HospitalInspections.org

Based on observation and interview it was determined the hospital failed to ensure the condition of the physical environment was maintained in good repair and kept clean in order to ensure the safety and well being of patients as follows:
* The walls, flooring, furniture and other surfaces in the BH unit were not kept clean and in good repair, and were not maintained in a manner to ensure the surfaces were cleanable.

Findings included:

A tour of the 4300 BH unit was conducted with the Risk Manager and the Accreditation and Standards Coordinator on 12/03/2015 beginning at 1640.
In patient room 4317 observations were made and included but were not limited to the following:
* The door frame at the room entry had numerous areas of chipped paint.
* The bathroom door frame had a crumbling, dark colored matter near the floor that was not cleanable and was in disrepair.
* The grout on the floor and walls in the bathroom was discolored.
* An area of base floor molding near the window was not attached to the wall and an area of loose and crumbling wall surface was exposed.
* There were numerous areas of base floor molding that were peeling away from the floor.
* The flooring was dirty near the base floor molding throughout the room.
* The cupboard below the sink had areas of peeling and chipped wood laminate that were not cleanable and were in disrepair.
* The countertop had a large area of missing laminate and was not cleanable. The cupboard below the countertop had numerous areas of chipped laminate that were not cleanable.
* There were areas of scraped paint on the wall between the window and sink.

In patient room 4315 observations made included but were not limited to the following:
* Near the room entry, a corner area near the floor had exposed sheet rock and other construction material, and the base floor molding was cracked.
* The bathroom door frame had areas of brown and gray discoloration near the floor.
* The floor at the bathroom entry had areas of gray discolored grout.
* The grout around the sink edge was gray and discolored.
* The cupboard below the sink had areas of peeling and chipped wood laminate that were uncleanable and in disrepair.

In the patient "group" room observations made included but were not limited to the following:
* A corner of base floor molding was cracked and the wall above the molding had large areas of chipped paint.
* The sink, the grout around the sink, and the sink countertop were dirty. A used and soiled sponge was on the edge of the sink.
* The bathroom entry floor had a thick, grimy discolored matter.
* The base floor molding and floor were dirty in numerous areas in the room and bathroom.
* The cupboard below the sink had areas of peeling and chipped wood laminate that were uncleanable and in disrepair.
* Numerous wall areas were dirty and appeared splattered with an unknown substance.

Similar findings were identified during observations made of patient room 4316.
* Also in patient room 4316, a chair was observed and had numerous cracks in the upholstery and was therefore uncleanable.

Observations made of the entry into numerous patient rooms/areas reflected the rubber transition strip was peeling or missing including but not limited to rooms 4302, 4303, 4304, 4305, 4307, 4306, 4309, 4311 and 4312.

These findings were acknowledged and confirmed during an interview at the time of the observations with the Risk Manager.

Based on interview, documentation reviewed in 2 of 2 ED records of a patient (Patient 1 and 2) who presented to the ED with suicidal and homicidal symptoms, and review of ED policies and procedures, it was determined the hospital failed to ensure its policies and procedures were enforced:
* BH assessments and interventions were not completed and documented in accordance with hospital ED policies and procedures.

Findings included:

1. The ED policy and procedure titled "Behavioral Health Patient - Management in Emergency Department" dated effective 05/21/2013 was reviewed. The "Purpose" section reflected "...Provide a safe environment and maintain dignity during evaluation/treatment of Behavioral Health (BH) mentally ill patients while in the Emergency Department (ED)...Prevent harm to patients, visitors and staff...Provide appropriate
interventions/treatments."

The "Definitions" section reflected "Safety Hold: An emergency detention...ordered by the physician for persons who are incapacitated, at medical risk, or dangerous to self or others and are unable to make a rational decision to accept assistance or treatment."

The "Procedure" section reflected "...Clothing Removal...To ensure the safety of patients and staff, and allow for proper physical examination, all ED behavioral health patients (those presenting for care with behavioral health symptoms, behavioral reason for visit and/or chief complaint including, but not limited to, confusion, anxiety, stress, intoxication, etc.) will be placed in teal scrubs or hospital gown...Clothing removal will be initiated by ED staff...If patient refuses to comply with clothing removal, a head to toe metal detection wanding will occur...Optimally, the clothing removal process will occur simultaneously as the initial patient assessment...RN should document in FirstNet System any contributing factors which may delay this process from occurring within the first few minutes of arrival...Patient and Belongings Search...The first consideration must be the safety of all persons involved...Searches will be done by security officers with assistance from nursing staff, when needed...Use of metal detection devices will be used when needed. Wands will be used head to toe...Belongings will be searched for any of the following items...Weapons...Medications...Illicit drugs/contraband...Sharps (needles, knives, scissors, fingernail clippers)...Matches or lighters...Items made of glass or sharp plastic...Other potential weapons...Metal detector will be used if street clothes remain...Personal belongings will be placed in patient belonging bags and separated from patient as soon as possible after patient is taken to room...Belongings and valuables will be documented...Belongings will be stored in BH lockers in the ED until patient disposition is made...All belongings are to be sent with patient as patient leaves ED."

The "Patient Care" section of the policy reflected "...Patient Assessment/history/documentation...RN will complete appropriate patient assessment based on patient history and presentation...Specific examples of patient behavior should be included in assessment documentation...BH patients will receive a Suicide/Self-Harm risk assessment and/or Assault Violence assessment based on their reason for visit (chief complaint) and/or initial assessment...Assessment scores will be used to determine the frequency of patient checks...Documentation will be completed on the Suicide/Self-Harm Documentation, Emergency Department, form which is located in the ED forms drawer."

The "Documentation" section of the policy reflected "...ad hoc forms will be utilized as appropriate for patient presentation, including Suicide/Self-Harm Screen and Assault/Violence..."

2. The ED record of Patient 1 was reviewed and reflected that the patient presented to the ED by ambulance on 10/13/2015 at 2215.

The "Orders" section of the "Physician's Report" reflected an order for a "safety hold" at 2220.

The RN "ED Triage and Initial Assessment" dated 10/13/2015 at 2228 reflected "Reason for Visit...Feelings of being 'boxed in,' paranoia, and HI in grocery store. SI on and off today...Triage...Very Urgent..." The "ED Social History" section of the assessment reflected "Are you thinking of harming or killing yourself?: Yes Are you thinking of harming or killing anyone else?: Yes...[Patient reports] thoughts of SI, intermittently but denies having a plan. Also acknowledges thought of harming others but nobody in particular, 'just people on the streets." The "Suicide/Self-Harm Risk" assessment documented by the RN reflected "...Suicide/Self Harm risk: Moderate risk (4-9)."

The physician "Emergency Department Reports" electronically signed by the physician and dated 10/13/2015 at 2331 were reviewed and reflected the following:

The "History of Present Illness" section of the report reflected "...history of anxiety and schizoaffective who arrives to the ED via EMS for evaluation of a psychiatric problem. Per EMS, the [patient] called 9-1-1 complaining of feeling overwhelmed and paranoid, and endorses a desire to harm others. The [patient] endorses paranoia...[He/she] reports 'rage' recently."

The "Medical Decision Making" section of the report reflected "...Patient is ambulatory, in no distress, and does not appear to be actively responding to internal stimuli at the time [he/she] leaves the department."

The record reflected the patient was discharged home on 10/13/2015 at 1109.

There was no documentation in the medical record that the patient's belongings were searched, separated from the patient and a list of the patient's belongings documented in accordance with the hospital's ED policy.

These finding were reviewed and confirmed during an interview with the Interim ED Director on 12/04/2015 at 1200.

3. The ED record of Patient 2, the same patient who presented to the ED on 10/13/2015 at 2215 above, was reviewed.

The record reflected the patient returned to the ED on 10/13/2015 at 2347.

The RN "ED Triage and Initial Assessment" dated 10/13/2015 at 2350 reflected "[Patient] presents with police stating [he/she] was suicidal and wanted to run into traffic...Triage..2-Very Urgent..." The "ED Social History" section of the assessment reflected "Are you thinking of harming or killing yourself?: Yes" and "Are you thinking of harming or killing someone else?: Yes."

The physician "Emergency Department Reports" electronically signed by the physician and dated 10/14/2015 at 0209 were reviewed and reflected the following:

The "History of Present Illness" section of the report reflected "The patient presents with psychiatric problem. The onset was just prior to arrival. Character of symptoms angry agitated. The degree of symptoms is moderate. Self injury: stabbed self with pen to arm...history of anxiety and schizoaffective who arrives to the ED via police for evaluation of a psychiatric problem. This [patient] was discharged from the ED around 1 hour [prior to arrival], and comes back with police for a re-evaluation. Police report that the [patient] called 911 from a pedestrian bridge threatening suicide, and stabbed [him/herself] with a pen in [his/her] left arm..."

The "Medical Decision Making" section of the physician report reflected "...does not appear to be acutely psychotic...[patient] deemed appropriate for discharge...Patient is discharged in the company of police."

The record reflected the patient was discharged on 10/13/2015 at 2358, 11 minutes after the patient presented to the ED at 2347.

There was no documentation in the medical record reflecting that a Suicide/Self-Harm or a Assault/Violence assessment was completed; there was no documentation that the patient was placed in scrubs or a hospital gown for the physical examination; there was no documentation that the patient and patient belongings were searched; there was no documentation to reflect that a head to toe metal detection wanding was conducted; and there was no documentation to reflect that the patient's personal belongings were separated from the patient or why these assessments and interventions were not conducted in accordance with the hospital's ED policy.

These findings were reviewed and confirmed during an interview with the Interim ED Director on 12/04/2015 at 1450.