HospitalInspections.org

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Based on Medical Record (MR) review, document review and interview, in 2 (two) of 3 (three) cases reviewed, the facility failed to protect patients from self-injury. Specifically, the facility failed to;
(a) effectively implement " Search-Contraband" Policy and Procedures by restricting access to sharp objects that had the potential to be used as weapons and,
(b) ensure the windows in the Behavioral Health Unit met the specification guidelines of the New York State Office of Mental Health (NYS-OMH) and the American Architectural Manufacturers Association (AAMA) for safety.

These failures made it possible for a patient (Patient #1) to jump through a window and sustained life-threatening injuries, and placed all patients at potential risk for harm and self-injury.

Findings include:

See Tag 0144

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Based on Medical Record (MR) review, document review and interview, in 2 (two) of 3 (three) cases reviewed, the facility failed to protect patients from self-injury. Specifically, the facility failed to;
(a) effectively implement "Search-Contraband" Policy and Procedures by restricting access to sharp objects that had the potential to be used as weapons and,
(b) ensure the windows in the Behavioral Health Unit met the specification guidelines of the New York State Office of Mental Health (NYS-OMH) and the American Architectural Manufacturers Association (AAMA) for safety.

These failures potentially placed patients at risk of harm.

Findings:

Review of the facility policy and procedures titled "Search-Contraband" last revised 4/16 states, ...To identify contraband (also known as prohibited items) that potentially could be harmful to patients, visitors, and/or staff. The Behavioral Health Services is committed to maintaining a safe and secure environment by promoting preventative strategies to decrease the risk of untoward events, while respecting the rights of all patients, visitors and staff ... Restricted items include but are not limited to: Any sharp or pointed object that can be used as a weapon* (Any item marked with an Asterisk (*) will be confiscated and NOT returned.)

Review of MR for Patient #1 indicated a 35 year-old female behavioral health patient with the primary diagnosis of Major Depressive Disorder. The patient was admitted inpatient on 5/17/2020 following a suicide attempt by overdose after ingesting 8-10 Benadryl and multiple self-inflicted wounds over her face, neck and arms. Patient carried history of prior suicide attempts and a pattern of self-injurious behaviors, including cutting and burning herself. The physician documented in the admission note that the patient was seen and evaluated and required admission based on her imminent danger to self and long standing untreated mental illness.

The patient was admitted inpatient on 5/17/2020 into a single patient room (Room 11). The treatment plan included observations every fifteen minutes.

On 5/18/20 at 11:20 AM, a Nurse noted, Patient #1 expressed increased anxiety, was crying, and yelling and she received Ativan for her agitation with good effect noted by staff. At approximately 1:40 PM, the window of the patient's room was found shattered and she had jumped through the window. The patient sustained a left cranial blunt trauma, multiple fractures, liver damage, requiring resuscitation, massive blood transfusions and emergency surgery.

Review of Incident Report documented, on 5/18/2020 at 1:37 PM, "the patient was able to dislodge the window in her room, she was able to loosen the screws to the frame of an inner shatterproof window. The plastic - glazed safety window was cracked and opened. The outer glass windowpane was found broken and the patient had dived headfirst through the opening from the 8th floor. She landed three floors below on the pavilion roof of an adjacent structure."

Per interview on 5/26/20 at 10:34 AM, Staff M (Weekend On call Psychiatrist 8 Clark) stated, " I was the admitting doctor for this patient. When I met with her on Sunday, the patient didn't meet criteria for a one to one observation because she wasn't endorsing suicidal ideation. The level of observation was for her to have the routine checks every fifteen minutes ...the patient was admitted into a safe and secure area ..." when Staff M was asked about Patient #1 finding a way to breach the safe setting and jump out of a window undetected by staff, he replied ..."yes, but none of us would ever expected that to happen."

Per interview on 5/21/20 at 11:32 AM, Staff D, (Associate Director of Psychiatric Services) stated, "The patient was alone in room 11 ...we are not sure how she was able to open the window ...the inner window is impact resistant but the outer window is not ...we didn't find any screws on the floor and not a pencil either ...she would need an Allen Tool to open all three screws ...we think it's likely she could have used the bedside table and a body slam against the window to break through it ..."

Per interview on 5/26/20 at 10:05 AM, Staff O (Unit Secretary 8 Clark) stated, " the patient came to the desk sometime before 1:00 PM and asked me for a pencil. I gave her a pencil and she walked away with the pencil. I have heard about the Contraband Policy, but I gave her the pencil because she wasn't on a one to one and I didn't think that she couldn't have it."

There was no indication the facility implemented their Search- Contraband policy/procedures by removing 'sharp pointy objects' that posed a risk to a patient with recent history of suicide attempt and self-injurious behavior.
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Review of MR for Patient #2 identified the following: a 16-year female evaluated in the Comprehensive Psychiatric Emergency Program (CPEP) on 3/12/2019 after a suicide attempt by jumping in front of a moving train. The patient presented with a complaint of feeling depressed for the past few weeks and having thoughts of suicide. She carried a history of cutting herself, chronic feelings of depression and anxiety with psychotic features (behavior often accompanied by perception of stimuli voices, images, sensations and other hallucinations). During the physician's interview, the patient was guarded, tearful and dysphoric (a state of unease or generalized dissatisfaction with life). The patient was identified as a moderate risk for suicide and placed on a 1:1 Observation. The patient was admitted to the inpatient Adolescent Behavioral Health Unit on 3/13/19 for her history of self-injurious behaviors. The level of observation was downgraded on 3/13/19 at 2:45 AM to Q 15 minute checks. On 3/16/2019, the patient tried to hang herself by a bedsheet tied around her neck to the door divider in a bathroom. The attempt was unsuccessful. The patient stated she was suicidal and was hearing her voices telling her to kill herself. She was then seen scraping her right arm with a pencil in front of the Nurse. Patient #2 was then placed on a 1:1 Observation.

There was no indication the facility implemented their Contraband policies by withholding a sharp pointy object that posed a risk to a patient with history of suicide attempt and self-injurious behaviors.

These findings were confirmed during survey activities on 5/26/20 at 10:50 AM by Staff A (Director Quality/ Vice President), Staff E (Vice Chair Psychiatry), and Staff Q (Chief Medical Officer).

(b) Review of New York State - Office of Mental Health (NYS-OMH) Specification Guideline revised 1/30/2020 states that "New and Retrofit Exterior Window Applications Comply with 2,000 ft-lb impact test as specified by NYS-OMH and AAMA (American Architectural Manufacturers Association) 501.8 - 14 Standard Test Method for Determination of Resistance to Human Impact of Window Systems Intended for Use in Psychiatric Applications." In addition, the NYS-OMH guideline recommends ½ inch polycarbonate glass where escape or jumping are the risks to be mitigated.

Review of facility incident report dated 5/18/20, noted that on 5/18/20 at 1:37 PM, Patient #1 jumped out through a two-pane window in Room C8-11. The patient disengaged the interior plastic - glazed safety window (Plexiglass) and broke the exterior glass window.

During the tour of the 8th floor (Clark Building) Inpatient Behavioral Health unit on 5/21/2020 at 12:00 PM, it was observed that Room C8-11 had one double pane window that was damaged and opened. The interior window is hinged to the window frame and made of safety plastic glazing material (Plexiglass) with an aluminum frame; the plexiglass was fractured but not broken. The three latches that held the frame of the interior window to the window frame was disengaged and the window was swung open. The exterior window was made of glass in aluminum frame; the glass was broken.

Review of the Behavioral Health Unit risk assessment for 2019 and 2020 revealed there was no documented evidence that the exterior windows and the interior windows, in both supervised and unsupervised areas of the unit have been evaluated and met the NYS-OMH and AAMA specification.

During interview with Staff B on 5/22/20 at 11:30 AM, she acknowledged that the facility does not have any information on the human impact tolerance or resistance of the windows on the 8th floor behavioral health unit. Staff B reported that the thickness of the plexiglass interior windowpane was 1/4 inch and not the recommended ½ inch specified by NYS-OMH to mitigate the risk for escape and jumping.

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Based on observation, interview and document review, the facility failed to maintain the condition of the window system in the behavioral health unit in such a manner that the safety and well-being of patients are assured. Specifically, the facility failed to ensure that windows in the Behavioral Health Unit met the specification guideline of the New York State Office of Mental Health (NYS-OMH) and the American Architectural Manufacturers Association (AAMA).

This failure made it possible for a patient to jump through a window and sustained life-threatening injuries.

Findings include:

During the tour of the 8th floor (Clark Building) Inpatient Behavioral Health unit on 5/21/2020 at 12:00 pm, it was observed that Room C8-11 had one double pane window that was damaged and opened. The interior window is hinged to the window frame and made of safety plastic glazing material (Plexiglass) with an aluminum frame; the plexiglass was fractured but not broken. The three latches that held the frame of the interior window to the window frame was disengaged and the window was swung open. The exterior window was made of glass in aluminum frame; the glass was broken. Except for Room C8-11 that was locked, it was observed that the facility had installed "L" braces to secure all 48 windows in the unit.

During interview with Staff B (Environmental Health and Safety Director) at the time of observation, she stated the latches of the interior window can be opened and closed with an Allen wrench.

Upon interview with Staff A (Nurse Manger) on 5/22/20 at 12:30 pm, she reported that on 5/18/20 at 1:37 pm, the occupant of the room (C8-11), Patient #1 was "somehow able to disengage the latches" of the interior windowpane and opened it, she then broke the exterior glass window and jumped through it. The patient landed on the 5th floor roof of the building extension and sustained severe injuries.

Review of New York State - Office of Mental Health (NYS-OMH) Specification Guideline last updated 1/31/2020 states that "New and Retrofit Exterior Window Applications Comply with 2,000 ft-lb impact test as specified by NYS-OMH and AAMA (American Architectural Manufacturers Association) 501.8 - 14 Standard Test Method for Determination of Resistance to Human Impact of Window Systems Intended for Use in Psychiatric Applications."

Review of the Behavioral Health Unit risk assessment for 2019 and 2020 revealed there was no documented evidence that the exterior windows and the interior windows, in both supervised and unsupervised areas of the unit have been evaluated and met the NYS-OMH and AAMA specification for safety.

During interview with Staff B on 5/22/20 at 11:30 am, she acknowledged that the facility does not have the information on the human impact tolerance or resistance of the windows on the 8th floor behavioral health unit. In addition, Staff B stated that the thickness of the plexiglass interior windowpane was 1/4 inch.

The facility did not implement the NYS-OMH guidelines last updated 1/30/2020 that recommends ½ inch polycarbonate glass where escape or jumping are the risks to be mitigated.