HospitalInspections.org

Based on document review, observation, and interview, it was determined that the Hospital failed to ensure patients were safe from ligature risks. This potentially places all current and future patients who are suicidal, at risk for serious harm. As a result, the Condition of Participation, 42 CFR 482.13 Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure that patient rooms were free from ligature risks and environmental hazards to prevent harm to patients. (A144-A).

2. The Hospital failed to ensure infant safety monitors alarmed when removed (A144-B).

3. The Hospital failed to ensure a physician's order was obtained for restraint usage (A168).

An Immediate Jeopardy (IJ) began on 7/30/18, for the Hospital's failure to identify and remove ligature risks from patient rooms on the Behavioral Health Unit, thus potentially placing all psychiatric patients, who are suicidal, at risk for serious harm.

The IJ was identified and announced on 7/31/18 at 3:45 PM, during a meeting with the President, Chief Nursing Executive, Chief Nursing Officer, Vice President of Quality, and Vice President of Operations. The IJ was
not removed by the survey exit date of 8/2/18.

A. Based on document review, observation and interview, it was determined that for 27 of 27 patient rooms on the Behavioral Health Unit (BHU-Galter 13), the Hospital failed to ensure that patients' rooms were free from ligature risks. This has the potential to affect the safety of the 5 patients (Pt. #'s 16-20) diagnosed with suicidal ideation on census as of 7/30/18 and future patients who are suicidal.

1. The CMS (Centers for Medicare and Medicaid Services) S & C (survey and certification ) Memo: 18-06- Hospitals (dated 12/8/17), was reviewed on 7/30/18, and included, "Memorandum Summary...Definition of a Ligature Risk: A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include...door frames..."

2. The Hospital's 13th floor (BHU-Galter 13) Risk Assessment (dated 6/24/16), Implementation Plan (dated 2/13/17) and Implementation Report (from 7/6/17 to 9/26/17), were reviewed on 7/30/18. Door frames were not identified as a ligature risk in the Risk Assessment or Implementation Plan. The Implementation Report indicated no changes have been made to reduce that risk.

3. On 7/30/18, the Hospital's policy titled, "Therapeutic Protective Measures: Precautions, Levels of Observation" (effective 1/12/16), was reviewed and included, "... Depending upon an evaluation of the patient's clinical condition... other precautionary levels are used to ensure the patient's safety. The physician ordering either of these levels (Constant Visual Observation or 1:1 [staff member within arms reach at all times]) will specify the reason for the increased level of observation/supervision (i.e., potential for suicidal or self-injurious behavior)... B. Constant Visual Observation (CVO) ...Indications for use: CVO is appropriate when clinical judgment indicates that the patient...
requires a staff member to observe him/her at all times in close proximity in order to provide him/her with sufficient supervision and to maintain safety. This may be an appropriate level of observation to place a patient on at admission when it is determined the patient is at imminent risk for self harm, and additional monitoring is needed ..."

4. On 7/30/2018, at approximately 10:15 AM, an observational tour was conducted on the Behavioral Health Unit (BHU-Galter 13). There were 29 patients on the unit during the tour. Of the 29 patients, 5 were admitted for suicidal ideation (Pt. #16 to Pt. 20). The unit consisted of a total of 29 patient beds. Two patient rooms were semi-private (2 beds per room) while the other twenty-five rooms were private (1 bed per room). Each of the 27 patient rooms had a private bathroom. The room entrance doors and the bathroom doors were all unlocked. The doors and frames were square, and the doors reached to the top. Bed sheets were present on each bed, and movable furniture was present in each room including a chair and side table.

5. The clinical records were reviewed on 7/30/18, for the 5 patients (Pt. #16 to Pt. #20), diagnosed with suicidal ideation, currently on census in the BHU. Treatment Plans for all 5 patients indicated that "Close Supervision - [every] Q15 minutes visual checks" was used as an intervention to prevent "violence towards self." There was no documentation to indicate that any of the 5 patients were placed on a higher level of observation (CVO or 1:1) during their admission to the BHU.

6. During an interview on 7/30/18, at approximately 10:30 AM, with the Director of Psychiatry (E#1). E#1 stated that bathroom doors do not have locks and patient room doors are not locked. All patients on the BHU are on Close Supervision (CS) which means they are monitored every 15 minutes. Of the current patients on census, none were put on Constant Visual Observation (CVO) or 1:1.

7. During an interview with the Medical Director of Psychiatry (MD#1) on 7/30/18, at approximately 10:35 AM, MD#1 stated,"We did consider locking the bathroom doors, but we felt that keeping them open would provide a more empowering environment for our patients." We assess each patient daily for suicide risk using the Columbia scale [C-SSRS]. The team then determines the patient's risk, and if it is high, the patient will be placed on CVO or 1:1 precautions.


32820


B. Based on document review, observation and interview, it was determined that the Hospital failed to detect the displacement of a Hugs sensor (an abduction prevention bracelet, worn around an infant's ankle) for 1 of 3 newborns (Pt. #28) on Prentice 11, Mother/Maby Unit. This failure potentially increased the risk of infant abduction for Pt. #28.

Findings Include:

1. The Hospital's policy titled, "Infant Security Program (ISP)" (effective 7/6/18), was reviewed on 7/30/18. The policy required, "II. Postpartum Unit A. Immediately upon the infant's and mother's arrival to the postpartum unit, the postpartum nurse will verify the identification bands, attach a security sensor to the infant."

2. The Hugs System [abduction prevention bracelet] Quick Reference Guide (February 2014) was reviewed on 7/30/18. The guide included, "Tag Loose Alarm Occurs when a Check Tag Tightness Event has been cleared, but the tag is still too loose to make consistent contact with the infant's skin ...Check Tag Tightness Event Occurs when the tag is too loose to 'sense' contact with the infant's skin."

3. On 7/30/18 at approximately 9:30 AM, an observational tour was conducted in the Prentice building on the 11th floor mother/baby unit. Pt. #28 was observed in the room without an ankle sensor bracelet. The Hugs infant safety sensor was laying in the bassinet. Pt. #28 was being held by a visitor, and the mother was in the bathroom. No alarm sounded due to the detached infant safety sensor. No one could identify how or when the ankle sensor bracelet was detached or why the alarm did not activate.

4. Pt. #28's medical record was reviewed on 7/30/18. Pt. #28 was a 2 day old infant who was born/admitted to the mother/baby unit on 7/28/18 following a vaginal delivery. Pt. #28's safety sensor alarm (ankle bracelet) event report showed that Pt. #28 was admitted on 7/28/18 at 9:10 AM. Pt. #28's safety sensor alarm (ankle bracelet) event report lacked activity of the removal and reattachment of Pt. #28's safety sensor on 7/30/18 at approximately 9:30 AM. Pt. #28's flowsheet included documentation that Pt. #28's ankle bracelet was last checked for placement on 7/30/18 at 4:00 AM.

5. On 7/30/18 at approximately 9:40 AM, an interview was conducted with the Mother/Baby Unit Manager (E #2). E #2 stated that the Hugs (ankle bracelet) sensor will alarm when tampered with, but it did not alarm during this event.

6. On 7/30/18 at approximately 1:53 PM, an interview with a Security Systems Manager (E #3) was conducted. E #3 stated that the Hugs (ankle bracelet) band is not designed to alarm when it is removed or loses contact with the infant's skin.

7. On 8/1/18 at approximately 12:31 PM, a second interview was conducted with E #3. E #3 stated that the infant safety sensor sounds if the sensor is cut, detached, improperly applied or is too close to an exit door.

8. On 8/1/18 at approximately 12:37 PM, an interview was conducted with the Director of Women's Health (E #11). E #11 stated that the Hugs (ankle bracelet) skin sensitive sensor option was not selected/installed due to alarm fatigue (desensitization to alarms). Parents are educated on the Hugs (ankle bracelet) infant safety sensor and instructed to notify staff if the sensor comes off of the infant. Pt. #28's father did not notify staff that Pt. #28's Hugs (ankle bracelet) safety sensor came off. E #11 stated that infants lose about 10 percent of their body weight within 48 hours after birth, and the safety sensors become loose. The staff check every 8 hours to make sure infant Hugs (ankle bracelet) safety sensors are in place.

Based on document review and interview, it was determined that for 2 of 3 (Pt. # 32 and Pt. #33) patients in restraints, the Hospital failed to ensure a physician's order was obtained for restraint usage.

Findings include:

1. The Hospital's policy titled, "Use of Restraints (dated 1/25/16)" was reviewed on 7/31/18 and required, "Restraint is used upon the order of a physician..."

2. The clinical record of Pt. #32 was reviewed on 7/31/18. Pt. #32 was a 75 year old male, admitted on 5/11/18, with the diagnosis of acute decompensated heart failure. The nursing assessment flow sheet dated 5/23/18, included that Pt. #32 was placed in soft wrist restraints from 2:00 PM to 6:00 PM. The clinical record lacked documentation of a physician's order for restraints.

3. The clinical record of Pt. #33 was reviewed on 7/31/18. Pt. #33 was a 56 year old male, admitted on 5/29/18, with the diagnosis of altered mental status. The nursing assessment flow sheet dated 5/29/18, included that Pt. #33 was placed in soft wrist restraints from 2:00 PM to 5/30/18 at 4:00 AM. The clinical record lacked documentation of a physician's order for restraints.

4. During an interview on 7/31/18 at approximately 2:00 PM, the Project Manager of Operations for Informatics (E#10) stated, "I am unable to find an order for restraints for either of those patients in the computer."

Based on document review, observation, and interview, it was determined, that for 1 of 1 adverse occurrence related to a suicide attempt (Pt. #15) and 1 of 1 detached infant abduction prevention band (Pt. #28), the Hospital failed to ensure adverse events were reported and/or adequately investigated.

Findings include:

1. On 8/2/18 at 9:20 AM, the Hospital's policy titled, "Risk Management Incident and Event Reporting" (effective 6/15/18), was reviewed. The policy required, "II. A. all events which do or could negatively affect patient care... and which has the potential to cause harm... are to be reported to Risk Management through the electronic system or by telephone... IV. C. 1. Events should be reported as soon as possible after identification... E. 5. Significant events which caused or could have caused harm are allocated sufficient resources to conduct a comprehensive systemic analysis... and addresses themes such as human factors... environment and equipment..."

2. Pt. #15's clinical record was reviewed on 7/31/18 with the Director of Psychiatry (E#1). Pt. #15 was a 19-year old female, admitted on 5/12/18 with a diagnosis of major depressive disorder (severe) with suicide ideation. A nurse's noted dated 5/14/18 at 11:45 AM included, "Patient found sitting in the bathroom with telephone cord wrapped around neck telephone cord released reddened area observed where cord was Patient stated 'It was a mistake I'm sorry' Physician notified patient assessed patient placed on constant visual observations"

3. On 7/30/18 at 2:00 PM, the adverse occurrence logs from 5/3/18 to 7/30/18, were reviewed. Pt. #15's adverse occurrence was included. The report included the event, but no comprehensive systemic analysis was documented.

4. On 7/30/18 at approximately 9:30 AM, an observational tour was conducted on the 11th floor, Mother Baby Unit. Pt. #28, in room 1183, was not wearing an abduction prevention bracelet (Hugs sensor), and was being held by a visitor. Pt. #28's ankle abduction prevention bracelet was laying in the bassinet.

5. On 8/1/18 at 1:15 PM and on 8/2/18 at 9:30 AM, interviews were conducted with the Director of Quality (E #15). E #15 stated that an incident report had not been done for Pt. #28's detached ankle bracelet. E #15 stated that a root cause analysis should have been done for Pt. #15's attempted suicide. E #15 disagreed that an incident should have been completed for the displaced abduction prevention bracelet, because nursing staff monitors the patients for safety.

Based on document review and interview it was determined that for 1 of 2 (Pt #22) clinical records reviewed on the Feinberg 10 West (Neurological, Orthopedic) Unit, the Hospital failed to ensure the patient remained free of injury/skin breakdown.

Findings include:

1. On 7/31/2018 at approximately 10:00 AM, the clinical record of Pt #22 was reviewed. Pt # 22 was 59 year old male, admitted on 7/24/2018 with a diagnosis of spinal tumor (cancerous mass on the spine). The Initial Nursing Assessment, dated 7/24/2018 at 4:45 PM, included, "...No Pressure Injury Present." The Nursing Flow Sheet, dated 7/29/2018 at 8:00 AM, included, "Back-Lower mid posterior, Blister, 3 centimeter (cm) in legnth, by 2 cm in width. Drainage-Serosanguinous [slightly yellow color], edges of wound defined."

2. On 7/31/2018 at approximately 12:50 PM, an interview was conducted with the Wound Care Nurse (E #13). E #13 stated, "If a patient develops a skin tear, ulcer, or deep tissue injury, the nurses refer to our pocket guide for instructions on how to care for the wound. They would also notify the doctor."

3. On 8/1/2018 at approximately 1:30 PM, an interview was conducted with the Manager of Feingberg 10 West (E #14). E #14 stated, "The nurses will notify an MD [medical doctor] of a pressure ulcer if it is a stage 3 or higher. For this type of wound, the nurses are to follow the RN [Registered Nurse] Pocket Guide." During this interview, E #14 stated, "We do not have a policy for pressure prevention."

Based on interview and document review, it was determined that the Hospital failed to ensure the completion of medical record after 30 days of patient discharge.

Findings include:

1. On 07/31/18 at approximately 2:30 PM, an interview with E #6 (Systems Director for Medical Records) was conducted. E #6 stated, "You would be amazed, we have such a small number of charts that are delinquent."

2. On 07/31/18 at approximately 3:45 PM, E #6 presented the document titled, "Medical Record Documentation Deficiencies" (dated 07/31/18), that included, "30+ [or more] days of deficiency report by deficient type ...grand total 26."

3. On 08/01/18, the Hospital's policy titled, "Health Information Management" (dated 03/03/18), was reviewed and included, " ...B. Medical Record Deficiencies ...The absence of any of the elements defined below leads to the identification of the record as "deficient" or "delinquent" ...D. Administrative Suspension Timeline ...3. Medical records are considered delinquent at 30 days post-discharge."

A. Based on document review, observation and interview it was determined that for 2 of 2 dietary servers (E #5 and E #6) observed plating food on the tray line, the Hospital failed to ensure the performance of proper hand hygiene during food preparation. This could potentially affect the 478 patients receiving food from the kitchen on 7/31/18.

Findings Include:

1. The Hospital's policy titled, "Hand Hygiene" (effective 8/24/16), was reviewed on 7/31/2018. The policy required, " ...IV Procedure: A. Indications for hand hygiene: 4. Before preparing food ..."

2. On 7/31/18 at approximately 11:00 AM, an observational tour of the tray line was conducted. A Dietary Server (E #6) opened the hot box (metal box for food storage) with gloved hands, removed food from the hot box, returned to the tray line, and touched a hamburger bun without performing hand hygiene.

3. On 7/31/18 at approximately 11:20 AM, during the tray line observation, a Dietary Server (E #5) opened the hot box with gloved hands, removed a food tray, removed a grilled cheese sandwich from the food tray with the same gloved hands, returned the food tray to the hot box, and continued working on the tray line without performing hand hygiene.

4. On 7/31/18 at approximately 11:25 AM, an interview was conducted with the Food Service Director ( E #12) . E #12 stated that staff should follow hand hygiene procedures when handling food.

B. Based on document review, observation and interview, it was determined that for 1 of 1 cold entree/salad refrigerator observed for food storage, the Hospital failed to ensure that the dietary staff disposed of expired food items.

Findings Include:

1. The Hospital's policy titled, "Food and Supply Storage" (revised 1/18), was reviewed on 7/31/18. The policy required that, "Refrigerated Storage Life of Foods...Add the time in the opened column to the date when the food is prepared or opened...Unused portions of foods prepared on site; not reheated...opened +2 [or more] days..."

2. On 7/31/18 at approximately 10:30 AM, during an observational tour of the kitchen, a tray of tuna salad was labeled with a preparation date of 7/26/18 and a expiration date of 7/29/18.

3. On 7/31/18 at approximately 10:30 AM, an interview was conducted with the Director of Food Services (E #12). E #12 stated that the chefs are responsible for checking the dates on prepared food daily, and the tuna salad should have been disposed of 48 hours after preparation.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted 07/30/18 - 08/02/18, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were cited. Also see A710.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted 07/30/18 - 08/02/18, the facility failed to comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with the K-Tags.

Based on document review, observation and interview, it was determined that for 2 of 2 refrigerators/freezers on Prentice 11 (Mother/Baby Unit) reviewed for temperature monitoring, the Hospital failed to ensure that a thermometer was present in the freezers and to maintain a freezer temperature monitoring log. This failure potentially increased the risk for unsafe food consumption for the 21 patients on the post-partum unit.

Findings Include:

1. The Hospital's policy tilted, "Cold Storage Device: Operation, Monitoring and Maintenance" (effective 1/22/16), was reviewed on 7/30/18. The policy required, "II. Policy Statement: A. Cold storage (refrigerators and freezers) containing products including ...patient food products ...IV. Responsibilities: A. Management for each area that utilizes cold storage manual ... are responsible for ensuring compliance with; 1. Reviewing temperature monitoring logs and alarm reports ...B ...5. Manual Monitoring: If automated monitoring is not available, then manual monitoring must be maintained. Daily logs of temperatures must be maintained and available for inspection on the unit ..."

2. On 7/30/18 at approximately 9:50 AM, an observational tour of the 11th floor Mother/Baby Unit was conducted. The south nourishment room's refrigerator did not include a thermometer or temperature log for the freezer. There were no food items present in the freezer.

3. On 7/30/18 at approximately 9:55 AM, during the observational tour of the 11th floor Mother/Baby Unit, the north nourishment room's refrigerator did not include a thermometer or temperature log for the freezer. The freezer contained ice cream (dated 7/29/18).

4. On 7/30/18 at approximately 9:52 AM, an interview was conducted with the Mother/Baby Unit Manager (E #2). E #2 stated that the freezer temperatures are not monitored because there is no food stored in the freezers.