HospitalInspections.org

The Condition of Participation of Patient Rights has not been met.

Based on clinical record review, interviews, and review of hospital documentation for 1 of 4 patients reviewed for Patient Rights (Patient #201) the hospital failed to ensure that thorough personal property searches were conducted on two occasions and that an adequate room search was conducted after a patient was found with contraband smoking material that was later used to ignite a fire on the behavioral health unit, resulting in a finding of Immediate Jeopardy, and for 2 of 4 sampled patients (Patients #202 and #203) who were reviewed for Patient Rights, the hospital failed to ensure that behavioral health patients who were temporarily housed on a surgical unit which was not a behavioral health safe environment were provided with supervision resulting in a finding of Immediate jeopardy.


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Based on clinical record review, interviews, review of hospital documentation, and policy review, for 1 of 4 patients reviewed for Patient Rights (Patient #201) the hospital failed to ensure that thorough personal property searches were conducted on two occasions and that an adequate room search was conducted after a patient was found with contraband smoking material that was later used to ignite a fire on the behavioral health unit, resulting in a finding of Immediate Jeopardy, and for 2 of 4 sampled patients (Patients #202 and #203) who were reviewed for Patient Rights, the hospital failed to ensure that behavioral health patients who were temporarily housed on a surgical unit which was not a behavioral health safe environment were provided with supervision resulting in a finding of Immediate Jeopardy. The findings include:


a. Patient #201's diagnoses included bipolar disorder with psychosis and the patient was admitted for inpatient psychiatric care.

The inpatient admission assessment dated 2/28/22 identified that a patient search and property search were completed.

The nurse's note dated 3/10/22 at 11:08 AM identified Patient #201 was found smoking in the bathroom and a room and clothing search was done immediately.

The nurse's note dated 3/11/22 at 1:57 PM identified that at 1:15 PM Patient #201's bed was on fire. Patient #201 was found hiding in a corner of the dark bedroom and was prompted by the nurse to leave the room; however, Patient #201 ran past the burning bed away from the bedroom door. A physical assist by the nurse was required to remove the patient from the bedroom.

Interview with Manager #1 and Director of Regulatory Affairs on 3/11/22 at 7:00 PM identified that Patient #201 set fire to his/her room by using a lighter that was retrieved from a jacket lining that was in his/her possession. There were 20 patients on the unit at the time of the fire, no injuries were noted, and all patients were evacuated to an area of refuge.

Observation of Patient #201's bedroom on 3/11/22 at 7:15 PM identified that the bedroom sustained significant fire and smoke damage including a large burn in the center of the patient's mattress, a burned privacy curtain, heavy smoke and soot damage, and soot in the air handler system.

Interview with Manager #1 on 3/14/22 at 10:00 AM identified that Patient #201 stated that on the evening of 3/9/22 he/she got the contraband items (cigarettes, lighter, and matches) from his/her leather jacket and hid the lighter in the paper towel dispenser in the room. Manager #1 identified that when Patient #201 was found smoking on 3/10/11, the patient relinquished the cigarettes and matches. Manager #1 identified that after the fire on 3/11/22, the jacket was searched again, and it was discovered that the jacket had a hole in the pocket that would allow items to be hidden in the lining of the jacket and that a lighter was found by the fire marshal in the paper towel dispenser in the patient's room.

The hospital failed to ensure that a thorough search was conducted after Patient #201 was found smoking and in possession of smoking material.

Interview with RN #3 on 3/14/22 at 12:00 PM identified on 3/10/22 at approximately 9:15 AM after the patient was found smoking in his/her bathroom she went in the patient's room with Milieu Counselor #1 and two protective services officers to search for contraband. RN #3 identified that she searched the patient's clothing and linens, removed excessive clothing, and discarded food and garbage found in the room. RN #3 identified that she did not search the paper towel holder. RN #3 identified that she did not do a more thorough search because she did not expect to find any additional contraband because the patient had already turned in the cigarettes and matches.

Interview with Mental Health Worker #1 on 3/14/22 at 12:15 PM identified that she did the initial property search on 2/28/22 upon Patient #201's transfer from the emergency department to the secured inpatient behavioral health unit. She searched the patient's belongings and noted that all of Patient #201's clothing was wet, soiled, and had a strong odor, and that she washed all the clothing except for the leather jacket. Mental Health Worker #1 identified that she shook the jacket, patted it down and searched the pockets. Mental Health Worker #1 identified that she found loose tobacco and wet matches in the pockets, discarded them, and did not find any cigarettes, lighters, or a hole in the pockets. Mental Health Worker #1 identified that when she was done searching the jacket, she secured it in a bin in the locked property room. Mental Health Worker #1 identified on that 3/10/22 the charge nurse directed her to search Patient #201 after the patient was found smoking in the bathroom. Mental Health Worker #1 identified she only searched the patient's pockets.

Interview with Milieu Counselor #2 on 3/14/22 at 12:45 PM identified that Patient #201 requested to have his/her jacket on the evening of 3/9/22. Milieu Counselor #2 identified that it is acceptable to give patient's their clothing from the property room provided that the clothing does not have strings or obscene language. He identified that he assumed that the jacket had already been thoroughly searched because only searched items are allowed in the property room and the pockets were pulled inside out as if they had been searched. Milieu Counselor #2 identified that he shook the jacket in the air, did not detect any contraband items, did not notice the hole in the pocket, and gave the jacket to Patient #201.

Further interview with Manager #1 on 3/14/22 at 12:50 PM identified that based on descriptions of the initial property search provided by Milieu Counselor #1, the property search was adequate, but he wished the Milieu Counselor knew to check the lining of the jacket. He further identified that a room search should include looking anywhere contraband could be found including clothing, trash, linens, and under the mattress and bed. Manager #1 identified that in retrospect he wished that staff looked in the paper towel dispenser, but it is unlikely that the lighter would have been found without removing all the paper towels and that is not the expectation. Manager #1 identified that he has been doing informal education about patient's personal belongings with staff on the unit and in daily staffing huddles since the fire on 3/11/21 and formal education did not begin until 3/14/22.

The policy for patient search and contraband management in psychiatric and behavioral health dated 1/31/22 identified that patient and/or belongings searches are performed when an individual is admitted to the inpatient unit or suspected of harboring contraband. Patient belongings are searched, and unsafe patient belongings are secured. Room searches are performed any time a patient's behavior suggests contraband or harmful objects may be present on the unit. Body searches are performed when a patient is believed to have contraband on their person. The patient is taken to a private room with two staff and the patient is requested to remove clothing and give clothing items to staff to search. The patient wears a hospital gown during the search.

The hospital provided a plan to abate the finding of Immediate Jeopardy on 3/15/22 at 2:00 PM. The plan included revising the process of patient search on admission operating procedure and contraband searches, reeducating staff on the belongings process and contraband search process, conducting a unit search on all current inpatient behavioral health units for contraband, and conducting five random room searches weekly for four weeks. The Immediate Jeopardy was abated on 3/15/22.



b. On 3/11/22 at 1:15 PM, a fire occurred in the adult behavioral health unit, significant damage was sustained, and all 20 patients were safely evacuated. Two of the behavioral health patients (Patients #202 and #203) were transferred to a surgical unit on 2/12/22 at 3:15 AM and 4:05 AM respectively.

Review of the hospital's post fire action plan dated 3/11/22 and interview with Director #1 on 3/11/22 at 8:30 PM identified that 4 patients were sent to medical/surgical units because of space constraints on the affected behavioral health unit and the Director was not certain what the observation status of the patients would be. Surveyor #1 (3/11/22) and Surveyor #2 (3/11/22) identified that the medical/surgical units were not behavioral health safe environments, that multiple ligature points and other environmental factors were a concern for patient safety, and that the patients would require observation and monitoring while on the medical/surgical unit.

Patient #202 was admitted to inpatient psychiatry on 2/28/22 with history of psychosis and presented with bizarre behaviors (unpredictability, driving erratically and responding to internal stimuli). The admission assessment identified Patient #202 required inpatient hospitalization for safety and stabilization. The Columbia Suicide Severity rating scale identified patient was a low risk for suicide. Patient was on standard observation (every 15 minutes/2x 30 minutes).

A nurse's note dated 3/10/22 at 6:44 PM indicated Patient #202 was observed by staff scanning exit doors but was not noted pushing on doors.

A plan of care note dated 3/11/22 at 10:55 AM identified the patient continued to be on standard observation, denied suicidal ideation, and was low risk for suicide and self-harm.

A physician process notes dated 3/11/22 at 3:33 PM identified Patient #202 would be started Risperidone and Cogentin and would be monitored to determine if the patient tolerated the medications.

A physician progress note dated 3/11/22 at 10:14 PM (post fire) identified that the physician spoke with the patient about being transferred to another unit (surgical floor) and that he/she would continue with psychiatric care from there. The progress note indicated that the patient agreed and denied having suicidal or homicidal ideations.

Review of Patient #202's clinical record failed to identify that a safety risk assessment was performed when Patient #202 was transferred to another unit of the hospital that was not a behavioral health safe environment. In addition, the clinical record failed to identify the level of supervision that Patient #2 required while on that unit.


c. Patient #203 was admitted to the inpatient behavioral health unit on 3/4/22 with a chief complaint of suicidal ideation and depression.

Review of the psychiatric inpatient admission note dated 3/4/22 identified that when asked if the patient wished he/she was dead and could go to sleep and never wake up, Patient #202 responded "yes". In addition, on the Columbia Suicide Severity Screen, Patient #203 responded "yes" to having thoughts of killing self. The admission note identified Patient #203 was at moderate risk for self- injury in the community, low self-injurious risk in the hospital, and required line-of-sight level of observation.

An inpatient progress note dated 3/11/22 at 4:06 PM identified Patient #203 appeared to be improving but continued to note depression and anxiety. The progress note identified that Patient #203 continued to warrant inpatient psychiatric hospitalization for safety, stabilization, close monitoring, diagnostic clarity, and aftercare planning.

A physician's progress note dated 3/11/22 at 10:13 PM (post fire) identified Patient #203 was informed of the potential of being transferred to another unit (surgical floor) and identified that Patient #203 denied having any concerns about the transfer and denied having suicidal or homicidal ideations.

Review of Patient #203's clinical record failed to identify that a safety risk assessment was performed when Patient #3 was transferred to another unit of the hospital that was not a behavioral health safe environment. In addition, the clinical record failed to identify the level of supervision that Patient #3 required while on that unit.

Observation on 3/12/22 at approximately 3:00 PM identified that Patients #202 and #203 were on the surgical unit in private rooms. Patient #203 was observed with privacy curtains drawn and there were no staff providing supervision to Patient #202 or Patient #203.

Interview with RN #1 (charge nurse) on 3/12/22 at approximately 3:00 PM identified that she was not aware that the patients required any level of supervision. RN #1 stated that from shift report she understood that neither of the patients were at risk.

Subsequent to surveyor observations and inquiry, Patients #202 and #203 were placed on 1:1 observation.

Review of a nursing assessment dated 3/12/22 at 3:49 PM identified that Patient #202 was placed on 1:1 observation for safety to self and a diet order was placed that include a safety tray.

Additional observations of Patient #202 and #203's rooms on 3/12/22 at 5:30 PM identified multiple ligature risk points to include doorknobs and hinges, exposed plumbing, towel rods, electric bed cords, call bell cords, side table and cabinet pulls, and bed side rails.

Interview with the Vice President of Regulatory affairs on 3/12/22 at 7:30 PM identified that there were no orders for observation in place for Patient #202 or Patient #203, as MD #1 (Chief of Psychiatry) completed assessments of the patients before they were admitted to the surgical unit and indicated that the practice was consistent with hospital's policy.


Review of the hospital's Suicidal Risk Screening, Assessment and Precautions Policy for inpatient non behavioral health settings identified that patients evaluated or treated for behavioral health conditions as their primary reason for care are screened in the non-behavioral health setting if screening in the emergency department was not possible due to patient's condition. The policy further noted that if the patient's medical condition precludes complete screening, safety interventions are individualized to each patient depending on clinical status and reason for care.

Review of the Patient Level of Observation policy directed that a patient is maintained at a minimum level of observation assessed as necessary for safety to themselves and others, with respect to patient privacy and dignity, and in consideration of maintenance of safety for patients, visitors, and staff.

The hospital failed to ensure that behavioral health patients who were temporarily housed on a surgical unit that was not a behavioral health safe environment were provided with supervision resulting in a finding of Immediate Jeopardy.

In a discussion with the hospital's Director of Regulatory, VP of Regulatory, the Chief Nursing Officer, and the Patient Service Manager on 3/12/22 at 8:45 PM, it was determined that the Immediate Jeopardy was abated.

The hospital provided an immediate action plan to abate the finding of Immediate Jeopardy on 3/15/22 at 2:00 PM, the plan was reviewed, and the Jeopardy was abated as of 3/15/22. The plan included revising the patient search on admission operating procedure and contraband searches, reeducating staff on the belongings process and contraband search process, conducting a unit search on all current inpatient behavioral health units for contraband, and conducting five random room searches weekly for four weeks.