HospitalInspections.org

The Condition of Participation: Patient Rights was out of compliance.

Findings included:

Based on record review and interviews, the Hospital failed to ensure one Patient (#3) was cared for in a safe environment out of a total sample of 10 patients. Patient #3 presented to the Emergency Department with a foreign body in the rectum and was able to continue to ingest and/or insert foreign bodies into the rectum requiring surgical intervention.


Cross Reference:
482.13(c)(2): Care in a Safe Setting (A0144)

Based on record review and interviews, the Hospital failed to ensure one Patient (#3) was cared for in a safe environment out of a total sample of 10 patients. Patient #3 presented to the Emergency Department with a foreign body in the rectum and was able to continue to ingest and/or insert foreign bodies into the rectum requiring surgical intervention.

Findings include:

Review of Hospital Policy titled, "Patient at Risk of Harm to Self or Others" review date, 3/21/22, included the following:

1:1: One Sitter provides uninterrupted direct visualization of one patient, including when in the bathroom.

Suicide observation: 1:1 observation of the patient at imminent risk of self-harm.

Policy: The licensed provider and the nurse are responsible for implementing interventions to mitigate the risk of suicide or harm to others and maintain patient safety.

When items that pose a risk of harm cannot be removed from the room, staff must have heightened awareness to the environmental hazards present and be vigilant in protecting the patient from access to the hazards.

A behavioral health clinician will complete a comprehensive mental health evaluation for any patient at risk of harm to self or others, including a suicide risk assessment.

Patient #3 was admitted to the Hospital multiple times in November 2024 with diagnoses including rectal foreign body, cannabis use disorder, hemoptysis, opioid use disorder and schizophrenia.


Review of Patient #3 ' s General Surgery Consult Note dated, 11/2/2024, indicated Patient #3 had been taken to the operating room earlier in the day to remove a foreign body that was reportedly placed after an assault. It was unclear if this was truly accurate or not, but the piece of metal enveloped in hard plastic was unable to be removed with a proctoscopic approach and Gastroenterology was able to use flexible sigmoidoscope to remove the foreign bodies. Patient #3 returned back to prison, broke eyeglasses and put those up his/her rectum and was transferred back to the Hospital. Review of Patient #3 ' s progress notes indicated further measures would need to be taken in order to keep the Patient from continuing to put things into his/her rectum, especially so rapidly after removal of a foreign body.

Review of Emergency Department Note dated 11/2/2024 indicated that Patient #3 stated he/she is having auditory and visual hallucinations, telling him/her to insert objects into his/her urethra and rectum. Of note presented on 11/1/2024 with rectal pain and a rectal foreign body noted on CT. Patient went to the Operating Room (OR) on 11/2/2024 for foreign body removal. A repeat Pelvic Xray did not demonstrate any further retained bodies.



Review of Patient #3 ' s History and Physical Report dated 11/2/2024 indicated Patient #3 had a history of schizophrenia, depression and anxiety. Patient #3 ' s History and Physical further Indicated MCI (Massachusetts Correctional Institute) officers were by the Patient ' s bedside; there was an indication for one-to-one to prevent further attempts to hurt self.


Review of a Physician ' s progress note dated 11/5/2024 at 6:36 P.M., indicated the following:

-Patient had a repeat Xray today concerning for an additional screw in the upper abdomen.

-1:1 observation.


Review of a Physician Event Note dated 11/6/2024, indicated Patient #3 returned from a sigmoidoscopy pending discharge. Patient #3 notified RN that he/she ingested several metal bits and also inserted a wire into his/her rectum. MCI Officers were close to the patient but may not have witnessed the incident since Patient #3 is going to the bathroom privately. The Physician Event Note further indicated Patient #3 had a one to one in place, as well as MCI officers at the bedside. Patient #3 ' s discharge was placed on hold.


Review of Patient #3 ' s physician orders indicated an order for continuous observation dated 11/8/2024 at 9:53 P.M.


Further review of Patient #3 ' s medical record failed to indicate any documentation of Hospital staff constant observations prior to 11/8/24 nor any orders to initiate constant observation for Patient #3 prior to 11/8/24 despite a known history of inserting objects into his/her own body and physician assessments and plans for 1:1 observation for Patient #3 on 11/2/24 and 11/5/24.


During an interview on 2/4/2025 at 11:48 A.M., the Hospitalist said Patient #3 had multiple admissions for foreign bodies. The Hospitalist said the Hospital has different types of 1:1 ' s, one for safety including falls and another type for self-harm. The Hospitalist said there was a question if Patient #3 was ingesting or inserting the foreign bodies into the rectum maliciously. The hospitalist said he puts in most of his own orders and recalls there being a Behavioral Health consultation, but behavioral health services did not evaluate Patient #3 the night of admission.


During an interview on 2/4/2025 at 1:12 P.M., Registered Nurse (RN) #5 said she recalled Patient #3. Registered Nurse #5 said on 11/5/24 she had reported Patient #3 ' s imaging results demonstrating foreign bodies in the Patient ' s rectum. Nurse #3 said the Hospitalist came up to the floor and she didn ' t recall new physician orders.


During an interview on 2/4/2025 at 1:45 P.M., the Director of Risk Management said if a Patient is on a 1:1 or constant observation an order should be in the medical record. The Director of Risk Management said the 1:1 observer is expected to fill out observation sheets every 15 minutes that are then scanned into the medical record.


Further review of the Hospital's Internal Investigation indicated there was no documentation to support the Hospital completed a thorough investigation or review of Patient #3's multiple ingestion events to include developing and implementing a systemwide corrective action plan to prevent further potential of similar adverse events.


The Hospital failed to maintain a safe environment for Patient #3; the Hospital did not implement interventions in order to prevent the Patient from ingesting and inserting foreign objects into his/her body.