HospitalInspections.org

Based on medical record review, document review, and interview, in one (1) of five (5) medical records reviewed, the facility failed to identify and implement care in a safe setting for a patient who was at risk for self-harm.


Findings:

Review of medical record for Patient #1 identified: a 24-year-old female, admitted on 11/21/20 for Pica (the persistent eating of substances such as dirt or paint that have no nutritional value). Patient is a resident at a Psychiatric Facility, and a staff from the facility, accompanied the patient to the ED and remained as a companion. At 9:25 PM a Rapid Response Team (RRT) was called to the patient's room. As per RRT record, the Psychiatric Facility Companion was in attendance and had notified the RN that "the patient had removed three AA batteries from her telebox cardiac monitor and swallowed them ...a nurse is needed for Constant Observation because battery ingestion happened with the non-hospital employee watching the patient."

Review of an Incident Report dated 11/24/20 stated, "the outside facility's companion reported to the RN on 11/21/20 that the patient removed three batteries from the Cardiac Tele box and swallowed them... Three batteries confirmed on x-ray were seen in the patients' stomach."

Review of the facility's Incident Reports from August 2020 to present, identified an Incident report dated 8/30/2020, revealed the patient had swallowed four double A batteries on 8/29/20 at this facility... x-ray confirmed batteries were in the patient's stomach ....companion staff from the outside facility that was sitting at bedside stated the patient told her she swallowed batteries from the cardiac monitor."

Interview on 5/25/2021 at 11:15 AM Staff D, Clinical Director Psychiatry, stated, "The Psychiatric Hospital will always send a staff member /companion who stays with the patient for the entire hospitalization ...when the patient is evaluated by the ED physician and needs a 1:1 ...an order is placed by the physician, and nursing staff from this facility will do the constant observation watch. The patient will then have two people with them at the bedside...one from the Psychiatric Hospital who stays as a companion ...and one employed by this facility to do the 1:1."

There was no documented evidence that this patient, with a history for potential for self-harm, was assessed by the physician to need a 1:1 and no order for a Constant Observation was placed by the physician.

There was no nursing documentation that Constant Observation (CO) was initiated or that monitoring was implemented by a nurse in the ED, PACU and Inpatient medical unit.


Review of the facility policy titled "Constant Observation" revised December 2019 states: "The purpose of this document is to establish the standard for the use of special observation procedures in the acute care (non-behavioral health) environment ...It is our policy to provide a safe care environment for patients ... Constant Observation should be utilized after all other alternative interventions have been exhausted. (I: I) This level of observation is utilized for patients who demonstrate acute suicidal ideation / intent or other clinically indicated behavioral health concerns which require this level of observation ...a Registered Nurse may initiate Constant Observation pending prescriber order ..."

This patient who presented with history of Pica and a history of removing and swallowing batteries from the cardiac tele box in this facility, was not assessed as at risk for self-harm.

Interview on 5/27/2021 at 1:15 PM, Staff C, Director Quality Management, acknowledged these findings.