of hinge revealed it slipped into a slit on the top side of the hinge and became a ligature point.

5) Exit door by room 104 had an open push arm that is not flush to door, which is an example of a ligature point which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation.

6) The interior side of the Fire door next to the nurses' station had an open push arm that is not flush to the door, which is an example of a ligature point which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation. The exterior side of this exit door had perpendicular side handles, which is an example of a ligature point which could be used to attach a cord, rope or other material for the purpose of hanging or strangulation

7) Three fire doors with total of 12 beveled side hinges on each side that could easily be a ligature point used to attach a cord, rope or other material for the purpose of hanging or strangulation.

8) One electric box, between the shower room and rooms #3 and #4, had a combination lock on it that could easily be a ligature point used to attach a cord, rope or other material for the purpose of hanging or strangulation. .

The hospital reported 0 current patients with suicidal thoughts or self harming behaviors. The hospital staff could not provide the number of patient admissions with suicidal thoughts or self-harming behaviors in the last 6 months.

Interview with the Director of Nursing (DON) on 08/02/17 at 1:30 PM, she reports the hospital does care for patients with suicidal thoughts or self harming behaviors, and if they receive a patient that is suicidal, that patient will be 1:1 immediately upon admission, we have back up staff for situations like that. We want our patients to be safe. Our new employees are educated how to handle patients when they become suicidal. The DON stated that our patients are in a safe environment, she has no concerns.

Interview with CEO Staff A on 08/01/17 at 2:45 PM, he reported the fire doors and the fire lights were required by the life safety if the generator kicks on. Their accrediting organization approved the hinges on the fire doors. The facility was going to put plastic around those hinges but not sure how it would work. Staff A stated the beveled hinges were on the list of ligature items that were allowed.

Policy titled, "Safety," reviewed on 08/02/17 directed the hospital, to ensure a safe and secure environment of care.

Policy titled, "Hospital Wide-Patient Safety Plant," reviewed on 08/02/17 directed the hospital, Hazard condition-any set of circumstances, exclusive of the disease or condition for which the patient is being treated, which significantly increases the likelihood of a serious physical or psychological adverse patient outcome.

Policy titled, "Suicide Precautions," reviewed on 08/02/17 directed, To ensure a safe environment for potentially self-destructive patients and to establish specific guidelines for staff observation of these patients. All patients placed on suicide precautions will be assigned an acuity level based upon the severity of the suicidal thoughts, plan or behavior. The levels are as follows: Every 15 minute observation...Line of sight observation...1-to-1 observation at all times.