HospitalInspections.org

Based on observation, record review and interview the hospital failed to ensure patients received care in a safe setting as evidenced by a patient being able to remove a screw from a ceiling vent and inserting the screw into his arm. Findings:

Patient #2 was a 19 year old male admitted on 4/24/15 on CEC (Coroner's Emergency Certificate) dated 4/24/15 for increase paranoia and threatening behavior, off medications (again), removed from mother's house by police, dangerous to others, gravely disabled and unable to seek voluntary admission.

Review of the E.R. (Emergency Room) Report from 4/28/15 at 5:25 p.m. revealed the patient shoved a nail in his left forearm.

Review of the 24 hour Nursing Assessment, dated 4/29/15 at 9:10 p.m. revealed pt. (patient) broke face plate off ceiling vent and shoved screw into L (left) forearm. Pt went to ER (emergency room) in ambulance. While there pt. threatened to kill people at hospital upon return.

An observation was conducted on 5/5/15 at 10:35 a.m. of Patient #2's left forearm. Patient #2 had a linear 1 inch abrasion on his left inside forearm. The abrasion was about 1/8 inch in width with a scab over the abrasion. No redness, swelling or drainage was noted. Patient #2 reported the wound was good.

An interview was conducted with S12Director of Plant Operations on 5/5/15 at 9:30 a.m. He reported Patient #2 was somehow able to get a screw out of the breakaway ceiling vent in his room. S12Director of Plant Operations further reported the vent was breakaway due to ligature risk and the screws were screwed into a box in the ductwork in the ceiling. The screws were also tamper proof.

An interview was conducted with S6RN on 5/5/15 at 2 p.m. S6RN reported she was the nurse taking care of Patient #2 when he inserted the screw into his arm. S6RN reported the patient came to the nurses' station and asked if he was hurt would he get to leave the hospital? The patient then reported to S6RN that he needed an ambulance since he inserted a screw into his arm. S6RN reported he allowed her to look at his arm and she called a code(security) and an ambulance. S6RN reported Patient #2 was extremely paranoid and he thought his father and brother had hired a "hit man", who was in the hospital to kill him. S6RN further reported after Patient #2 left for the hospital, she examined his room to see where he obtained the screw and that is when she discovered the face sheet off the ceiling vent with a missing screw.

Based on observation, record review and interview the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by a wound obtained in the hospital not being assessed every shift per hospital policy. Findings:

Review of the hospital's policy on Wound Care/Staging revealed in part, Purpose: to provide for the assessment, care and monitoring of patients with wounds...Wound areas will be evaluated by a nurse every shift with or without dressing change as ordered, and findings documented on the progress notes.

Patient #2 was a 19 year old male admitted on 4/24/15 on CEC (Coroner's Emergency Certificate),dated 4/24/15, for increase paranoia and threatening behavior, off medications (again), removed from mother's house by police, dangerous to others, gravely disabled and unable to seek voluntary admission.

Review of the E.R. (Emergency Room) Report from 4/28/15 at 5:25 p.m. revealed the patient shoved a nail in his left forearm.

Review of the 24 hour Nursing Assessment, dated 4/29/15 at 9:10 p.m. revealed pt (patient) broke face plate off ceiling vent and shoved screw into L (left) forearm. Pt went to ER (emergency room) in ambulance.

An observation was conducted on 5/5/15 at 10:35 a.m.of Patient #2's left forearm. Patient #2 had a linear 1 inch abrasion on his left inside forearm. The abrasion was about 1/8 inch in width with a scab over the abrasion. No redness, swelling or drainage was noted. Patient #2 reported the wound was good.

Review of the 24 Hour Nursing Assessment from 4/28/15 until 5/5/15 revealed the first assessment of Patient #2's wound was on 5/3/15 at 10:45 a.m. This RN assessed the wound from screw in L (left) FA (forearm) no redness/heat or drainage noted, healing well.

Review of the 24 Hour Nursing Assessment from 5/5/15 at 10:10 a.m. revealed the second attempted assessment of the wound. Pt (patient) refused Keflex and antibiotic ointment, "I don't need these." Pt. asked nurse "show me the sealed packages so I know you didn't poison them and new water, it is contaminated."

Review of the Nursing Progress Notes form 5/5/15 at 10:43 a.m. revealed the following documentation when the surveyor asked to observe Patient #2's wound. At approximately 10:35 a.m., this nurse assessed pt's abrasion on left forearm, it is approximately one inch in length, free from s/s (signs and symptoms) infection (no redness, no swelling, no drainage present) . Pt stated " it feels good;" voices no complaints.

An interview was conducted with S5Nurse Manager on 5/4/15 at 1:15 p.m. She reported wounds are assessed every shift, but the assessments don't always get documented. She confirmed the first documented assessment of the wound (self-inflicted wound on 4/28/15 at the hospital) was documented on 5/3/15.