HospitalInspections.org

Based on interview and document review the hospital failed to protect and promote patient rights for of 1 of 20 patients (P-1). The hospital failed to provide physical safety for P-1 who exhibited behavioral symptoms including self injurious behavior (SIB) by obtaining inedible objects in the treatment environment on 13 occasions and ingested them or inserted them in her skin, requiring hospitalization in a local acute care hospital on 10 occasions. This resulted in an Immediate Jeopardy (IJ) situation for P-1 who continued to gain access to and ingest inedible objects, despite staff supervision and P-1 residing on the Intensive Care Area (ICA).

Findings include:

The hospital did not meet the Condition of Participation of Patient Rights at 42 CFR 482.13. This deficient practice had the potential to impact patients with the SIB of Pica (swallowing inedible objects).

The IJ was called on 7/13/2015 at 4:15 p.m.. The hospital Administrator and Director of Nursing were informed of the finding. The IJ began on 4/3/2015 when the hospital failed to ensure the adequacy of a system to prevent self injurious behaviors (SIB) for P-1 after P-1 was able to obtain a pen to swallow, requiring acute care hospital procedural treatment to remove the foreign body. P-1 swallowed a pen on 3/28/2015, 6 days prior, which also required hospital treatment. P-1 subsequently was able to obtain objects to swallow requiring procedural intervention at an acute care hospital 10 times since admission. 8 of these foreign bodies were pens obtained from staff or the unit environment.

The hospitals established protocols for patient safety had not been implemented by staff to provide a safe environment for the therapeutic treatment of behavioral symptoms of P-1. Despite P-1's sanitized and limited environment, P-1 still obtained contraband inedible items, including pens on 8 different occasions, batteries, a screw and metal and required hospital procedural interventions to remove the objects 10 times since admission. P-1 had a prior history of ingesting inedible items necessitating surgical intervention and resulting in septic shock.

The failure to ensure staff followed the hospital's approved systems for environmental modifications to manage patient symptoms such as Pica resulted in the hospital's inability to protect the physical safety of P-1. Therefore the hospital was unable to meet the Condition of Participation of Patient Rights at 42 CFR 482.13.

The IJ was removed on 7/16/2015 at 3:10 p.m. when an acceptable removal plan was implemented to protect the health and safety of P-1. Observation, interview and document review verified and established that the hospital's leadership had begun a process of reeducation with staff regarding: Contraband items in P-1's care area (ICA), supervisory staff to inspect all staff entering the ICA every time they enter, limiting and inspecting items brought into and used in the ICA, regular environmental sweeps of the ICA, signage for the area and regular supervisory monitoring of the ICA, as well as a plan for sanitizing all other areas of the unit if/when P-1 has access to other areas.

Based on interview and document review, the hospital failed to protect the physical safety for 1 of 20 patients reviewed who exhibited Pica (swallowing inedible items) SIB after obtaining inedible objects on 13 occasions, swallowing them on 12 occasions resulting in hospital admission and procedural intervention to remove the items on 10 occasions since admission. (A144)

Based on interview and document review, the hospital failed to protect and promote patient rights for of 1 of 20 patients (P-1). The hospital failed to provide physical safety for P-1 who exhibited behavioral symptoms including self injurious behavior (SIB) by obtaining inedible objects in the treatment environment on 13 occasions, swallowing them on 12 occasions that resulted a in hospital admission and procedural intervention to remove the items on 10 occasions since admission.

Findings include:

The IJ was called on 7/13/2015 at 4:15 p.m.. The hospital Administrator and Director of Nursing were informed of the finding. The IJ began on 4/3/2015 when the hospital failed to ensure the adequacy of a system to prevent self injurious behaviors (SIB) for P-1 after P-1 was able to obtain a pen to swallow, requiring acute care hospital procedural treatment to remove the foreign body. P-1 swallowed a pen on 3/28/2015, 6 days prior, which also required hospital treatment. P-1 subsequently was able to obtain objects to swallow requiring procedural intervention at an acute care hospital 10 times since admission. 8 of these foreign bodies were pens obtained from staff or the unit environment. The IJ was removed on 7/16/2015 at 3:10 p.m.

P-1's admission progress note dated 3/9/2015 revealed P-1 was admitted when P-1 was transferred from a local acute care hospital on 3/9/2015. P-1 had a long standing history of self-injury Pica with the most recent self-injury resulting in severe injury and sepsis. P-1's diagnoses included history of Major Depressive Disorder, recurrent, severe Pica, and Borderline Personality Disorder. P-1's initial treatment plan included 2 to 1 staffing in the Intensive Treatment Area (ICA).
P-1's Patient Treatment Plan Report, dated 3/12/2015 revealed P-1 was previously in an adolescent behavioral health setting when she was transferred to an acute care hospital on 2/17/2015 due to self injury and fever, then transferred to the ICU an another hospital related to difficulty oxygenating, required pressors and hemodialysis and remained in ICU until 2/24/2015. Prior to that P-1 had other hospitalizations for self injurious behavior including: stabbing herself with a pencil, banging her head, and shoving sharp objects into her stomach, and attempts to strangle herself. P-1 was admitted to the hospital into the ICA as it provides a sterile environment with decreased stimuli to support a safe treatment area for P-1. P-1 was placed on 2:1 (2 staff to 1 patient) staffing ratio on the day shift and late shift, and on 1:1 on nights when sleeping.

P-1's nursing assessment, dated 3/9/2015 revealed the nursing plan included 2:1 staffing on ICA, staff eyes on the patient at all times, and the environment will be maintained and she will not have access to eating or writing utensils.

P-1's environmental safety plan, initiated prior to admission on 3/5/2015 revealed P-1 was to be in the ICA, with no flatware for eating, pens and pencils not allowed, and flexipens in staff pockets only.

An incident report dated 3/28/2015 revealed at 8:30 p.m. P-1 requested staff give her a pen to draw with. Staff gave P-1 a pen and P-1 swallowed it. P-1 was sent to a local hospital and required Esophagastroduodenoscopy (EGD) foreign body removal of the pen. The incident occurred in room D-41 in ICA.

An incident report dated 4/3/2015 revealed P-1 took a pen out of a staff members hand and swallowed the inside portion of the pen. P-1 was sent to a local hospital and required EGD with foreign body removal. The incident occurred in room D-41, in ICA.

Nursing notes dated 4/9/2015 revealed P-1 requested staff turn on the Television in the ICA, as staff used the remote control to turn on the Television, P-1 grabbed the remote control, pulled out the batteries and swallowed them. P-1 was sent to a local hospital for evaluation. The incident occurred in the ICA TV room.

An incident report dated 4/10/2015 revealed P-1 ingested a screw she was able to remove in the hallway. No medical intervention was implemented. The incident occurred in the ICA.

An incident report dated 4/20/2015 revealed P-1 grabbed a flexipen from the counter of the nursing station and swallowed the inner, ink portion of the pen. P-1 was sent to a local hospital and required EGD foreign body removal of the pen. The incident occurred on unit E near the nursing station.

An incident report dated 4/23/2015 revealed P-1 pulled out a 3 inch screw from a wall and swallowed it. P-1 was sent to a local hospital and required EGD foreign body removal of the screw. The incident occurred on unit C, in the ICA..

An incident report dated 4/29/2015 revealed P-1 grabbed a flexipen from a staff members hand and swallowed it. P-1 was sent to a local hospital and required EGD foreign body removal of the pen. The incident occurred on Unit C in the ICA.

Progress notes dated 5/12/2015 revealed P-1 informed staff she swallowed a metal clip. An x-ray confirmed the presence of a 3.5 cm radiopaque foreign body in the proximal esophagus. P-1 was sent to a local hospital and required EGD foreign body removal. The incident occurred in the ICA.

An incident report dated 5/24/2015 revealed P-1 told staff she ingested a pen. No staff members witnessed the incident. P-1 was sent to a local hospital for EGD removal of the foreign body. This was an unwitnessed ingestion, location unknown.

An incident report dated 6/2/2015 revealed P-1 told her medical provider that she inserted a piece of metal into her left hand. X-ray confirmed presence of metal in the dorsum of her hand. P-1 was treated at the facility. The incident occurred in the ICA.

Progress notes dated 6/25/2015 revealed P-1 accessed a flexipen while out of the ICA for a group and swallowed it. P-1 was sent to a local hospital for EGD removal of the foreign body.

An incident report dated 7/5/2015 revealed P-1 grabbed a pen from the pocket of a staff member, took out the inside tube and swallowed it. P-1 was sent to a local hospital for EGD removal of the foreign body. This incident occurred in the ICA.

Progress notes dated 7/12/2015 revealed P-1 informed staff that she swallowed the inner part of a regular ink pen that she found on the floor. P-1 was sent to a local hospital for EGD removal of the foreign body. This incident occurred in the ICA.

P-1's acute care hospital records dated 4/1/2015 - 6/8/2015 revealed P-1 was admitted and treated for Esophageal foreign body ingestion which required removal during endoscopy on 4/3/2015, 4/20/2015, 4/24/2015, 4/30/2015, 5/12/2015, and 5/24/2015.

During an interview on 7/9/2015 at 10:30 a.m. Human Services Technician K (HST-K) stated he has worked with P-1 as one of her 2:1 staff. On one occasion HST-K stated he was working with a float staff member. HST-K stated he could not recall the date, but P-1 requested to watch television. When he left to get the remote control, P-1 grabbed a pen from the other HST and swallowed it. HST-K stated there was a rule that the HST's should not have pens, but the other HST had a pen. HST-K stated P-1's support plan included her area was to be clear of everything she can use to swallow. HST-K stated that he was not sure if the float staff member had been informed that no pens were to be used in P-1's ICA area.

During an interview on 7/9/2015 at 10:50 a.m. Licensed Practical Nurse M, (LPN-M) stated she has worked as one of P-1's 2:1 staff. LPN-M stated that once P-1 was able to get a pen from a staff member, when that staff member was documenting on the patient. LPN-M stated that she didn't think it was made clear to some people that the documentation materials should be locked up and only accessed hourly. LPN-M stated it seemed to usually be float staff who were uninformed about the patient's behavior plan. LPN-M stated the process is: staff get report on patients on a tape recording from the previous shift. The behavior plan is also posted on a clip board and locked in the ICA. LPN-M stated she questioned if some staff members just weren't reading it. LPN-M stated there is not policy to remove everything from your pockets before going back to the ICA.

During an interview on 7/9/2015 at 11:10 a.m. HST-N stated she works as one of P-1's 2:1 staff. HST-N stated there should be no pens back in the ICA with P-1, but just that morning a float staff brought one back and HST-N had to remind her not to have pens back in the ICA with P-1. HST-N stated just last Sunday, 7/5/2015, someone had a pen back in the ICA and P-1 grabbed it, pulled it apart and swallowed the inside portion. HST-N stated P-1 is still at risk for getting lanyard clips, pens and badge clips because the behavior plan is not being communicated well. HST-N stated that the behavior treatment plan should be posted on the team board for all staff to review before caring for P-1, but not everyone is reviewing the plan.

During an interview on 7/15/2015 at 1:30 p.m. HST-S stated she worked with P-1 on 7/5/2015. HST-S stated she was floated to P-1's unit and instructed to be one of P-1's 2:1 staff. HST-S stated she was not informed that she was not to bring a pen back to the ICA with P-1, so one was in her pocket. HST-S stated P-1 quickly pulled the pen from her pocket and swallowed it.

During an interview on 7/13/2015 at 2:15 p.m., Registered Nurse-P (RN-P) stated she worked with P-1 on 6/25/2015. P-1 was on close 2:1 supervision, but P-1 still somehow managed to gain access to a pen and swallow it without the 2:1 staff seeing the incident. RN-P stated P-1 is very fast and can turn her back and swallow something very quickly.

During an interview, Dr.-O, P-1's psychiatrist stated P-1's mental health issues include the compulsive need to create medical problems that require intervention. Dr.-O stated he met with staff at shift change meetings to explain the plan for interacting with P-1. Dr.-O stated that P-1 is very adept at getting items to ingest, but the fact that P-1 is getting items over and over again, is a problem and he is concerned that float staff and weekend staff in particular, may not be well suited for caring for P-1.

During an interview on 7/15/2015 at 1:45 p.m., RN-FF from the local acute care hospital's emergency department stated they have seen P-1 in their emergency room numerous times since her admission to her current facility. RN-FF stated this year alone the hospital has performed 10 EGD's to remove foreign objects that P-1 has ingested. RN-FF stated she is wondering how P-1 is continuing to access the objects.

The policy titled Therapeutic Observations dated 3/9/2015 and provided by the hospital was reviewed. Under section Procedures: 5. All potentially dangerous items will be removed from the patient. 6. For close one-to-one, there will be no physical barriers between staff and patient. Staff will maintain continuous visual observation at all times.

The policy titled Suicide/Deliberate Self Harm Assessment dated September 25, 2014 and provided by the hospital was reviewed. Under the section Procedures: G. If therapeutic Observations are initiated for suicide/self harm risks, the RN will delegate an appropriately trained staff member, who has been informed of the suicide risk and assessment findings and understands the purpose of therapeutic precautions, to complete the frequent observations or to provide the 1:1 observation.

The policy Incident Reporting and Management dated January 16, 2014 and provided by the hospital was reviewed. Under the section Policy: In order to protect the safety and well being of clients and staff in the State Operated Services facilities, incidents must be managed, documented, reported, reviewed, and investigated in a timely manner utilizing a common sense approach.

The IJ was removed on 7/16/2015 at 3:10 p.m. when an acceptable removal plan was implemented to protect the health and safety of P-1. Observation, interview and document review verified and established that the hospital's leadership had begun a process of reeducation with staff regarding: Contraband items in P-1's care area (ICA), supervisory staff to inspect all staff entering the ICA every time they enter, limiting and inspecting items brought into and used in the ICA, regular environmental sweeps of the ICA, signage for the area and regular supervisory monitoring of the ICA, as well as a plan for sanitizing all other areas of the unit if/when P-1 has access to other areas.

Based on interview and document review, the hospital failed to ensure a process for Quality Assessment and Performance Improvement activities that reflected the need for patient safety and enhanced health outcomes when providing treatment for behavioral symptoms for 1 of 20 patients reviewed, Patient #1 (P-1), who ingested inedible objects obtained from the hospital environment or staff that resulted in hospitalization and procedural intervention on 10 occasions.

Findings include:

The failure to ensure the Quality Assessment and Performance Improvement committee had a process to identify quantitative and qualitative measures in accordance with the hospital's complexity to provide safe environment when treating individuals with behavior symptoms resulted in the hospital's inability to determine qualitative assessment measures and implement improvement activities. Therefore, the hospital was unable to meet the Condition of Participation: Quality Assessment and Performance Improvement Program at 42 CFR 482.21.

The deficient practice had the potential to impact all patients receiving services at the hospital.

Based on interview and document review the hospital failed to ensure a Quality Assessment and Performance Improvement program that measured, analyzed and tracked aspects of performance that assess processes of care, hospital service and operations and therefore, failed to use that data to monitor the effectiveness and safety of services and quality of care for 1 of 20 patients reviewed, Patient #1 (P-1), who obtained inedible objects and ingested them on 12 occasions, requiring hospitalization and procedural intervention to remove foreign bodies after 10 of those incidents. (A273)

Based on interview and document review the hospital failed to ensure a Quality Assessment and Performance Improvement (QAPI) program that measured, analyzed and tracked aspects of performance that assess processes of care, hospital service and operations and therefore, failed to use that data to monitor the effectiveness and safety of services and quality of care for 1 of 20 patients reviewed, Patient #1 (P-1), who obtained inedible objects and ingested them on 12 occasions, requiring hospitalization and procedural intervention to remove foreign bodies after 10 of those incidents.

Findings include:

P-1's admission progress note dated 3/9/2015 revealed P-1 was admitted when P-1 was transferred from a local acute care hospital on 3/9/2015. P-1 had a long standing history of self-injury Pica (ingesting inedible items) with the most recent self-injury resulting in severe injury and sepsis. P-1's diagnoses included history of Major Depressive Disorder, recurrent, severe Pica, and Borderline Personality Disorder. P-1's initial treatment plan included 2 to 1 staffing in the Intensive Treatment Area (ICA).
P-1's Patient Treatment Plan Report, dated 3/12/2015 revealed P-1 was previously in an adolescent behavioral health setting when she was transferred to an acute care hospital on 2/17/2015 due to self injury and fever, then transferred to to the ICU at another hospital related to difficulty oxygenating, required pressors and hemodialysis and remained in ICU until 2/24/2015. Prior to that P-1 had other hospitalizations for self injurious behavior including: stabbing herself with a pencil, banging her head, shoving sharp objects into her stomach, and attempts to strangle herself. P-1 was admitted to the hospital into the ICA (Intensive Care Area) as it "provides a sterile environment with decreased stimuli to support a safe treatment area" for P-1. P-1 was placed on 2:1 (2 staff to 1 patient) staffing ratio on the day shift and late shift, and on 1:1 on nights when sleeping.

P-1's nursing assessment, dated 3/9/2015 revealed the nursing plan included 2:1 staffing on ICA, staff eyes on the patient at all times, and "Her environment will be maintained and she will not have access to eating or writing utensils."

P-1's environmental safety plan, initiated prior to admission on 3/5/2015 revealed P-1 was to be in the ICA, with no flatware for eating, pens and pencils not allowed, and flexipens in staff pockets only.

An incident report dated 3/28/2015 revealed at 8:30 p.m. P-1 requested staff give her a pen to draw with. Staff gave P-1 a pen and P-1 swallowed it. P-1 was sent to a local hospital and required Esophagastroduodenoscopy (EGD) with foreign body removal of the pen.

An incident report dated 4/3/2015 revealed P-1 snatched a pen out of a staff members hand and swallowed the inside portion of the pen. P-1 was sent to a local hospital and required (EGD) with foreign body removal.

Nursing notes dated 4/9/2015 revealed P-1 requested staff turn on the Television in the ICA, as staff used the remote control to turn on the Television, P-1 grabbed the remote control, pulled out the batteries and swallowed them. P-1 was sent to a local hospital for evaluation.

An incident report dated 4/10/2015 revealed P-1 ingested a screw she was able to remove in the hallway. No medical intervention was implemented.

An incident report dated 4/20/2015 revealed P-1 grabbed a flexipen from the counter and swallowed the inner, ink portion of the pen. P-1 was sent to a local hospital and required EGD foreign body removal of the pen.

An incident report dated 4/23/2015 revealed P-1 pulled out a 3 inch screw from a wall and swallowed it. P-1 was sent to a local hospital and required EGD Foreign body removal of the screw.

An incident report dated 4/29/2015 revealed P-1 grabbed a flexipen from a staff member's hand and swallowed it. P-1 was sent to a local hospital and required EGD Foreign body removal of the pen.

Progress notes dated 5/12/2015 revealed P-1 informed staff she swallowed a metal clip. An x-ray confirmed the presence of a 3.5 cm radiopaque foreign body in the proximal esophagus. P-1 was sent to a local hospital and required EGD Foreign body removal.

An incident report dated 5/24/2015 revealed P-1 told staff she ingested a pen. No staff members witnessed the incident. P-1 was sent to a local hospital for EGD removal of the foreign body.

An incident report dated 6/2/2015 revealed P-1 told her medical provider that she inserted a piece of metal into her left hand. X-ray confirmed presence of metal in the dorsum of her hand. P-1 was treated at the facility.

Progress notes dated 6/25/2015 revealed P-1 accessed a flexipen while out of the ICA for a group and swallowed it. P-1 was sent to a local hospital for EGD removal of the foreign body.

An incident report dated 7/5/2015 revealed P-1 grabbed a pen from the pocket of a staff member, took out the inside tube and swallowed it. P-1 was sent to a local hospital for EGD removal of the foreign body.

Progress notes dated 7/12/2015 revealed P-1 informed staff that she swallowed the inner part of a regular ink pen that she found on the floor. P-1 was sent to a local hospital for EGD removal of the foreign body.

P-1's acute care hospital records dated 4/1/2015 - 6/8/2015 revealed P-1 was admitted and treated for Esophageal foreign body ingestion which required removal during endoscopy on 4/3/2015, 4/20/2015, 4/24/2015, 4/30/2015, 5/12/2015, and 5/24/2015.

During an interview on 7/9/2015 at 10:30 a.m. Human Services Technician K (HST-K) stated he has worked with P-1 as one of her 2:1 staff. On one occasion HST-K stated he was working with a float staff member. HST-K stated he could not recall the date, but P-1 requested to watch television. When he left to get the remote control, P-1 grabbed a pen from the other HST and swallowed it. HST-K stated there was a rule that the HST's should not have pens, but the other HST had a pen. HST-K stated P-1's support plan included her area was to be clear of everything she can use to swallow. HST-K stated that he was not sure if the float staff member had been informed that no pens were to be used in P-1's ICA area.

During an interview on 7/9/2015 at 10:50 a.m. Licensed Practical Nurse M, (LPN-M) stated she has worked as one of P-1's 2:1 staff. LPN-M stated that once P-1 was able to get a pen from a staff member, when that staff member was documenting on the patient. LPN-M stated that she didn't think it was made clear to some people that the documentation materials should be locked up and only accessed hourly. LPN-M stated it seemed it was usually be float staff who were uninformed about P-1's behavior plan.

During an interview on 7/9/2015 at 11:10 a.m. HST-N stated she works as one of P-1's 2:1 staff. HST-N stated there should be no pens back in the ICA with P-1, but just that morning a float staff brought one back and HST-N had to remind her not to have pens back in the ICA with P-1. HST-N stated just last Sunday, 7/5/2015, someone had a pen back in the ICA and P-1 grabbed it, pulled it apart and swallowed the inside portion. HST-N stated P-1 is still at risk for getting lanyard clips, pens and badge clips because the behavior plan is not being communicated well.

During an interview on 7/15/2015 at 1:30 p.m. HST-S stated she worked with P-1 on 7/5/2015. HST-S stated she was floated to P-1's unit and instructed to be one of P-1's 2:1 staff. HST-S stated she was not informed that she was not to bring a pen back to the ICA with P-1, so one was in her pocket. HST-S stated P-1 quickly pulled the pen from her pocket and swallowed it.

During an interview on 7/13/2015 at 2:15 p.m., Registered Nurse-P (RN-P) stated she worked with P-1 on 6/25/2015. P-1 was on close 2:1 supervision, but P-1 still somehow managed to gain access to a pen and swallow it without the 2:1 staff seeing the incident. RN-P stated P-1 is very fast and can turn her back and swallow something very quickly.

During an interview, Dr.-O, P-1's psychiatrist, stated P-1's mental health issues include almost the compulsive need to create medical problems that require intervention. Dr.-O stated that P-1 is very adept at getting items to ingest, but the fact that P-1 is getting items over and over again, is a problem and he is concerned that float staff in particular, may not be well suited for caring for P-1.

During an interview on 7/15/2015 at 1:45 p.m., RN-FF from the local acute care hospital's emergency department stated they have seen P-1 in their emergency room numerous times since her admission to her current facility. RN-FF stated this year alone the hospital has performed 10 EGD's to remove foreign objects that P-1 has ingested. RN-FF stated she is wondering how P-1 is continuing to access the objects.

During an interview on 7/15/2015 at 8:55 a.m. and 2:00 p.m., Quality Assessment representative T, (QA-T) stated the hospital tracks patient adverse events including patient injuries, falls, elopements, contraband and medical errors. QA-T stated she was unaware of the frequency of P-1's ingestion of foreign objects. QA-T stated she had no explanation as to why she was not informed about these incidents. QA-T stated she should have been informed, and initiated preventative measures. When a policy related to tracking and analyzing of incidents related to patient safety that may not be defined by the facility as adverse events was requested, QA-T stated the hospital had no such policy.

A review of QAPI minutes dated 3/26/2015 and 5/28/2015 revealed the committee met once every 2 months to review Quality data.

The policy Incident Reporting and Management dated January 16, 2014 and provided by the hospital was reviewed. Under the section Policy: In order to protect the safety and well being of clients and staff in the State Operated Services facilities, incidents must be managed, documented, reported, reviewed, and investigated in a timely manner utilizing a common sense approach.

The policy titled Adverse Healthcare Events Reporting dated September 25, 2010 and provided by the hospital was reviewed. Under the section titled Definitions: Critical Event Review: A process that uses the same analytical process as a root cause analysis; the term is used to distinguish adverse events or near misses that the organization decides to analyze even when it is not required by policy, standard or statute. Under Procedures: b. 3. Consult with Chief Operations officer and Chief Medical Officer as needed. 6. If the adverse event does not meet criteria for either reporting requirement the Primary Contact will advise the local authority on whether a Critical Incident Review or other type of review is recommended. 12. Submit reports to the State Operated Services Governing Board and upon request.