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Based on document review, observation and interview, the facility failed to ensure a safe environment was maintained for 1 of 10 MR (medical records) reviewed (Patient #3) (see tag 144).

The effects of the failure to provide a safe environment resulted in the hospital's inability to ensure that Patients Rights were promoted.

Based on document review, observation and interview, the facility failed to ensure a safe environment was maintained for 1 of 10 MR (medical records) reviewed (Patient #3) and 1 of 1 hazard identified during a facility tour (quiet room door handle).

Findings include:

1. Review of the policy/procedure Inpatient Professional Services Plan (revised 2-18) indicated the following: "Patients served in [the facility's] Inpatient unit are adults over the age of 18 and seriously mentally ill and/or dually diagnosed. They are in need of a safe environment in order to have their symptoms assessed and stabilized. Patients admitted to the Inpatient unit usually have severe symptoms that impair the person's ability to function in a less-supervised setting."

2. Review of the policy/procedure Patient Safety Event Incident Report Process (revised 6-17) indicated the following: "Serious bodily injury: Serious physical or psychological injury on [the facility's] property that specifically includes loss of limb or function. Permanent loss of function means sensory, motor, physiologic, or intellectual impairment requiring continued treatment, services or care or lifestyle change."

3. Review of the MR for Patient #3 indicated the patient had a history of multiple suicide attempts (including a recent episode where the patient swallowed several razor blades) and multiple psychiatric hospital admissions prior to 10-18-18 when the patient was brought to the psychiatric facility by Law Enforcement after receiving medical treatment for a suicide attempt involving ingestion of 270 Flexeril (cyclobenzaprine) tablets.

4. The MR for Patient #3 indicated admission orders on 10-18-18 including Level 1 (every 15 minute checks) suicide precautions and indicated on 10-23-18 at 1920 hours the patient reported ingesting parts of an ink pen to staff. The MR indicated on 10-24-18 an order for Level 2 (line of sight) precautions and indicated the patient was evaluated by medical staff at an ED (emergency department) and released.

5. The MR for Patient #3 indicated on 10-25-18 at 1845 hours the patient reported obtaining and ingesting a colored pencil to staff while on line of sight precautions, at 1940 hours an order for Level 3 (within arm's reach) precautions was obtained, and on 10-26-18 indicated the patient was evaluated by medical staff at an ED and released.

6. Review of the Daily Shift Report (a shift staffing worksheet indicating the names of staff assigned to work on the inpatient unit) for the evening shift on 10-25-18 lacked documentation indicating an additional staff member was assigned to ensure that continuous line of sight observations of Patient #3 were maintained as ordered.

7. On 11-27-18 at 1545 hours, The Vice President of Nursing, staff A1 confirmed that an additional staff member was not assigned to work on the 10-25-18 evening shift in response to the Level 2 precautions order.

8. Review of the Daily Shift Reports for the night shifts on 10-25-18 and 10-26-18 and the evening shift on 10-26-18 after 1930 hours lacked documentation indicating additional staff were on duty in response to the Level 3 precautions order.

9. On 11-27-18 at 1550 hours, staff A1 confirmed the indicated Daily Shift Reports lacked documentation indicating an additional staff member was assigned to work on the indicated shifts in response to the order for Level 3 suicide precautions.

10. The MR for Patient #3 indicated an order on 10-27-18 to reduce the suicide precautions to Level 2 and on 10-28-18 to Level 1 precautions.

11. The MR for Patient #3 indicated on 11-1-18 at 1535 hours the patient reported ingesting batteries obtained from an unsecured television remote control to staff and indicated the patient was evaluated by medical staff at an ED and admitted to the medical facility.

12. On 11-26-18 at 1220 hours, staff A1 confirmed the direct care staff are responsible for maintaining control of the television remote controls and no patient should have access to the remote control device at any time.

13. The MR for Patient #3 indicated on 11-14-18 the patient was readmitted to the psychiatric hospital after experiencing a perforated colon and undergoing abdominal surgery with creation of a colostomy. The MR indicated the patient had a midline abdominal wound at the time of readmission and treatment orders for daily wet-to-dry wound dressing changes were noted.

14. On 11-27-18 at 1045 hours, staff A1 confirmed the acute change in condition involving Patient #3's admission to a medical hospital after ingesting non-food items on several occasions and resulting in abdominal surgery due to a perforated bowel with creation of a new colostomy and daily wound treatments was consistent with the facility definition for serious bodily injury observed in the policy/procedure Patient Safety Incident Report Process and confirmed that an investigation and/or Root Cause Analysis (RCA) had not been conducted into all possible factors that may have contributed to Patient #3's admission to a medical hospital.

15. On 11-26-18 at 1710 hours, during a tour of the inpatient unit in the company of A1, the Inpatient Supervisor A2 and the Quality and Risk Manager A4, the following environmental hazard was identified as follows: a blade-type door handle installed with the blade end up on the inside of the quiet room door was observed to be represent a potential ligature hazard for inpatients at risk for suicide by self-asphyxiation.

16. On 11-26-18 at 1710 hours, during a tour of the inpatient unit in the company of A1, A2 and A4, the staff confirmed the observation of a blade-type door handle installed with the blade end up on the inside of the quiet room door was a hazard due to potential ligature risk to patients.

Based on document review and interview, the facility failed to identify, investigate and analyze adverse patient events for their causes and implement corrective measures to prevent future occurrences for 2 adverse patient events identified during a MR (medical record) review (Patient #3).

Findings include:

1. Review of the policy/procedure Sentinel Events (revised 4-17) indicated the following: "A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof ... Root Cause Analysis (RCA) - Root Cause Investigation (RCA): a specific type of investigation that is geared toward understanding and changing the systems in which [a] Sentinel event has occurred ... A Patient Safety Incident Form will be completed within 24 hours of the incident when there is a sentinel event ... If a sentinel event has occurred, the Patient Safety Chair will assign team members to begin an RCA within 7 days of the receipt of the sentinel event."

2. Review of the policy/procedure Patient Safety Event Incident Report Process (revised 6-17) indicated the following: "The Patient Safety Committee will review all Patient Safety Reports and if necessary conduct an RCA investigation, highlight system failures and report such to Quality Council ... Patient Safety Reports shall be written when any unusual situation, adverse event, or good catch occurs. The facts and circumstances surrounding the incident should be documented as soon as possible after the event, but no later than 24 hours after the incident ... The Patient Safety Committee Chair and/or the Patient Safety Committee will determine what action needs to be taken with respect to the Patient Safety Incident Report."

3. On 11-27-18 at 1400 hours, staff A4 confirmed a requested list of all inpatient incident reports during the past 6 months was not available at the time of the investigation to evaluate individual occurrences with regard to time of day/day of the week, concurrent admissions and discharges or other factors with potential influence.

4. Review of a sample of recent Inpatient Patient Safety Reports provided in response to a request indicated two events involving Patient #3 and review of the 11-1-18 event indicated the patient was admitted to the facility after ingesting some batteries obtained from a television remote control. The documentation indicated it was reviewed on 11-19-18 by the Vice President of Nursing, staff A1 and no documentation indicating the causes associated with the medical admission were investigated and (if indicated) an action plan with interventions were implemented in response.

5. Review of the 11-15-18 Patient Safety Committee Meeting minutes lacked documentation indicating which Inpatient unit Patient Safety Reports and other Patient Safety Reports were reviewed and the committee-recommended action to be taken (including no further action).

6. On 11-27-18 at 1810 hours, the Manager of Quality and Risk, staff A4 confirmed the committee minutes lacked the indicated documentation.

7. Review of the MR for Patient #3 indicated on 11-14-18 the patient was readmitted to the psychiatric hospital after experiencing a perforated colon and undergoing abdominal surgery with creation of a colostomy. The MR indicated the patient had a midline abdominal wound at the time of readmission and treatment orders for daily wet-to-dry wound dressing changes were noted.

8. On 11-27-18 at 1045 hours, staff A1 confirmed the critical injury and acute change in condition associated with ingesting foreign objects on several occasions prior to admission at a medical hospital resulting in a perforated bowel and abdominal surgery with creation of a new colostomy and daily abdominal wound treatments was consistent with the definition for serious bodily injury observed in the policy/procedure Patient Safety Incident Report Process and A1 confirmed an investigation and/or Root Cause Analysis (RCA) had not been conducted into all possible factors that may have contributed to Patient #3's admission to a medical hospital. Staff A1 confirmed the change in condition involving Patient #3 was consistent with criteria identified on the Indiana Family and Social Services Administration Critical Incident Report section for Private Mental Health Institutions as follows: "A serious, unexpected consumer injury resulting in or potentially resulting in loss of function and/or marked deterioration in a consumer's condition ..." and confirmed a written Critical Incident Report had not been completed and submitted to the State within ten (10) working days of Patient #3's re-admission to the facility as indicated on the State report form.

9. Review of the 10-18-18 admission for Patient #3 indicated on 10-25-18 at 1845 hours that Patient #3 reported ingesting a colored pencil while line of sight (Level 2) suicide precautions were in effect and no facility administrative documentation indicated a Patient Safety Incident Report was completed within 24 hours of the event.

10. On 11-26-18 at 1420 hours, the Quality and Risk Manager, staff A4 confirmed no Patient Safety Incident Report on 10-25-18 indicating Patient #3 ingested a colored pencil while being monitored by line of sight precautions was available.

Based upon document review and interview, the facility failed to follow its staffing plan and ensure adequate numbers of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and other personnel were available to provide care to 1 of 10 patients (Patient #3).

Findings include:

1. Review of the policy/procedure Clinical Staffing Plan (revised 2-18) indicated the following: "On a daily basis it may be necessary to adjust the staff pattern for acuity, call offs, or low census..." and Attachment A: A Clinical Staffing Guideline indicated 2 day shift and evening shift RNs and 2 Psychiatric Techs and for 1 night shift RN, 1 LPN and 1 Psychiatric Tech were to be utilized for a patient census from 5 to 16 patients.

2. Review of daily inpatient census documentation for October and November 2018 provided by the Vice President of Nursing, staff A1 indicated the following:
13 inpatients on 10-25-18,
11 inpatients on 10-26-18 and 10-27-18,
6 inpatients on 11-15-18, and
5 inpatients on 11-16-18, 11-17-18, 11-18-18 and 11-19-18

3. Review of the MR (medical record) for Patient #3 indicated Level 2 suicide precautions (line of sight) were ordered on 10-24-18 at 0907 hours and indicated on 10-25-18 at 1845 hours that Patient #3 reported to the Registered Nurse N34 they had swallowed a colored pencil.

4. Review of the Daily Shift Report (a shift staffing worksheet indicating the names of staff assigned to work on the inpatient unit) for the evening shift on 10-25-18 lacked documentation indicating an additional staff member was assigned to ensure that continuous line of sight observations of Patient #3 were maintained as ordered.

5. On 11-27-18 at 1545 hours, the Vice President of Nursing, staff A1 indicated the staff responsible for maintaining continuous line of sight observations of Patient #3 on 10-25-18 around the time when the patient ingested pieces of a colored pencil may have been conducting their staffing change over, or may not have been close enough to the patient, or may not have been facing in the right direction to properly observe the patient at the time of the event and confirmed an additional staff member was not assigned to work on the 10-25-18 evening shift in response to the Level 2 precautions order.

6. Review of the MR for Patient #3 indicated a new order on 10-25-18 at 2110 hours for Level 3 suicide precautions (within arm's reach) and review of the Suicide III Precaution Monitoring Sheets on 10-25-18 and 10-26-18 indicated the patient was required to sleep in the day room at night while accompanied by staff to ensure Level 3 precautions were maintained.

7. Review of the Daily Shift (staffing) Reports for the night shifts on 10-25-18 and 10-26-18 and the evening shift on 10-26-18 after 1930 hours lacked documentation indicating additional staff were on duty to ensure a staff was within arm's reach of Patient #3 at all times.

8. Review of the MR for Patient #3 indicated admission orders on 11-14-18 for Level 3 suicide precautions and review of the Suicide III Precaution Monitoring Sheets on 11-14-18, 11-15-18, and 11-16-18 indicated the patient was required to sleep in the day room at night while accompanied by staff to ensure Level 3 precautions were maintained.

9. Review of the Daily Shift (staffing) Reports for 11-15-18, 11-16-18, 11-17-18, 11-18-18 and 11-19-18 lacked documentation indicating additional staff were on duty to ensure a staff was within arm's reach of Patient #3 at all times.

10. On 11-27-18 at 1550 hours, staff A1 confirmed that the policy/procedure Clinical Staffing Plan lacked a provision ensuring additional staff were on duty in the event of patient orders for Level 2 or Level 3 suicide precautions and confirmed the Daily Shift Report documentation identified above failed to indicate additional direct care staff were on duty in response to the orders for Level 2 and Level 3 suicide precautions.

Based upon document review and interview, the facility failed to ensure patient care plans were maintained for 1 of 10 medical records (MR) reviewed (Patient #3).

Findings include:

1. Review of the policy/procedure Treatment Plan (revised 2-18) indicated the following: "Every patient shall have an individualized treatment plan based on a professional assessment and a multi-disciplinary approach as appropriate to the case ... Treatment plans shall be kept current through treatment plan reviews [and] be reviewed and updated at least every 7 days.

2. Review of the IP Treatment Plan for Patient #3 on 10-27-18 indicated the following under Problem 1. IP Suicide Risk as follows: " ...Progress: Patient is progressing towards goal AEB (as evidenced by) patient is documented as not having harmed self on inpatient unit ..." and the following under Problem 4. IP Medical Condition as follows: "Goal: Patient will not require ER medical care while inpatient ... [and] ... Progress: Patient is progressing towards goal AEB no ER care required thus far this hospitalization ..." and lacked documentation indicating the plan was updated after the patient reported ingesting parts of a pen to staff on 10-23-18 at 1920 hours, or on 10-24-18 when the suicide precaution level was increased to Level 2 and the patient was sent to the ED for evaluation of abdominal pain, or after the patient reported ingesting a colored pencil to staff on 10-25-18 at 1845 hours while on Level 2 precautions and the suicide precaution level was increased to Level 3, or on 10-26-18 when the patient was sent to the ED for evaluation of abdominal pain, or indicating new safety interventions were implemented to ensure the environment of care is free of small objects and/or the patient's access or use of items with a potential swallowing risk was continuously monitored.

3. On 11-27-18 at 1010 hours, the Vice President of Nursing, staff A1 confirmed the treatment plan for Patient #3 failed to indicate on 10-27-18 it had been updated under Problem 1. Suicide Risk with regard to orders on 10-24-18 to increase the suicide precautions to Level 2 after the patient reported ingesting pieces of a pen on 10-23-18, or an order on 10-25-18 to increase the suicide precautions to Level 3 after the patient reported eating a colored pencil while Level 2 precautions were in effect. Staff A1 confirmed the treatment plan had not been updated under Problem 4. IP Medical Condition after Patient #3 was sent to the ED on 10-24-18 after reporting they had ingested pieces of a pen on 10-23-18, or after being sent to the ED on 10-26-18 after reporting they had ingested a colored pencil on 10-25-18.

4. Review of the IP Treatment Plan for Pt#3 on 11-2-18 indicated the following under Problem 1. IP Suicide Risk as follows: " ...Progress: Patient is progressing towards goal AEB patient denies SI (suicidal ideations) or thoughts to self-harm at time of this entry. Patient is on 15 minute safety checks ..." and lacked documentation indicating the patient's suicide precautions level was increased to Level 3 after ingesting batteries on 11-1-18 and was admitted to a medical hospital.

5. Staff A1 confirmed the treatment plan for Patient #3 lacked documentation on 11-2-18 indicating it had been updated under Problem 1. Suicide Risk with regard to orders to increase the suicide precautions to Level 3 after the patient ingested batteries on 11-1-18 and was admitted to a medical hospital.