HospitalInspections.org

Based on review of 1 of 10 medical records (Patient #1), interview and review of Hospital meeting minutes, the Hospital failed to protect and promote each patient's rights including their right to receive care in a safe setting.

Findings include:
1.) The Hospital failed to address critical patient safety risks (breakable glass windows) on Units #1, #2 and #3. Patient #1 broke a large pane of glass in a window in the Community Room on Unit #1 on 6/30/13 with a chair and the windows were not replaced with safety glass as had been discussed by Administration in January 2013. On 12/11/13, Patient #1 broke another large pane of glass in the same window with a chair and jumped to his/her death. On 12/13/13, temporary Lexan (safety glass) was installed over breakable glass windows on Unit #1, #2 and #3.

2.) The Hospital failed to ensure `that choking and strangulation risks were minimized on Units #1, #2 and #3 for all patients.

See A-0144

Based on review of 1 of 10 medical records (Patient #1), interview and Hospital meeting minutes the Hospital failed to:
1.) address a critical patient safety risk (breakable windows) in Units #1, #2, and #3 and
2.) ensure that the choking and strangulation risks were minimized in Units #1, #2, and #3, for all patients.

Findings include:

The Attending Physician Summary Report, dated 12/11/13, indicated that Patient #1 had a long psychiatric history, a diagnosis of chronic paranoid schizophrenia and impulsive behavior.

Surveyors #1 and #2 interviewed the Attending Psychiatrist, on 12/16/13 at 11:40 A.M. The Attending Psychiatrist said Patient #1 had very impulsive behaviors and was not predictable from one moment to another. The Attending Psychiatrist said Patient #1 had an episode of extreme anger, broke a window in the Community Room on Unit #1 and fell to his/her death on 12/11/13.

1.) Surveyors #1 and #2 interviewed the Hospital's Chief Operating Officer (COO), on 12/18/13 at 9:25 A.M. The COO said she was of the impression that all windows in patient care areas were Lexan (unbreakable substitute for glass) windows, until January 2013. The COO said she initiated requests for funds to replace all non-Lexan windows in patient care areas in January 2013. The COO said she escalated the requests for funds to replace all non-Lexan windows in patient care areas, after Patient #1 threw a chair through a window in the Community Room on Unit #1, breaking the window on 6/30/13. The COO said that she was told that there were no funds for Lexan windows, but when Patient #1 threw a chair through a window and fell or jumped to his death, the funds were approved in less than 24 hours.

A.) Environment of Care Committee Meeting Minutes (ECCMM), dated 1/28/13, 3/11/13, 3/25/13, 4/22/13 and 5/13/13 indicated all areas that patients have access to should have Lexan windows and those patient rooms that did not have Lexan windows need to be identified.

B.) The ECCMM's, dated 1/28/13, 3/25/13 and 4/22/13 indicated the Hospital's Facility Engineer and Hospital Liaison to the Agency were obtaining cost estimates for the Lexan windows.

C.) An electronic message (e-mail) to the Agency Business Office, from the Capital Asset Management & Maintenance (CAMM) Department, dated 5/16/13 indicated CAMM could send out a bid request (request to companies for a cost estimate) in July. The e-mail indicated the bid request was to be sent in July because this would demonstrate the process to install the Lexan windows was in motion and resolution of the safety risk was moving forward.

D.) A Memorandum on the subject of fiscal year 2014, dated 7/26/13, to the Deputy Commissioner/Chief Financial Officer, from the Agency Area Director, indicated a request for funds for the installation of Lexan windows in patient care areas. The Memorandum indicated that a window was recently broken; glass fell onto a patient care area outside the building and this event highlighted the need for the Lexan windows for patient safety.

E.) The Proposal for Lexan Windows, dated 11/20/13, indicated a request for funding for 21 Lexan windows on Unit #1, 16 Lexan windows on Unit #2 and 12 Lexan Windows on Unit #3, for a total of 49 Lexan windows.

Surveyors #1 and #2 interviewed the Social Worker (SW), on 12/16/13 at 12:35 P.M. The SW said that Patient #1 was a large person and knew that he/she could break through the window. The SW said the Lexan window project went out for bid 5 ? months after Patient #1 broke the window on 6/30/13 and the money to replace the windows was approved the day after Patient #1 died.

Surveyors #1 and #2 interviewed the Nursing Supervisor on 12/16/13 at 1:25 P.M. The Nursing Supervisor said that she was not surprised about the Patient #1 incident on 12/11/13, because Patient #1 had thrown a chair through the window before.

During a tour of Unit #1, conducted on 12/16/13 at 8:10 A.M., Surveyors #1 and #2 observed that all windows identified as non-Lexan windows were covered with sheets of Lexan on the lower 3 ?-4 feet of the windows. The window panels broken on 6/30/13 and 12/11/13 were on the same window in the Community Room, on Unit #1.

The Patient Handbook titled, Patient Rights & Responsibilities, dated 3/20/12, indicated that patients have the right to be hospitalized in a safe and secure environment.

2.) On 12/16/13 at 8:10 A.M., Surveyors #1 and #2 observed blue rubber gloves in a trash receptacle in a Seclusion Room a patient was using as a quiet room on Unit #1. Rubber gloves are a choking hazard. The patient was not on one-to-one observation.

On Unit #1 at 8:10 A.M. on 12/16/13, Unit #2 at 10:45 A.M. on 12/17/13 and Unit #3 at 8:30 A.M. on 12/18/13, Surveyors #1 and #2 observed Christmas trees decorated with a cord-like strings of multicolored lights. The strings of lights are a strangulation hazard.

The COO said that the philosophy of the Hospital was consistent with newer philosophies of psychiatric recovery in regards to the Christmas tree lights and rubber glove concerns. The COO described the document titled Six Core Strategies, dated November 2005. The COO said that nurses assess patients individually for safety risks, patients at risk would be placed on 1:1 observation and that the newer philosophy was to normalize the patient's environment as an intervention to recovery because patients will have access to Christmas tree lights and rubber gloves after discharge from the Hospital.

Based on interview the Hospital failed to ensure a well-organized nursing service plan for coverage of administrative responsibilities for the vacant director of nurses (DON) position and that the nursing service was under the direction of one Registered Nurse.

See A-0386.

Based on interview the Hospital failed to ensure coverage of administrative responsibilities for the vacant director of nurses position and that the nursing service was under the direction of one Registered Nurse.

Findings include:

Surveyors #1 and #2 interviewed the Chief Operating Officer (COO) on 12/18/13 at 9:25 A.M. The COO said that the last Director of Nurses (DON) left employment at the Hospital on 6/30/13.

The COO said she performed all the responsibilities and duties of the DON position and as the Hospital's Chief Operating Officer; two full-time positions.

The COO's personnel file indicated she is licensed as a registered nurse.