HospitalInspections.org

Based on review of 5 (Patients #1, #2, #3, #5 and #10) of 7 suicidal patient medical records, interviews, and observations, the Hospital failed to ensure that patients on the Psychiatric Unit and in the Emergency Room consistently received care in a safe setting. On 8/26/15, while in the Psychiatric Unit, Patient #1 attempted suicide, by hanging, using gauze tied to the side rail of a Hospital Bed. Patient #1 subsequently died on 8/27/15.

Findings include:

1.) The Surveyor interviewed Associate Chief Nursing Officer (CNO) #1 at 10:00 A.M. on 9/9/15. Associate CNO #1 said Patient #1's Hospital room contained a Hospital Bed (bed with side rails designed for patients with medical surgical needs; side rails can be used as anchor points to secure material for hanging) although Patient #1 did not need a Hospital Bed. Associate CNO #1 said although a prior patient required the Hospital Bed for medical needs, Hospital staff did not remove the Hospital Bed from the room after the patient's discharge. Associate CNO #1 said that a process was not identified that assigned responsibility for removing a Hospital Bed from a Psychiatric Unit or monitoring when the patient no longer needed the Hospital Bed or removal upon discharge. Associate CNO #1 said the Medical Equipment on Psychiatric Unit policy was in draft form, however, the policy did not identify who was responsible for removing medical equipment from a Psychiatric Unit, and monitoring staff compliance with the policy.

2.) Environment of Care Committee Meeting Minutes, dated 7/27/15, indicated that a patient wrapped the cord of an air mattress (specialized bed mattress to prevent or alleviate bed sores) around his/her neck. The Minutes indicated that immediate corrective actions included: 1.) the Charge Nurse or Nurse Manager would review the psychiatric patient's medical need for use of the hospital equipment, and 2.) draft a policy (Sharps and Other Potentially Dangerous Objects). The Minutes did not indicate when or who was responsible for removing medical equipment from a Psychiatric Unit, when a psychiatric patient no longer needed the medical equipment or at the time of the patient's discharge. The Minutes did not indicate a process for monitoring staff compliance with the policy.

3.) The Inpatient Psychiatry policy titled Sharps and Other Potentially Dangerous Objects, dated March 2014, revised draft July 2015, indicated the revision that Medical equipment (for example: a medical bed), with cords, that the Registered Nurse Manager or designee inspected the equipment brought to the patient care unit to be used by an unsupervised patient and assessed the patient's ability to use the equipment without supervision. The policy did not indicate when or who was responsible for removing medical equipment from the unit when the patient no longer needed the medical equipment or at the time of the patient's discharge.

4.) The Surveyor interviewed the Psychiatric Clinical Leader at 10:45 A.M. and 2:30 P.M. on 9/9/15 and at 11:45 A.M. on 9/10/15. The Psychiatric Clinical Leader said that Emergency Department staff seldom searched Patient Belongings. The Psychiatric Clinical Leader said Patient Belongings bags arrived on Psychiatric Unit #1 and that staff did not know what was in the Patient Belongings bag. The Psychiatric Clinical Leader said that staff working on Psychiatric Unit #1 found marijuana and " crack " (street name for cocaine, a narcotic) in tinfoil on a regular basis, one to two times a month. The Psychiatric Clinical Leader said that it was common to find in Patient Belongings bags, cigarettes, knives, mace on key ring, and hypodermic needles but could not identify any specifics of patient names or dates. The Psychiatric Clinical Leader said he would like the Emergency Department staff to be more intense about searching Patient Belongings.

5.) Associate CNO #1 said that the Hospital may never know how Patient #1 obtained the gauze. The Associate CNO #1 said that searches remained a problem.

6.) The Surveyor interviewed Associate Chief Nursing Officer (CNO) #2 at 4:00 P.M. on 9/9/15. Associate CNO #2 said in March 2015, nationally known Consultants in Psychiatry evaluated that patient searches conducted in the Emergency Department had processes with "holes" and the process was inconsistent. Associate CNO #1 said the Psychiatric Consultants' evaluation, conducted in March 2015, and presented opportunities for improvement.

7.) However, the Chief Quality Officer, during Surveyor interview at 10:00 A.M. on 9/10/15, said that after the Consultation with the Psychiatric Experts, in March 2015, searches of Patient Belongings were being looked at in future planning and he was not aware that dangerous materials were getting through. The Chief Quality Officer said that the Emergency Department had adequate space to store Patient Belongings.

8.) The Surveyor interviewed Registered Nurse (RN) #1, at 2:00 P.M. on 9/15/15. RN #1 said that the Emergency Department did not have enough space to store Patient Belongings and that the Patient Belongings Cabinets had an odor (smelled).

9.) The Surveyor observed, at 2:00 P.M. on 9/15/15, in the Emergency Department, 1 of 2 Patient Belongings Cabinets was not locked and was readily accessible to patients and visitors. The Surveyor observed that the Patient Belongings Cabinet had a smell consistent with body odor and the Patient Belongings Cabinets were overfull with Patient Belongings bags.

10.) Review of 2 of 52 Hospital Reports, dated 5/1/15-8/31/15, indicated Patient Belongings contained knives. One of the two Hospital Reports, dated 6/28/15, indicated that Patient Belongings containing a knife was left in the hallway and not locked in the Patient Belongings locked cabinet and another patient took them and hid them in his/her belongings with the knife.

11.) The Hospital policies titled Receipt, Handling, and Safekeeping of Personal Property of Patients, dated 4/22/14; Search for Dangerous Objects on At Risk Patients, dated July 2014) ; Weapons on Hospital Property, dated 3/1/15; Contraband, dated March 2013 indicated staff searched and documented when Emergency Department patients were determined an imminent potential for risk or harm to self or others, prohibited any individual to have in their possession a weapon (for example firearms, and knives), staff assumed care, custody and control of a patients' Personal Property and Patient Personal Property was documented in the patient ' s medical record.

12.) Review of 5 (Patients #1, #2, #3, #5 and #10) of 7 medical records identified as patients' with suicidal ideation, indicated Patient Belongings and Searches were not documented according to Hospital policy.

13.) Review of Patients #1, #3, and #10's medical records did not indicate Emergency Department staff documented Patient Belongings. Review of Patient #3 ' s medical record did not indicate Emergency Department staff documented a Room Safety Check (room search). Review of Patient #2's medical record did not indicate signatures on 2 of 2 Patient Valuables Envelope forms, dated 8/17/15. Review of Patients #3 and 5 ' s medical record did not indicate Psychiatric Unit #1. staff documented Patient Belongings.

14.) Associate CNO #1 said that Patient #3 declined his/her belongings searched and it was a violation of his/her human rights to search the belongings.

15.) The Emergency Department Patient Safety Watch Flow Sheet, dated 8/22/15, indicated Patient #3 was suicidal.

16.) The Inpatient Psychiatry policy titled Searches, dated June 2014, indicated that patient searches may be conducted when information exists that leads to concern that a patient was at risk of harm due to self-destructive impulses; and when information exists that leads to concern that a weapon or other harmful object may be present. The policy indicted that all searches were documented in the medical record. The Policy indicated that belongings were searched when brought to the unit by a family member and or visitor. The policy indicated that if a patient refused a patient search the Physician and Charge Nurse conducted an individualized clinical assessment to determine the appropriate response and the patient would not be given access to his/her belongings until a personal belongings search was completed.