HospitalInspections.org

Based on a review of facility policy and medical records (MR), observation and interview with staff (EMP), it was determined that Pinnacle Health Harrisburg Hospital failed to provide for personal privacy and failed to obtain informed consent prior to video monitoring of all patients admitted to the "Progressive Care/Toxicology Care Unit."

Findings include:

A review conducted on October 25, 2010, of facility documentation titled "Program Narrative Pinnacle Health Harrisburg Hospital Renovations to North-10 Pulmonary Nursing Unit" revealed "Pinnacle Health at Harrisburg Hospital is proposing minor renovations to its existing Pulmonary(Med/Surg) Nursing Unit, Located on the 10th floor of North Building. This area did not undergo any renovations as part of our Consolidation and Modernization Project. These renovations primarily consist of creating nurses' sub-stations and installation of view windows for patient observation and monitoring. There will be 3 sub-stations and view windows installed at 6 semi-private rooms... These modifications are being proposed in order to address the nursing needs of our patients requiring close observation and monitoring of their medical conditions. While this is essentially a 'unit within a unit', we are identifying these 12 beds as a "Progressive Care Unit..."

A review conducted on October 19, 2010, of facility policy: "Suicide Precautions for the Non-Psychiatric Setting", revision date September 1, 2009, revealed "Patients with suicidal ideation with/without a psychiatric history may be admitted to a hospital department other than Psychiatry due to treatment needs brought on by physical illness or injury. This policy is intended to decrease the possibility of suicide in these types of patients by instituting necessary safety and observation precautions. These precautions, known as Suicide Precautions, will insure these patients are visualized by a staff member via direct 1:1 observation or video monitoring for safety ... Procedure Guidelines Within the Toxicology Unit: 1. In the Toxicology Unit, video monitoring may be used on place of direct 1:1 observation for the suicidal patient. Patients will be informed upon admission that the video cameras are present in the rooms and hallways ..."
The policy lacked direction for the staff as to what to do if the patient was not capable of understanding or if the refused to be monitored.

A review of the standing "Toxicology Admission Orders revealed " ... 2. Vital Signs with neuro checks (with check boxes for the following options) q 15 min x 4 ... q2 hr x 4... q 4 hr ... telemetry ... Continuous video monitoring (all suicidal &/or delirious patients) ... 20. Consults: Psychiatric consults for suicidal ideation when awake. Must be detained on unit until Psych clears..."

1) An interview conducted on October 25, 2010, with EMP4 confirmed that the Program Narrative Pinnacle Health Harrisburg Hospital Renovations to North-10 Pulmonary Nursing Unit" was sumitted for review to the Department of Health in 2001 and the Progressive Care Unit or Toxicology Unit beds are licensed as medical/surgical beds, not intensive care beds. Further interview with EMP4 revealed that an occupancy inspection was not required as the renovation were viewed as "minor" and Pinnacle Health Harrisburg Hospital did not request an occupancy survey from Department of Health prior to the installation of the video monitoring equipment.

2) An interview conducted on October 26, 2010, with EMP2 revealed the video monitoring equipment was installed and became functional in June 2003, on the Progressive Care/Toxicology Care Unit.

3) Observation conducted on October 25, 2010, of the Progressive Care/Toxicology Care Unit monitoring room revealed that the census was six and that all six patients were being video monitored.

4) A review conducted on October 25, 2010, of MR3 and MR6 revealed that the medical records did not contain a physician order ( the option to order continuous video monitoring had not been checked off by the physician) and/or a signed consent for the video monitoring.

5) An interview conducted on October 25, 2010 with EMP2 confirmed that MR3 and MR6 did not contain orders for video monitoring.( the option to order continuous video monitoring had not been checked off by the physician)
Further interview revealed all patients admitted to the Progressive Care/Toxicology Care Unit are video monitored.

6) A review conducted on October 25, 2010, of MR4 revealed a physician order dated "10/21/2010, 12:25, for a 1:1 sitter. MR4 did not reveal a physician order to discontinue the sitter. Further review revealed the video monitor was utilized in place of a 1:1 sitter.

7) An interview conducted on October 25, 2010, with EMP3 confirmed that MR4 had a physician order for a 1:1 sitter. Further interview revealed that the patient did not have sitter, the order for a sitter had been discontinued and the patient was still being video monitored.

8) A review conducted on October 25, 2010, of MR2 revealed a physician order dated "10/24/2010, 13:27, to D/C (discontinue) suicide precaution. Patient does not need one to one video monitoring continued". It was observed that the patient was still being video monitored.

9) A interview conducted on October 25, 2010, with EMP3 confirmed that every patient admitted to the Progressive Care/Toxicology Care Unit is video monitored per the facility policy. The cameras are on at all times and are covered with a sheet of paper during personal care.

10) An interview conducted on October 25, 2010, at 11:20AM with EMP2 revealed "our policy allows us to substitute video monitoring for 1:1 observation for all patients on the 'Tox' unit."

Based on review of policy and procedures, review of medical records (MR) and interview with staff (EMP), it was determined that Pinnacle Health Harrisburg Hospital failed to ensure the physical safety of the patient in one of one medical record. (MR1)

Findings include:

A review conducted on October 19, 2010, of Pinnacle Health Harrisburg Hospital policy "Suicide Precautions for the Non-Psychiatric Setting, revised September 1, 2009," revealed " ... These precautions, known as Suicide Precautions, will insure these patients are visualized by a staff member via direct 1:1 observation or video monitoring for safety ... General Procedure Guidelines ... 5. Potentially harmful patients belongings and environmental objects must be removed from the patient's room ... Nursing staff will document that harmful objects were removed from the patient's room ... Procedure Guidelines Within the Toxicology Unit ...1. In the Toxicology Unit, video monitoring may be used on place of direct 1:1 observation for the suicidal patient ... ."

1) A review conducted on October 19, 2010, of MR1 revealed the following:
The Emergency Department report revealed "Chief Complaint: This is a ...who presents with an overdose...states took Valium, Tramadol and handful of Wellbutrin ..."
Review of "Emergency Nursing Assessment Sheet" revealed "Chief Complaint ... tonight overdosed with (10) 5mg Valium and (approx 5) 50mg tramadol, handful of Wellbutrin. Problems at home with spouse."

Review of the "Emergency Nursing Flow Sheet Continuation" revealed "22:45 patient affect is strange; acts as if overdose is not a problem and talks about it in a matter of fact way ... 2330 ... explained patient and spouse were arguing and "spouse doesn't care what happens to patient " Further review revealed the patient was admitted to the Progressive Care/Toxicology Care Unit.

MR1 revealed "Consultation Record"... reason for consultation: OD (over dose): see dictation ... Impression and Recommendations: Inpatient Psy/ Pt had opted to go. I believe this was an intentional overdose with intent to die, even though patient will not admit it. 10/15/10 9:00 ..."

MR1 revealed "clinical flowsheet ...10/14/10, 02:38 ... Belongings ... belongings sent to security, except teddy bear, phone(sic).

MR1 revealed "Clinical Notes Report" 10/15/10 21:06 ... that pt had cell phone charger cord and pillow case wrapped around neck. Pt's head was turning blue still had rhythm on telemetry, sinus tach 120's. When took that off the neck pt woke up within a minute, all vital signs stable. Pt said that they wanted to die quietly, since no one will probably would even notice(sic). MD was notified, pt was put on 1:1 observation, cell phone charger and other extra cords removed from the room. Nursing supervisor notified. Will cont to monitor."
Further review of the medical record did not reveal documentation of vital signs, nursing assessment or evidence of a telemetry monitor strip done at the time of the event.

MR1 revealed "Clinical Flowsheet ... 10/15/2010, 00:00 ... Psychosocial Comments 1: Currently demonstrating suicidal ideation."

MR1 revealed a lack of documented evidence that the patient was maintained on a 1:1 observation.

MR1 revealed "Progress Record ... 10/16, 9:10(S) ... Overnight, Pt had a suicidal attempt around midnight. ..."

2) An interview conducted on October 19, 2010 at 2:00 PM with EMP1 confirmed MR1 was admitted after a suicide attempt and was placed on video monitoring.

3) An interview conducted on October 25, 2010 at 1:30 PM with EMP2 confirmed the patient was admitted for overdose. "The staff was aware of the psychiatric consultation but did not see the patient as a risk because the patient was pleasant, happy and cooperative. The best patient on our floor."
Further interview revealed that there is one monitor tech who watches all 30 cardiac monitors and the ten toxicology and two hallways monitors.

4) An interview on October 26, 2010 at 11:45 AM with EMP2 revealed that nursing staff makes the determination what items will be removed from patient's environment when the patient is placed on suicide precautions.

Based on a review of facility policy, facility documents, medical records (MR) and interview with staff (EMP), it was determined that Pinnacle Health Harrisburg Hospital failed to provide nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available, and failed to recognize and to notify a physician of a significant change in condition for one of 11 medical records reviewed (MR1).

Findings include:

A review conducted on October 19, 2010, of Pinnacle Health Harrisburg Hospital policy "Suicide Precautions for the Non-Psychiatric Setting, revised September 1, 2009," revealed "... Procedure Guidelines Within the Toxicology Unit ... 1. In the Toxicology Unit, video monitoring may be used on place of direct 1:1 observation for the suicidal patient ... Procedure Guidelines for Strict Suicide Precautions: Increased level of suicide surveillance is necessary for patients who communicate or display active suicidal intentions or other high-risk behavior ... 2. An RN may initiate Strict Suicide Precautions or escalate the existing Suicide Precautions to strict Suicide Precautions based upon assessment of findings of high-risk behaviors. The RN will notify the physician and obtain an order. 3. A staff member will be assigned to provide direct 1:1 observation of the patient at a distance of no more then five feet at all times ..."

A review conducted on October 26, 2010, of nursing orientation and education of nurses assigned to the Progressive Care/Toxicology Care Unit revealed the staff received two hours of education incorporated in the "Outline and Objectives for Tox day in Critical Care Course 2010." A review conducted on October 26, 2010 of the "Outline and Objectives for Tox day in Critical Care Course 2010", revealed the "Objective: After the presentation, the learner will be able to : 1.appreciate the role of the psych tech on care of toxicology patients: 2. discuss the usual process for aftercare for patients who have suicidal intent as part of their toxicology profile; 3. describe psychological care for patient with toxicology admission who have a psychiatric co-moridity."

A review conducted on October 25, 2010 of personnal files revealed that the Progressive Care/Toxicology Care Unit registered nuses attend the critial care course annually.

1) An interview conducted on October 26, 2010, at 10:00 AM with EMP5 revealed the staff received the Outline and Objectives for Tox day in Critical Care Course 2010 annually.

2) An interview conducted on October 25, 2010, at 2:00 PM with EMP3 revealed over "95% of the patients on the Progressive Care/Toxicology Care Unit have psychiatric problems and 75% are discharged to a psychiatric facility." Further interview revealed the staff were not comfortable with the psychiatric care the patients needed and a psychiatric tech was assigned to the unit to Monday through Friday on the dayshift to help with the patients.

3) A review conducted on October 19, 2010, of MR1 of the physician orders lacked documented evidence of an increase level of suicide surveillance after the suicidal attempt.

4) An interview conducted on October 19, 2010, at 2:00 PM with EMP2 confirmed that MR1 did not contain evidence that the physician or the RN increased the level of suicide surveillance after the suicide attempt or documentation of staff providing direct 1:1 observation of the patient at a distance of no more than five feet at all time.
Further interview confirmed MR1 lacked documented evidence that the facility had followed their adopted policy on Suicide Precautions for the Non-Psychiatric Setting.

Based on review of facility policy, medical records (MR) and interview with staff (EMP), it was determined that Pinnacle Health Harrisburg Hospital failed to ensure the nursing records were pertinent, accurate, concise and reflected the care rendered and the progress of the patient to ensure continuity care that was provided to one of one patient. (MR1).

Findings include:

A review conducted October 25, 2010, of Pinnacle Health Harrisburg Hospital policy "Guidelines for Completing Daily Clinical Documentation", last revised May 2010, revealed "... Implementation ... Notes Free text information as needed ... Special considerations ... Notes should be used for events not able to be categorized within specific body systems. Individual remarks/assessments should be documented in comment section which follows each body assessment whenever possible ... Implementation ... Unstable event: Indicate if the Rapid Response Team was notified, select the event problem(s) and free text and other pertinent information. Enter the vital signs at the time of the event."

1) A review conducted on October 19, 2010, of MR1 revealed "Clinical Notes Report: Collected Date/Time: 10/15/10, 21:06 ... noticed on video monitor that pt was leaning towards the chair (half of the body on the chair and other half on the bed). Came into the pt room and told patient to get back in the bed, otherwise they can fall. Pt did not respond, (I thought that pt fell asleep) and was put back into bed. Than noticed that pt had cell phone charger cord and pillow case wrapped around the neck. Pt's head was turning blue, still had rhythm on telemetry, sinus tach in 120's. When took that off neck pt woke up within a minute, all vital signs are stable ... MD was notified, pt was placed on 1:1 observation, cell phone charger and all other extra cords removed from the room ..."
Further review of the medical record revealed that the patient's vital sign were recorded October 15, 2010, at 15:00 and were not recorded again until October 16, 2010, at 00:08.

2) An interview conducted on October 19, 2010, at 2:00 PM with EMP3 confirmed the patient did have a suicide attempt and that the medical record did not contain documentation of vital signs, nursing assessment or evidence of a telemetry monitor strip at the time of the event (21:06). The next set of vital signs was documented as October 16, 2010, at 00:08.