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Based on a review of medical records, review of hospital documentation, review of hospital policies and interviews, the hospital failed to ensure that patients received care in a safe setting. Patient #1 presented to the Emergency Department with mental status changes, active hallucinations and was admitted to an in-patient medical unit with hypertension. On the second day of hospitalization, Patient #1 was observed with a gun, which he/she discharged resulting in harm to a staff member and the patient. The hospital failed to follow policies for ascertaining and documenting patient valuables/belongings upon admission to the Emergency Department and upon transfer to the inpatient unit.

Please refer to A-114.

Based on a review of the clinical record, review of hospital documentation, policies, and staff interviews for one of six patients reviewed (Patient #1), hospital staff failed to follow policies related to patient valuables/belongings to assist in rendering a safe environment. The findings include:

1. Patient #1 was brought to the Emergency Department (ED) via ambulance on 3/1/10 at 1:08 AM for an emergency psychiatric evaluation. The Police Emergency Evaluation Request (PEER) dated 3/1/10 identified that the patient was scared, confused and hearing voices. Review of the ED record identified that the patient was treated for hypertension. The patient's thought processes were delusional, with flight of ideas and loose associations. The patient experienced auditory and visual hallucinations. The patient denied depression or suicidal thoughts. The clinical record indicated that the patient presented with suspected dementia with onset of hallucinations with the etiology questioned. Patient is considered a risk to himself. Review of the clinical record and interview with MD #1 on 3/4/10 at 1:05 pm identified that the patient denied suicidal ideation and was not safe to be discharged home. MD #1 stated that the patient required admission to the medical unit, as he/she was not medically stable to be evaluated in the crisis intervention unit.

Review of the clinical record and interview with RN #1 on 3/10/10 at 8AM identified that the patient was assisted into a hospital gown while in the ED. RN #1 identified that she did not ascertain what the patient's valuables were while in the ED as the patient's medical condition was the top priority.

Interview with RN #2 on 3/11/10 identified that she completed the admission nursing assessment on 3/1/10 at 4:18 AM while Patient #1 was in the ED. Review of the assessment identified that the patient was disoriented to place/situation/time and that the patient was informed of the valuables policy. RN #2 stated she did not complete a valuables checklist for the patient as he/she was already in the hospital gown when she went to the ED to perform the assessment. The hospital ED valuables policy identified that any patient who is not capable of looking after his/her own valuables will have valuables placed in a valuables envelope, contents will be recorded on the envelope and will accompany the patient to the nursing unit.

RN #1 and RN #2 failed to follow the hospital's valuables and personal belongings policy.

The patient was admitted to a medical unit of the hospital with diagnoses that included altered mental status, hallucinations and hypertension. Review of the clinical record and interview with RN #7 on 3/12/10 at 11 AM (assigned nurse on the medical unit) identified that the patient arrived to the unit with belongings in a bag, however, did not inquire as to what was in the bag or complete a belongings form.

Review of the hospital belongings policy indicated that a personal belongings form must be filled out listing items that will remain in the patient's possession and signed by the patient or a family/friend. The belongings sheet directed to check off appropriate boxes when belongings are present, including but not limited to clothing as well as other patient items and valuables.

Review of the clinical record failed to identify that a valuables envelope or belongings form had been completed for Patient #1's admission in accordance with policy.

Review of the history and physical dated 3/1/10 identified that the patient believed people wanted to kill him with a plan to have psychiatry evaluate for psychosis. Review of the psychiatry consultation dated 3/1/10 identified that the patient denied suicidal ad/or homicidal ideation and did not require inpatient psychiatric care at this point. Review of Patient #1's clinical record dated 3/2/10 at 2:15 PM identified that the patient had increased agitation, thought the intravenous pump was going to kill him/her, was observed pointing a gun in the hallway then fired the gun at staff. The record indicated that before the gun was retrieved by security, a staff member as well as the patient had been shot. Interview with Nurse Aide (NA) #1 on 3/9/10 at 2:15 PM identified that the patient requested to see his/her two belonging bags and coat just before 11 AM-11: 30 AM on 3/2/10 and again at approximately 1:50 PM.

The hospital failed to ensure that staff followed the valuables and personal belongings policy while in the ED and once admitted to the medical unit.

Review of facility documentation identified that the medical unit had a census of 20 patients during the time of this incident. Interview with the Vice President of Quality and Patient Safety on 3/5/10 identified that immediately after the incident, staff provided reassurance to patients on the unit and ensured their safety was not at risk.

Based on review of medical staff files, interviews with staff, and review of policies, the medical staff failed to ensure that physicians were appraised every 24 months. The finding includes:

Seven emergency medicine physician's credentialing files were reviewed on 3/5/10. Six physicians were due to be reappointed in November 2009 and one physician was due to be reappointed in June 2009. Hospital documentation identified that the seven physicians were not reappointed until March 2010. According to the Medical Staff credentialing policy, reappointment shall be for a period of not more than two years. Interview with the Credentialing Manager on 3/5/10 at 10:15 PM identified that reappointment letters were sent out late resulting in all emergency medicine physicians being reappointed late.

Based on medical record review, review of facility policy and interview nursing staff failed to develop a comprehensive plan for one patient (Patient #1) who presented with hallucinations. The findings include:

1. Patient #1 was brought to the Emergency Department (ED) via ambulance on 3/1/10 at 1:08 AM for an emergency psychiatric evaluation. The Police Emergency Evaluation Request (PEER) dated 3/1/10 identified that the patient was scared, confused and hearing voices. Review of the clinical record dated 3/1/10 reflected that MD #1 noted that the patient had auditory/visual hallucinations and scary thoughts while in the ED. The patient was admitted to the medical unit with diagnoses that included hypertension, altered mental status and hallucinations. A psychiatric consultation dated 3/1/10 identified that the patient was actively hallucinating. Review of the care plan dated 3/1/10 identified the patient had altered mental status, a goal that the patient would not hallucinate with non-specific interventions that included monitor the patient. The hospital failed to develop a plan of care that identified specific interventions to address the patient's individual needs. The hospital policy identified that the multidisciplinary treatment plan (MTP) is initiated upon admission and updated to reflect changes as needed. The MTP incorporates active problems of the patient.

2. Patient #1 had a fall risk assessment dated 3/1/09 that identified the patient was at high risk for falls. The safety protocol was implemented that included the use of a bed alarm, toileting every 2-3 hours and more frequent monitoring. Review of the Flow sheets identified that patient's was monitored on an hourly basis in accordance with the routine unit protocol. Review of the clinical record dated 3/1/10 and 3/2/10 identified that the patient's gait was unsteady. Interviews with staff (NA #1 on 3/9/10 and RN #3 on 3/9/10) reported that the patient was confused, paranoid, set off the bed alarm most of the night and continued with the same behavior throughout the morning of 3/2/10. The fall prevention policy directed to provide more frequent rounding (more than hourly) for patients with high fall risk. The hospital failed to ensure that the plan of care was revised to include specific interventions to address the patient's confusion and paranoia.