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Based on interview, clinical record review and review of the facility's policies "General Hospital Policies, Section 3, Risk Management and Safety, Subsection C, Search," effective date for the Central Triage Center (CTC), 01/25/10, and "Risk Management Policy, Section C, Patient Supervision," undated, it was determined the facility failed to ensure care was given to patients in a safe setting as evidenced by four (4) of thirty-eight (38) sampled patients having experienced an adverse incident that could have or did result in harm to the patient: (1) Patient #1, medication overdose; (2) Patient #2, attempted asphyxiation; (3) Patient #31, resident abuse; and (4) Patient #4, elopement.

The findings include:

Review of facility policy "General Hospital Policies, Section 3, Risk Management and Safety, Subsection C, Search," effective date for the CTC, 01/25/10, revealed a search would be conducted on all patients admitted to the facility in the CTC. Further review revealed that two (2) staff members would be present for the non-invasive body search; and the patient should disrobe and put on a hospital gown and remove underwear, after which the clothing would be inspected for contraband. The search should include pockets, hems, inside shoes and socks and other places where items might be hidden. At the same time, a skin assessment would be done. Any contraband found or unusual skin conditions should be documented on the "Nursing Care Record B Form."

Review of policy, "Risk Management Policy, Section C, Patient Supervision," undated, revealed the level of supervision of a patient was based on the ability of the patient to manage safely within that level without unacceptable risk of serious harm to self or others. Support level with staff escort allowed the patient to leave the unit escorted by staff who were to maintain supervision of the patient. Safety level with fifteen (15) minute checks would be used when the patient was at low risk for injury but identified risk factors were present. Assigned staff must observe the patient and document this every fifteen (15) minutes, and the patient could not leave the unit. Safety level with close observation would be used when the patient was at moderate risk for injury. Assigned staff must observe the patient continually with a clear view and be within twelve (12) feet of the patient. Safety level with one (1) to one (1) observation would be used when the patient was at high risk for injury due to identified risk factors. Assigned staff must observe the patient continually with a clear view and be within leg's length of the patient.

1. Review of the clinical record of Patient #1 revealed he/she was admitted 11/21/11 at 9:45 PM through CTC with a diagnosis of Depressive Disease, Not Otherwise Specified (NOS). He/she was admitted on a seventy-two (72) hour involuntary court order because of a voiced threat and plan to commit suicide. Review of the "Suicide Risk Assessment" done in CTC on 11/21/11 by the Licensed Clinical Social Worker revealed the patient was at critical risk for suicide with a plan to overdose or hang self. Body/skin search done 11/21/11 on CTC by MHA #1 was documented with only his signature, and no contraband was found. Review of the "Progress Notes" by the Physician on 11/22/11 at 6:00 PM stated patient claimed at 4:00 PM or 4:30 PM that he/she took twelve (12) Seroquel XR (an antipsychotic medication used, along with antidepressants, to treat Major Depressive Disorder in adults) 400 mg pills. The notes further revealed that Patient #1 had an unsteady gait, dizziness and slurred speech. The patient was diagnosed as having a drug overdose and sent to the University of Kentucky Healthcare (UKHC) Emergency Department for treatment. Patient #1 had been on safety with fifteen (15) minute checks since admission. Review of Patient #1's clinical record from UKHC revealed the patient was admitted to Good Samaritan Hospital on 11/22/11 and sent back to this facility on 11/24/11. Urine drug screen revealed positive results from Seroquel.

Review of the clinical record of Patient #5 revealed he/she had been admitted 05/16/11 with a diagnosis of Schizoaffective Disorder and was the roommate of Patient #1 from the time of Patient #1's admission until he/she was transferred to UKHC Emergency Department. "Progress Notes" by the Resident Physician, on 11/23/11 at 11:30 AM revealed Patient #5 stated he took four (4) Seroquel pills his roommate, Patient #1, had given him. This occurred on 11/22/11. The Resident Physician further stated Patient #5 suffered no harm, slept eight (8) hours and was doing fine the AM of 11/23/11. Per "Patient Supervision Record," Patient #5 slept from 9:15 PM, 11/22/11, until 6:30 AM, 11/23/11. Patient #5 was checked every fifteen (15) minutes during this time. There were no additional Physician Orders for Patient #5.

Interview with Mental Health Associate (MHA) #1, on 12/07/11 at 09:55 AM, revealed he had performed the body search on Patient #1 in the CTC. He remembered the patient but did not specifically remember doing the body search. However, he did state that he did the body search as documented. He further revealed it is typically one (1) MHA that completed the body search/skin assessment; he did not have the patient put on a hospital gown; and he did not have the patient remove underwear. Interview with MHA #2, on 12/06/11 at 4:55 PM, revealed there was usually just one (1) staff member that did the body search; the patient did not put on a hospital gown; and the patient did not remove underwear. Interview with MHA #3, on 12/06/11 at 5:15 PM, revealed that usually one (1) MHA did the body search; the patient did not put on a gown; and the patient did not remove underwear.

Interview with the Acting Director of the CTC, on 12/07/11 at 9:30 AM, revealed two (2) staff members were supposed to do the body search and gowns needed to be used to do a more thorough search. However, she stated the CTC did not currently have hospital gowns; therefore, patients were not asked to put on a gown or to remove underwear.

Interview with Patient #5, on 12/07/11 at 3:05 PM, revealed he/she had seen Patient #1 take Seroquel the evening of 11/22/11, and he/she had been offered those pills by Patient #1 and had taken two (2), 1/2 pills at the same time. Patient #5 further revealed Patient #1 showed him a handful of pills which were wadded up and taped with gray tape, like gray masking tape. Patient #5 also stated he/she thought he/she remembered Patient #1 telling him/her that the pills were brought in from home.

Interview with MHA #4, on 12/07/11 at 5:24 PM, revealed MHA #4 pulled out a pouch from Patient #1's right pocket, on 11/22/11, after he/she he/she had taken pills. He stated he pulled out a duck tape pouch which was empty but had white residue still in it.

2. Review of the clinical record of Patient #2 revealed he/she was admitted on 11/03/11 with diagnoses of Major Depressive Disorder, Severe with Psychosis. Record review revealed on 11/22/11 at 7:50 AM, Patient #2 was found lying on the bathroom floor with a chipped front tooth and a plastic bag nearby. Patient #2 stated he/she tried to asphyxiate himself/herself with a plastic bag and fell off the commode. Patient #2's level of monitoring was safety with every fifteen (15) minute checks before and during the incident. Further record review revealed the level of supervision was changed by the Physician to safety with close observation after the incident. Review of "Shift Assessment/Daily Notes," 11/22/11 at 5:00 AM, revealed Patient #2 was found tearing a long piece of plastic garbage bag, and a four (4) foot piece of plastic was found on the floor next to the bed. The record further stated the bed was searched for any additional items the patient could use for self harm. All such items were removed, and linen bags were removed from the area per record. There was no change in level of supervision after this discovery.

Interview with Patient #2, on 12/13/11 at 3:58 PM, revealed he/she would not discuss the incident. Interview with the Nurse Manager for Wendell 3, on 12/19/11 at 12:08 PM, revealed nurses could move the patient to a more intensive level of monitoring, if warranted, and contact the on-call Physician or wait for the primary Physician to come and assess the situation. Interview with the Director of Nursing (DON), on 12/21/11 at 1:53 PM, revealed that as soon as she was informed of the incident, she initiated no plastic bags in patient care areas.

3. Review of the clinical record of Patient #31 revealed he/she was admitted on 11/23/11 with a diagnosis of Psychotic Disorder, Not Otherwise Specified. He/she was sent from another facility where he/she had been getting increasingly threatening in behavior. Record review revealed the level of supervision was safety with every fifteen (15) minute checks. Review of "Shift Assessment/Daily Notes" revealed, on 11/25/11 at 5:45 AM, Patient #31 made a threatening gesture to a peer and was redirected; on 11/25/11 at 9:30 PM, Patient #31 verbally threatened a peer and forced entry into the nurses' station which prompted calling a Code 500 and placing the patient in restraints/seclusion; on 11/28/11 at 12:15 PM, Patient #31 shoved another patient's attorney and was placed in time-out; on 11/28/11 at 9:50 PM, Patient #31 shoved a peer in the chest and was placed in time-out; on 11/30/11 at 9:25 AM, Patient #31 hit a peer, unprovoked and was placed in time-out; on 11/30/11 at 10:30 PM, Patient #31 attempted to attack the Physician and strike an MHA in the face with his/her fist and a Code 500 was called, placing the patient in restraints; on 12/01/11 at 4:45 PM, Patient #31 asked a peer "how bad do you think it would hurt if I hit you with the Bible"; and on 12/02/11 at 1:20 PM, Patient #31 attempted to swing at the Physician, pushed a peer (Patient #3) and chased a Social Worker, which prompted a Code 500 and the patient being placed in restraints. Patient #31 was not removed from restraints, until he/she was transferred to the Intensive Service Unit (ISU) for more intensive monitoring at 4:15 PM.

Review of the clinical record of Patient #3 revealed he/she was admitted on 11/28/11 with diagnoses of Psychotic Disorder, Alcohol Dependence and Inhalant Abuse. Per "Shift Assessment/Daily Notes," on 12/02/11, Patient #3 was pushed to the floor by a peer (Patient #31) and hit in the back of the head. There was no loss of consciousness. Patient #3 was sent to the UKHC Emergency Department via ambulance. Patient #3 returned to the facility at 10:40 PM, 12/02/11. Patient had received eight (8) staples to crown region of the head and had a fractured sacrum.

Attempts to interview Patient #3, on 12/16/11 at 8:45 AM, and, on 12/19/11 at 1:45 PM, were unsuccessful. Interview with Patient #31, on 12/16/11 at 12:56 PM, revealed he/she had felt like hitting someone when the incident occurred, and Patient #3 happened to be standing beside him/her. However, he/she stated Patient #3 was not hit, but shoved to the floor.

Interview with the Physician, on 12/16/11 at 4:15 PM, revealed he did not feel Patient #31 was a threat to Patient #3 because there was no animosity between them. He further revealed Patient #31 would make threatening gestures, but he could be redirected. He also stated Patient #31 was on safety level of supervision with checks every fifteen (15) minutes and was taking medication to control his/her behavior. The Physician stated he transferred Patient #31 after the incident because his/her behavior could be better monitored on ISU. He further revealed the criteria for placing patients on ISU was if their behavior represented a danger to self/others, and/or it was out of control.


4. Review of the clinical record of Patient #4 revealed he/she was admitted 12/07/11 with diagnoses of Bipolar Disorder, Severe with Psychotic Features and Polysubstance Abuse. Level of supervision changed from safety with fifteen (15) minute checks to support on 12/08/11 at 9:00 AM. Physician Order was written 12/08/11 that Patient #4 could attend an Alcoholics Anonymous (AA) Meeting on 12/08/11. "Shift Assessment/Daily Notes" from 12/08/11 indicate Patient #4 went to an AA Meeting which started at 12:00 PM. He/she eloped while at this meeting.

Interview with the Drug/Alcohol Education (DAE) Program Clinician who accompanied/supervised Patient #4 to the 12/08/11 AA Meeting, on 12/13/11 at 3:30 PM, revealed she had taken only Patient #4 to the meeting. Patient #4 asked to go to the bathroom. She further revealed she had a clear, unobstructed view of the bathroom door from where she was seated. However, she stated she looked away for probably no more than forty-five (45) seconds. When she looked at the bathroom door again, it was open, and Patient #4 had eloped.

Interview with the DAE Coordinator, on 12/14/11 at 3:15 PM, revealed she did not expect staff to go with patients to the bathroom at AA Meetings, but did expect them to monitor patients at all times, which included having a clear view of the bathroom door.

Based on interview, clinical record review and review of the facility's policies "General Hospital Policies, Section 3, Risk Management and Safety, Subsection C, Search," effective date for the Central Triage Center (CTC), 01/25/10, and "Risk Management Policy, Section C, Patient Supervision," undated, it was determined the facility failed to ensure care was given to patients in a safe setting as evidenced by four (4) of thirty-eight (38) sampled patients having experienced an adverse incident that could have or did result in harm to the patient: (1) Patient #1, medication overdose; (2) Patient #2, attempted asphyxiation; (3) Patient #31, resident abuse; and (4) Patient #4, elopement.

The findings include:

Review of facility policy "General Hospital Policies, Section 3, Risk Management and Safety, Subsection C, Search," effective date for the CTC, 01/25/10, revealed a search would be conducted on all patients admitted to the facility in the CTC. Further review revealed that two (2) staff members would be present for the non-invasive body search; and the patient should disrobe and put on a hospital gown and remove underwear, after which the clothing would be inspected for contraband. The search should include pockets, hems, inside shoes and socks and other places where items might be hidden. At the same time, a skin assessment would be done. Any contraband found or unusual skin conditions should be documented on the "Nursing Care Record B Form."

Review of policy, "Risk Management Policy, Section C, Patient Supervision," undated, revealed the level of supervision of a patient was based on the ability of the patient to manage safely within that level without unacceptable risk of serious harm to self or others. Support level with staff escort allowed the patient to leave the unit escorted by staff who were to maintain supervision of the patient. Safety level with fifteen (15) minute checks would be used when the patient was at low risk for injury but identified risk factors were present. Assigned staff must observe the patient and document this every fifteen (15) minutes, and the patient could not leave the unit. Safety level with close observation would be used when the patient was at moderate risk for injury. Assigned staff must observe the patient continually with a clear view and be within twelve (12) feet of the patient. Safety level with one (1) to one (1) observation would be used when the patient was at high risk for injury due to identified risk factors. Assigned staff must observe the patient continually with a clear view and be within leg's length of the patient.

1. Review of the clinical record of Patient #1 revealed he/she was admitted 11/21/11 at 9:45 PM through CTC with a diagnosis of Depressive Disease, Not Otherwise Specified (NOS). He/she was admitted on a seventy-two (72) hour involuntary court order because of a voiced threat and plan to commit suicide. Review of the "Suicide Risk Assessment" done in CTC on 11/21/11 by the Licensed Clinical Social Worker revealed the patient was at critical risk for suicide with a plan to overdose or hang self. Body/skin search done 11/21/11 on CTC by MHA #1 was documented with only his signature, and no contraband was found. Review of the "Progress Notes" by the Physician on 11/22/11 at 6:00 PM stated patient claimed at 4:00 PM or 4:30 PM that he/she took twelve (12) Seroquel XR (an antipsychotic medication used, along with antidepressants, to treat Major Depressive Disorder in adults) 400 mg pills. The notes further revealed that Patient #1 had an unsteady gait, dizziness and slurred speech. The patient was diagnosed as having a drug overdose and sent to the University of Kentucky Healthcare (UKHC) Emergency Department for treatment. Patient #1 had been on safety with fifteen (15) minute checks since admission. Review of Patient #1's clinical record from UKHC revealed the patient was admitted to Good Samaritan Hospital on 11/22/11 and sent back to this facility on 11/24/11. Urine drug screen revealed positive results from Seroquel.

Review of the clinical record of Patient #5 revealed he/she had been admitted 05/16/11 with a diagnosis of Schizoaffective Disorder and was the roommate of Patient #1 from the time of Patient #1's admission until he/she was transferred to UKHC Emergency Department. "Progress Notes" by the Resident Physician, on 11/23/11 at 11:30 AM revealed Patient #5 stated he took four (4) Seroquel pills his roommate, Patient #1, had given him. This occurred on 11/22/11. The Resident Physician further stated Patient #5 suffered no harm, slept eight (8) hours and was doing fine the AM of 11/23/11. Per "Patient Supervision Record," Patient #5 slept from 9:15 PM, 11/22/11, until 6:30 AM, 11/23/11. Patient #5 was checked every fifteen (15) minutes during this time. There were no additional Physician Orders for Patient #5.

Interview with Mental Health Associate (MHA) #1, on 12/07/11 at 09:55 AM, revealed he had performed the body search on Patient #1 in the CTC. He remembered the patient but did not specifically remember doing the body search. However, he did state that he did the body search as documented. He further revealed it is typically one (1) MHA that completed the body search/skin assessment; he did not have the patient put on a hospital gown; and he did not have the patient remove underwear. Interview with MHA #2, on 12/06/11 at 4:55 PM, revealed there was usually just one (1) staff member that did the body search; the patient did not put on a hospital gown; and the patient did not remove underwear. Interview with MHA #3, on 12/06/11 at 5:15 PM, revealed that usually one (1) MHA did the body search; the patient did not put on a gown; and the patient did not remove underwear.

Interview with the Acting Director of the CTC, on 12/07/11 at 9:30 AM, revealed two (2) staff members were supposed to do the body search and gowns needed to be used to do a more thorough search. However, she stated the CTC did not currently have hospital gowns; therefore, patients were not asked to put on a gown or to remove underwear.

Interview with Patient #5, on 12/07/11 at 3:05 PM, revealed he/she had seen Patient #1 take Seroquel the evening of 11/22/11, and he/she had been offered those pills by Patient #1 and had taken two (2), 1/2 pills at the same time. Patient #5 further revealed Patient #1 showed him a handful of pills which were wadded up and taped with gray tape, like gray masking tape. Patient #5 also stated he/she thought he/she remembered Patient #1 telling him/her that the pills were brought in from home.

Interview with MHA #4, on 12/07/11 at 5:24 PM, revealed MHA #4 pulled out a pouch from Patient #1's right pocket, on 11/22/11, after he/she he/she had taken pills. He stated he pulled out a duck tape pouch which was empty but had white residue still in it.

2. Review of the clinical record of Patient #2 revealed he/she was admitted on 11/03/11 with diagnoses of Major Depressive Disorder, Severe with Psychosis. Record review revealed on 11/22/11 at 7:50 AM, Patient #2 was found lying on the bathroom floor with a chipped front tooth and a plastic bag nearby. Patient #2 stated he/she tried to asphyxiate himself/herself with a plastic bag and fell off the commode. Patient #2's level of monitoring was safety with every fifteen (15) minute checks before and during the incident. Further record review revealed the level of supervision was changed by the Physician to safety with close observation after the incident. Review of "Shift Assessment/Daily Notes," 11/22/11 at 5:00 AM, revealed Patient #2 was found tearing a long piece of plastic garbage bag, and a four (4) foot piece of plastic was found on the floor next to the bed. The record further stated the bed was searched for any additional items the patient could use for self harm. All such items were removed, and linen bags were removed from the area per record. There was no change in level of supervision after this discovery.

Interview with Patient #2, on 12/13/11 at 3:58 PM, revealed he/she would not discuss the incident. Interview with the Nurse Manager for Wendell 3