HospitalInspections.org

Based on interviews, medical record reviews, and review of the facility's policies and procedures, it was determined the facility failed to ensure the safety of one (1) patient (Patient #1) in the selected sample of ten (10) due to failure to adhere to their policies and procedures pertaining to routine searches at the time of admissions and after visitation and as their policies pertain to 1:1 observations.

Patient #1 refused to be searched upon admission and after visitation. Mental Health Technician (MHT) #11 failed to report to the unit nurse she had not done the initial admissions search due to the patient's refusal and only reported that patient #1 had an underwire in his/her bra and refused to take it off. MHT #12, while providing 1:1 observations, turned away from patient #1 while the patient was changing his/her bra after visitation with his/her spouse. Both failures resulted in patient #1's successfully smuggling two (2) syringes and one (1) vial of insulin in his/her bra into the facility. Additionally, while providing 1:1 observations, MHT #6 failed to notice patient #1 attempting suicide by injecting himself/herself six (6) times using the insulin and the two syringes while in his/her bed under the covers.

Those failures placed patients at risk for injury, harm, impairment or death. On 09/2612, Immediate Jeopardy was identified and determined to exist related to Patient Rights. The facility initiated corrective actions on 09/26/12. It was determined the Jeopardy was abated on 09/27/12 prior to the survey exit.
Refer to A-144

Based on interviews, medical record reviews, and review of the facility's policies and procedures, it was determined the facility failed to ensure the safety of one (1) patient (Patient #1) in the selected sample of ten (10) due to failure to adhere to their policies and procedures titled Safe Environment as it pertains to routine searches at the time of admissions and after visitation and Levels of Observations/Special Precautions as it pertains to 1:1 observations. Patient #1 was admitted to the facility on 09/18/12 at 3:30 PM with a history of attempted suicide and was wearing an insulin pump which delivers a prescribed amount of insulin. Patient #1 refused to comply with the routine search upon admission and after visitation. Mental Health Technician (MHT) #11 failed to report the patient's refusal to the nurse on the unit. MHT #12, while providing 1:1 observations, turned away from patient #1 while he/she was changing his/her bra after visitation with his/her spouse. Both failures resulted in patient #1's successfully smuggling two (2) syringes and one (1) vial of insulin in the padding of his/her bra into the facility. Additionally, while providing 1:1 observations, MHT #6 failed to notice patient #1 attempting suicide by injecting himself/herself six (6) times using the insulin and the two syringes while in his/her bed under the covers.

Findings include:

A review of the facility's policies and procedures regarding Safe Environment, revealed the policy requires searches to be conducted on all patients and their belongings upon admission and after visitation. If the patient refuses the search, the nurse on the unit is to be notified.

A review of the facility's policy titled Levels of Observation/Special Precautions, revealed the policy requires staff providing 1:1 supervision to be within one arm's length of the patient at all times and to continuously maintain direct visual supervision of the patient at all times including when the patient is showering, changing clothing, or using the bathroom.

A review of Patient #1's medical record, revealed the Admissions Check List had a check mark in the area indicating an admissions search had been completed.

During an interview with Patient #1 on 09/24/12 at approximately 9:56 AM, he/she revealed he/she had hidden two syringes and a vial of insulin in the padding of their bra and refused the search at the point of admission. He/she stated they did a "pat down" and had patient #1 pull the bra away from the skin and up. The MHT asked him/her if there was an underwire in the bra. Patient #1 confirmed there was and the MHT told him/her they would need to cut the underwire out. Patient #1 stated he/she refused to remove his/her bra. The MHT told the nurse patient #1's bra had an underwire and that patient #1 had refused to remove his/her bra. The nurse told the MHT since it was so close to visitation that patient #1 could keep the bra on and could change the bra after visitation when his/her spouse was bringing in a sports bra. This allowed patient #1 to smuggle two syringes and a vial of insulin into the facility in the padding of the bra. Additionally patient #1 stated he/she was placed on 1:1 observations. After visitation, patient #1 was accompanied to the restroom by another MHT and was able to change the bra without removing his/her sweater enabling him/her to successfully transfer the contraband into the new bra and that the MHT doing the 1:1 had turned their head. Then patient #1 was accompanied to his/her room and stayed there the whole time. Patient #1 indicated the MHT was building rapport by talking to him/her pointing out all of the positive things in his/her life. Then Patient #1 told the MHT several times he/she was not going to be there the next day. The MHT asked how are you going to overdose if you don't overdose with your insulin pump? Patient #1 replied he/she only overdosed with insulin syringes. Patient #1 asked the MHT if he/she did something would the MHT get in trouble, the MHT replied no and continued talking to patient #1. Patient #1 stated at approximately 11:00 PM a nurse walked into the room and he/she felt like the nurse was grilling him/her with questions and stated if the nurse had not entered the room at that time, he/she was about to surrender the contraband to the MHT. The nurse left. At shift change another MHT was assigned the 1:1. Patient #1 spoke to the MHT regarding his/her snack and told the MHT he/she was getting insulin via the pump and if she heard a beep in the night it meant the pump did not deliver the dose and he/she needed to be woken up. Patient #1 stated he/she was lying in bed under the covers in the fetal position with his/her head exposed and would open and close his/her eyes to give the appearance of trying to fall asleep. Patient #1 stated he/she removed the two syringes and the vial of insulin, placed them by his/her side under the covers and was able to fill and inject each syringe three times for a total of six injections and was going to draw the insulin a seventh time but the syringe pricked his/her finger causing patient #1 to flinch so he/she returned the vial and the two syringes in the bra. Patient #1 stated the MHT was at the foot of the bed during the entire time and did not know what the patient was doing. Patient #1 stated he/she tried to talk to the MHT but was unable to speak. Patient #1 reported he/she did not know who realized he/she had overdosed as he/she was out of it and it was after returning to the facility from the emergency room he/she was told the MHT went to break around 3:00 AM and whoever was covering her break noticed something wasn't right due to patient #1's shortness of breath, sweating , and eyes being glazed over. Patient #1 stated he/she gave the syringes and the insulin bottle to the person who went with him/her to the emergency room in the ambulance.

An interview with MHT #11, on 09/26/12 at approximately 2:32 PM, revealed she was the MHT that checked in Patient #1. She stated patient #1 refused the body search and was very combative and aggressive. She stated she explained the process to patient #1 and the patient stated "I am not taking my clothes off". The MHT reported she had the patient pull his/her bra away from his/her body and shake it away from his/her skin and nothing fell out. She stated she asked patient #1 if the bra had an underwire in it, patient #1 said yes but he/she was not going to take the bra off until his/her spouse got to the facility with a sports bra. She stated she failed to report to the unit nurse that she did not do a body search due to patient #1's refusal and only reported the patient's bra had an underwire in it and the patient refused to remove the bra. The nurse told me patient #1 could keep the bra on and could change it after visitation when the spouse brought in another bra. Patient #1 was crying and angry because he/she was told the patient he/she would have to use the hygiene products provided by the hospital, the patient stated she would not use the hospital's products. The patient did remove the bobbypins from his/her hair and the belt from their shirt. Additionally she stated she had been trained regarding how to conduct a search and that if the patient refused it was policy to notify the nurse on the unit. MHT #11 also stated that MHT's did not complete the Admissions Check List, the nurse did and since she did not tell the nurse the patient refused the search, the nurse checked it had been completed.

An interview with MHT #12, on 09/26/12 at approximately 3:20 PM revealed she was the MHT assigned to 1:1 observations for Patient #1 on the unit. She stated she was told by MHT #11 the patient had refused the search at the time of admission, the patient's bra had an underwire, and patient #1 refused to remove his/her bra. She indicated she was told the nurse said patient #1's spouse was bringing a bra at visitation and patient #1 could change bras after visitation. MHT #12 reported she accompanied patient #1 to the rest room after visitation to change the bra. MHT # 12 stated she turned her head looking away from patient #1 and during this time, patient #1 changed the bra without removing his/her sweater and transferred the contraband into the new bra.

An interview with MHT # 6, on 09/26/12 at approximately 8:45 AM, revealed she was the MHT responsible for the 1:1 observation of patient #1 when patient #1 attempted suicide the night of 09/19/12. MHT #6 reported the patient had two blankets because the patient was cold and was quietly lying in bed with the covers pulled up to his/her chest leaving the patient's head exposed. Patient #1 was opening and closing his/her eyes and at one point jumped, she asked patient #1 if he/she was ok, the patient replied yes and seemed to got to sleep. Patient #1 began snoring and threw off the covers, MHT #6 states she noticed patient #1 was sweating and thought this was due to being covered by two blankets. Additionally she stated when it was time for her break, she was relieved by a nurse and when she returned from her break she was told patient #1 overdosed on insulin. The nurse who relieved MHT #6 thought the overdose occurred due to patient #1's insulin pump. The nurse asked MHT #6 to accompany patient #1 in the ambulance to the emergency room (ER). MHT #6 stated that when they arrived at the ER, they were taken to a room and the nurse asked the patient if he/she knew why he/she was there and patient #1 responded "I tried to kill myself". The patient was given some 7-Up to drink and the nurse stated that the patient needed to talk to help him/her come around. MHT #6 stated, "I began to talk to the patient". MHT #6 stated as we talked, patient #1 told me she had something to give me and then surrendered the two syringes and the vial of insulin that had been hidden in his/her bra and told me how he/she was able to smuggle the contraband into the facility. MHT #6 reported she told the nurse at the ER that patient #1's overdose was not caused from the insulin pump and that the patient had injected the insulin.


An interview with Registered Nurse (RN) #1, on 09/25/12 at approximately 7:36 AM, revealed patient #1 was admitted during shift change and that during shift report there was a concern regarding the patient's insulin pump. She was told and passed this information on to her staff that the patient's pump could not give the patient too much insulin. She was also informed the patient was on 1:1 due to suicide precautions. RN #1 stated she was not told patient #1 had refused the search upon admission. RN #1 reported it was time for the MHT to go to break, she relieved her and noticed patient #1 was breathing faster than she liked, was very sweaty, and she tried to wake the patient. Patient #1 propped himself/herself up and RN #1 noticed the patient's pupils were the size of his/her iris and the patient could not speak. RN #1 stated she called for the other nurse. They called Emergency Medical Service (EMS) personnel and told them they had a compromised patient with low blood sugar and they needed to get there quickly. Additionally she stated the patient's vitals were normal except his/her pulse was erratic, ranging 70's to 110's, the patients breathing was rhythmic up to 30 breaths per minute. EMS arrived and she gave them a quick report and the patient was posturing in toward the body with his/her arm above his/her head. EMS began to look for IV access as they loaded patient #1 in the ambulance. The MHT had returned from her break and accompanied the patient to the ER.

An interview with RN #3, on 09/27/12 at approximately 11:45 AM, revealed she was the nurse on the unit when patient #1 was admitted. RN #3 reported the MHT told her the patient had an underwire in his/her bra and was not going to take it off and that she told the MHT since patient #1 was on 1:1, the patient could swap bras after visitation. Additionally RN #3 stated she was concerned about the patient because he/she had made two attempts in two weeks and she reminded staff to have the patient change his/her bra after visitation and assigned and MHT to provide 1:1 observation for the patient. She further stated she was not made aware patient #1 had refused the search at the time of admission.

In an interview with the Director of Clinical Services, on 09/25/12 at approximately 9:35 AM, she stated "We missed it, we didn't search the patient and when patient #1 was on 1:1 we should have maintained 1:1. The 1:1 policy was not followed".


The facility failed to ensure a safe environment for their patients. This failure placed patients at risk for injury, harm, impairment or death. On 09/26/12, Immediate Jeopardy was determined to exist. The facility initiated corrective actions. Those actions were as follows: the CEO notified all departments that no employee could conduct searches until the staff member had successfully completed a two tier training and demonstrated competency. The first tier training included explaining the policies and procedures regarding safe environment and levels of observations which emphasized patients on 1:1 must have their head and hands visible at all times, and a multiple choice test covering the policy information. The second tier of the training included a reiteration of the afore mentioned policies, instruction on completing searches, and a participation demonstration on conducting searches. Staff competency was determined as staff completed mock searches in a staged setting which included an admissions search, a personal belonging search, and a patient room search.

The Immediate Jeopardy was determined to be abated on 09/27/12 prior to the exit of the survey.

Based on interviews, medical record reviews, and review of the facility's policies and procedures, it was determined the facility failed to to provide patients with nursing care which ensured patient safety for one (1) patient (Patient #1) in the selected sample of ten (10) due to failure to adhere to their policies and procedures as it pertains to routine searches at the time of admissions and after visitation and as their policies pertains to 1:1 observations.

Patient #1 refused to be searched upon admission and after visitation. Mental Health Technician (MHT) #11 Mental Health Technician (MHT) #11 failed to report to the unit nurse she had not done the initial admissions search due to the patient's refusal and only reported that patient #1 had an underwire in his/her bra and refused to take it off. MHT #12, while providing 1:1 observations, turned away from patient #1 while the patient was changing his/her bra after visitation with his/her spouse. Both failures resulted in patient #1's successfully smuggling two (2) syringes and one (1) vial of insulin in his/her bra into the facility. Additionally, while providing 1:1 observations, MHT #6 failed to notice patient #1 attempting suicide by injecting himself/herself six (6) times using the insulin and the two syringes while in his/her bed under the covers.

Those failures placed patients at risk for injury, harm, impairment or death. On 09/2612, Immediate Jeopardy was identified and determined to exist related to Nursing Services. The facility initiated corrective actions on 09/26/12. It was determined the Jeopardy was abated on 09/27/12 prior to the survey exit.
Refer to A-395

Based on interviews, medical record reviews, and review of the facility's policies and procedures, it was determined the facility failed to provide patients with nursing care which ensured patient safety for one (1) patient (Patient #1) in the selected sample of ten (10) due to failure to adhere to their policies and procedures titled Safe Environment as it pertains to routine searches at the time of admissions and after visitation and Levels of Observations/Special Precautions as it pertains to 1:1 observations. Patient #1 was admitted to the facility on 09/18/12 at 3:30 PM with a history of attempted suicide and was wearing an insulin pump which delivers a prescribed amount of insulin. Patient #1 refused to comply with the routine search upon admission and after visitation. Mental Health Technician (MHT) #11 failed to report the patient's refusal to the nurse on the unit. MHT #12, while providing 1:1 observations, turned away from patient #1 while he/she was changing his/her bra after visitation with his/her spouse. Both failures resulted in patient #1's successfully smuggling two (2) syringes and one (1) vial of insulin in the padding of his/her bra into the facility. Additionally, while providing 1:1 observations, MHT #6 failed to notice patient #1 attempting suicide by injecting himself/herself six (6) times using the insulin and the two syringes while in his/her bed under the covers.

Findings include:

A review of the facility's policies and procedures regarding Safe Environment, revealed the policy requires searches to be conducted on all patients and their belongings upon admission and after visitation. If the patient refuses the search, the nurse on the unit is to be notified.

A review of the facility's policy titled Levels of Observation/Special Precautions, revealed the policy requires staff providing 1:1 supervision to be within one arm's length of the patient at all times and to continuously maintain direct visual supervision of the patient at all times including when the patient is showering, changing clothing, or using the bathroom.

A review of Patient #1's medical record, revealed the Admissions Check List had a check mark in the area indicating an admissions search had been completed.

During an interview with Patient #1 on 09/24/12 at approximately 9:56 AM, he/she revealed he/she had hidden two syringes and a vial of insulin in the padding of their bra and refused the search at the point of admission. He/she stated they did a "pat down" and had patient #1 pull the bra away from the skin and up. The MHT asked him/her if there was an underwire in the bra. Patient #1 confirmed there was and the MHT told him/her they would need to cut the underwire out. Patient #1 stated he/she refused to remove his/her bra. The MHT told the nurse patient #1's bra had an underwire and that patient #1 had refused to remove his/her bra. The nurse told the MHT since it was so close to visitation that patient #1 could keep the bra on and could change the bra after visitation when his/her spouse was bringing in a sports bra. This allowed patient #1 to smuggle two syringes and a vial of insulin into the facility in the padding of the bra. Additionally patient #1 stated he/she was placed on 1:1 observations. After visitation, patient #1 was accompanied to the restroom by another MHT and was able to change the bra without removing his/her sweater enabling him/her to successfully transfer the contraband into the new bra and that the MHT doing the 1:1 had turned their head. Then patient #1 was accompanied to his/her room and stayed there the whole time. Patient #1 indicated the MHT was building rapport by talking to him/her pointing out all of the positive things in his/her life. Then Patient #1 told the MHT several times he/she was not going to be there the next day. The MHT asked how are you going to overdose if you don't overdose with your insulin pump? Patient #1 replied he/she only overdosed with insulin syringes. Patient #1 asked the MHT if he/she did something would the MHT get in trouble, the MHT replied no and continued talking to patient #1. Patient #1 stated at approximately 11:00 PM a nurse walked into the room and he/she felt like the nurse was grilling him/her with questions and stated if the nurse had not entered the room at that time, he/she was about to surrender the contraband to the MHT. The nurse left. At shift change another MHT was assigned the 1:1. Patient #1 spoke to the MHT regarding his/her snack and told the MHT he/she was getting insulin via the pump and if she heard a beep in the night it meant the pump did not deliver the dose and he/she needed to be woken up. Patient #1 stated he/she was lying in bed under the covers in the fetal position with his/her head exposed and would open and close his/her eyes to give the appearance of trying to fall asleep. Patient #1 stated he/she removed the two syringes and the vial of insulin, placed them by his/her side under the covers and was able to fill and inject each syringe three times for a total of six injections and was going to draw the insulin a seventh time but the syringe pricked his/her finger causing patient #1 to flinch so he/she returned the vial and the two syringes in the bra. Patient #1 stated the MHT was at the foot of the bed during the entire time and did not know what the patient was doing. Patient #1 stated he/she tried to talk to the MHT but was unable to speak. Patient #1 reported he/she did not know who realized he/she had overdosed as he/she was out of it and it was after returning to the facility from the emergency room he/she was told the MHT went to break around 3:00 AM and whoever was covering her break noticed something wasn't right due to patient #1's shortness of breath, sweating , and eyes being glazed over. Patient #1 stated he/she gave the syringes and the insulin bottle to the person who went with him/her to the emergency room in the ambulance.

An interview with MHT #11, on 09/26/12 at approximately 2:32 PM, revealed she was the MHT that checked in Patient #1. She stated patient #1 refused the body search and was very combative and aggressive. She stated she explained the process to patient #1 and the patient stated "I am not taking my clothes off". The MHT reported she had the patient pull his/her bra away from his/her body and shake it away from his/her skin and nothing fell out. She stated she asked patient #1 if the bra had an underwire in it, patient #1 said yes but he/she was not going to take the bra off until his/her spouse got to the facility with a sports bra. She stated she failed to report to the unit nurse that she did not do a body search due to patient #1's refusal and only reported the patient's bra had an underwire in it and the patient refused to remove the bra. The nurse told me patient #1 could keep the bra on and could change it after visitation when the spouse brought in another bra. Patient #1 was crying and angry because he/she was told was told the he/she would have to use the hygiene products provided by the hospital, the patient stated she would not use the hospital's products. The patient did remove the bobbypins from his/her hair and the belt from their shirt. Additionally she stated she had been trained regarding how to conduct a search and that if the patient refused it was policy to notify the nurse on the unit. MHT #11 also stated that MHT's did not complete the Admissions Check List, the nurse did and since she did not tell the nurse the patient refused the search, the nurse checked it had been completed.

An interview with MHT #12, on 09/26/12 at approximately 3:20 PM revealed she was the MHT assigned to 1:1 observations for Patient #1 on the unit. She stated she was told by MHT #11 the patient had refused the search at the time of admission, the patient's bra had an underwire, and patient #1 refused to remove his/her bra. She indicated she was told the nurse said patient #1's spouse was bringing a bra at visitation and patient #1 could change bras after visitation. MHT #12 reported she accompanied patient #1 to the rest room after visitation to change the bra. MHT # 12 stated she turned her head looking away from patient #1 and during this time, patient #1 changed the bra without removing his/her sweater and transferred the contraband into the new bra.

An interview with MHT # 6, on 09/26/12 at approximately 8:45 AM, revealed she was the MHT responsible for the 1:1 observation of patient #1 when patient #1 attempted suicide the night of 09/19/12. MHT #6 reported the patient had two blankets because the patient was cold and was quietly lying in bed with the covers pulled up to his/her chest leaving the patient's head exposed. Patient #1 was opening and closing his/her eyes and at one point jumped, she asked patient #1 if he/she was ok, the patient replied yes and seemed to got to sleep. Patient #1 began snoring and threw off the covers, MHT #6 states she noticed patient #1 was sweating and thought this was due to being covered by two blankets. Additionally she stated when it was time for her break, she was relieved by a nurse and when she returned from her break she was told patient #1 overdosed on insulin. The nurse who relieved MHT #6 thought the overdose occurred due to patient #1's insulin pump. The nurse asked MHT #6 to accompany patient #1 in the ambulance to the emergency room (ER). MHT #6 stated that when they arrived at the ER, they were taken to a room and the nurse asked the patient if he/she knew why he/she was there and patient #1 responded "I tried to kill myself". The patient was given some 7-Up to drink and the nurse stated that the patient needed to talk to help him/her come around. MHT #6 stated, "I began to talk to the patient". MHT #6 stated as we talked, patient #1 told me she had something to give me and then surrendered the two syringes and the vial of insulin that had been hidden in his/her bra and told me how he/she was able to smuggle the contraband into the facility. MHT #6 reported she told the nurse at the ER that patient #1's overdose was not caused from the insulin pump and that the patient had injected the insulin.

An interview with Registered Nurse (RN) #1, on 09/25/12 at approximately 7:36 AM, revealed patient #1 was admitted during shift change and that during shift report there was a concern regarding the patient's insulin pump. She was told and passed this information on to her staff that the patient's pump could not give the patient too much insulin. She was also informed the patient was on 1:1 due to suicide precautions. RN #1 stated she was not told patient #1 had refused the search upon admission. RN #1 reported it was time for the MHT to go to break, she relieved her and noticed patient #1 was breathing faster than she liked, was very sweaty, and she tried to wake the patient. Patient #1 propped himself/herself up and RN #1 noticed the patient's pupils were the size of his/her iris and the patient could not speak. RN #1 stated she called for the other nurse. They called Emergency Medical Service (EMS) personnel and told them they had a compromised patient with low blood sugar and they needed to get there quickly. Additionally she stated the patient's vitals were normal except his/her pulse was erratic, ranging 70's to 110's, the patients breathing was rhythmic up to 30 breaths per minute. EMS arrived and she gave them a quick report and the patient was posturing in toward the body with his/her arm above his/her head. EMS began to look for IV access as they loaded patient #1 in the ambulance. The MHT had returned from her break and accompanied the patient to the ER.

An interview with RN #3, on 09/27/12 at approximately 11:45 AM, revealed she was the nurse on the unit when patient #1 was admitted. RN #3 reported the MHT told her the patient had an underwire in his/her bra and was not going to take it off and that she told the MHT since patient #1 was on 1:1, the patient could swap bras after visitation. Additionally RN #3 stated she was concerned about the patient because he/she had made two attempts in two weeks and she reminded staff to have the patient change his/her bra after visitation and assigned and MHT to provide 1:1 observation for the patient. She further stated she was not made aware patient #1 had refused the search at the time of admission.

In an interview with the Director of Clinical Services, on 09/25/12 at approximately 9:35 AM, she stated "We missed it, we didn't search the patient and when patient #1 was on 1:1 we should have maintained 1:1. The 1:1 policy was not followed".

The facility failed to ensure a safe environment for their patients. This failure placed patients at risk for injury, harm, impairment or death. On 09/26/12, Immediate Jeopardy was determined to exist. The facility initiated corrective actions. Those actions were as follows: the CEO notified all departments that no employee could conduct searches until the staff member had successfully completed a two tier training and demonstrated competency. The first tier training included explaining the policies and procedures regarding safe environment and levels of observations which emphasized patients on 1:1 must have their head and hands visible at all times, and a multiple choice test covering the policy information. The second tier of the training included a reiteration of the afore mentioned policies, instruction on completing searches, and a participation demonstration on conducting searches. Staff competency was determined as staff completed mock searches in a staged setting which included an admissions search, a personal belonging search, and a patient room search.

The Immediate Jeopardy was determined to be abated on 09/27/12 prior to the exit of the survey.