HospitalInspections.org

Based on document review, observation and interview, the facility failed to ensure a safe setting was provided for patients on 1 nursing unit (see tag 144) Immediate Jeopardy was identified due to the Conditions of Patient's Rights was not in compliance and was not lifted at time of exit.


The cumulative effect of this systemic problem resulted in the hospital's inability to ensure that Patients Rights were promoted.

Based on document review, observation and interview, the facility failed to ensure a patient has a right to receive care in a safe setting, for 1 of 9 closed Medical records reviewed (Patient # 9).

Findings include:

1. Review of established hospital policy titled: "PATIENT RIGHTS STATEMENT", indicated on page 1, under Policy Statement/Purpose; 7. "Exercise rights while receiving competent, considerate care or treatment in a safe setting", and on page 2, 13. "Receive every consideration of privacy, security and safety in their physical surroundings".

2. Review of policy "Caring for the Suicidal Patient or Those Who are a Danger to Self or Others in Non-BHS Areas", policy number SFT.21.15, last reviewed 10/2019, indicated required documentation included observation monitoring sheet.

3. Review of Patient # 9's MR, indicated the following:
A. Patient # 9, presented to ER/ED (Emergency Room/Department) on 6/15/2020 at 6:32; brought in by family member, for Psychiatric Evaluation.
B. Patient was seen/evaluated by MD # 30 (ER/ED Physician) at 6:55 pm, with patient found to have Auditory hallucinations; patient denied suicidal and homicidal ideations. MD # 30 consulted MD # 32 (Psychiatrist) and reviewed case. Patient placed on EDO (Emergency detention order), and admitted to 4th floor -South - Medical/Renal unit on Observation status.
C. No beds were available at AH # 2 (Acute Care Facility- affiliated). Documentation lacked attempts for other Psychiatric facilities for admission availability - placement.
D. An event occurred - "code yellow" was called after midnight by nursing staff on 6/16/2020, for documented changes in patient's behavior and patient attempts to barricade sitter (S # 10) in room.
E. Patient # 9 had Security Officer (SP # 20) in a chokehold and higher level of force was used to stop patient # 9, with patient to have expired from shot fired.
F. MR documentation did not reflect that MD # 32 was in to evaluate patient prior to event that occurred.
G. MR lacked documentation of 1:1 observation log for patient # 9.

4. In interview on 6/18/2020 at approximately 10:20 am, with A # 5 (Administrative Director - Patient Care Services), the following was confirmed:
A. No psych (Psychiatric) unit at hospital.
B. No psych beds were available at that time, pending transfer to AH # 2. MD # 32 had accepted patient for psych.

5. In interview on 6/18/2020 at approximately 10:25 am, and at approximately 2:22 pm, with A # 7 (Manager - Systems & Regulatory Quality), the following was confirmed:
A. Patient was on Observation; on EDO; was to be further evaluated by Psych and transfer to AH # 2.
B. No psych beds were available at that time at AH # 2, to follow up on bed availability in am.
C. MR did not show contacts were made to other psych facilities for bed availability.