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Based on observation, interview and record review, the facility failed to provide a safe environment to protect patients from self- injury, in that 2 patients utilized broken epoxy from flooring in the bathroom, to self-inflict scratches and superficial cuts to their arms in one of 4 bathrooms monitored. The presence of the broken epoxy in the patients' bathroom flooring poses a threat of actual harm to all patients on the unit who use that bathroom. Patient #s 1, 2 and 4

Findings:

Interview on 10/28/2020 with Patient #1 revealed, she had self- inflicted superficial cuts and scratches to both inner aspect of her arms, which she had inflicted with a sharp object "tile", given to her by Patient #2 who obtained it from the male bathroom flooring on station #5.

Interview and observation on 10/28/2020 of Patient #2 who provided the sharp object to Patient #1, revealed she said, she gave Patient #1 a piece of sharp object secured from "tile" on the flooring, near the drain of the male bathroom on station 5. This was used by Patient #1 to self- inflict superficial cuts and scratches to both of her arms.

Patient #4
On 10/29/2020 at 2:58 p.m. Patient #4 was observed on station #7. The Patient was alert and oriented to person, place, and time. Interview with the Patient at that time in the presence of the Facility's Chief Nursing Officer revealed, she had cut herself many times. When asked what she had used to cut herself she refused to answer. Observation of the patient at that time revealed a laceration to the patient's left wrist approximately 4 cm in length, partially scabbed over.

Review of Patient #4's clinical record revealed a Psychiatrist daily progress notes dated 10/27/2020 at 2:15 p.m. with the following entry" "Cut self with broken pieces of tile."

Observation on 10/28/2020 of the male bathroom on station#5 revealed dark area on the flooring with sharp edges, near the drain. Interview with the Chief Operational Officer revealed dark area of the flooring was epoxy.

The facility did not investigate how the sharp object was secured by the patients and implement systems to remove the threat. There was no evidence documented that patients were searched for contraband or the object used to self-inflict scratches and superficial cuts to their arms.
As a result of these findings, the facility was notified that a threat exist to the health and safety of all patients housed on the unit was identified.

Cross Reference A502

Based on observation, interview, and record review, the facility failed to provide a safe environment to protect patients from self- injury, in that 2 patients utilized broken epoxy from flooring in the bathroom to self-inflict scratches and superficial cuts to their arms in 1 of 4 bathrooms monitored. The presence of the broken epoxy in the patients' bathroom flooring poses a threat of actual harm to all patients on the unit who use that bathroom. Patient #s 1, 2, and 4

Findings:

Patient #1

On 10/28/2020 at 12:28 p.m., Patient #1 was observed sitting in a common area on unit 5 near the nurses' station. This station houses adolescent patients. The Surveyor requested to conduct an interview with the patient from the Chief Nursing Officer . A private area was provided and the patient requested to speak to the Surveyor alone. Observation revealed the patient was alert and oriented to person, place, time, and situation.

Interview at that time with Patient #1 stated "Someone gave me a blade to cut myself, she told me to cut myself and I did with it. I threw it down the drain because another girl tried to get it from me. I asked the nurse to wrap it up, so no cotton could get in it, but she did not. Two girls came in my room and jumped me while I was sleeping. Whenever they moved me from 5-6, he banged my head against the wall. Mr D-- banged my head against the wall. I had a bump on my head, but it went away."

Observation at the time of the interview revealed the patient pulled back the sleeves on her blouse, which revealed multiple scratches and superficial cuts to her right and left inner arms. The patient said the scratches and superficial cuts were done with the blade given to her by another patient named --Patient #2.


Patient #2

On 10/28/2020 at 12:35 p.m., Patient # 2 was interviewed in the presence of the Facility's Chief Nursing Officer. The Patient was observed to be alert and oriented to person, place, time, and situation. Interview with Patient #2 revealed, she has been a patient at the facility for approximately a week and a half. The Surveyor asked the patient what was the relationship between her and patient#1.

Patient #2 stated "We use to hang out and talk. She begged me for something to cut with. I gave her a piece of tile from the bathroom, tile from the boy's bathroom, the tile was coming up. She gave me pills to take. She said it was pills she had in her hands. They were two big white pills, one small yellow pill and one small white pill. She had the tablets in her room. I took them with water from the dayroom. We are no longer friends because she had another girl attacked me in the head."

Observation with the Facility's Chief Nursing Officer on 10/28/2020 at 12:40 p.m. of the male bathroom, located on station #5 revealed, the bathroom is secured and opened with a key by a staff member and it alarms when the door is opened. Observation of the bathroom floor near the drain area revealed a plaster of dried black material with sharp edges broken away. The Surveyor, in the presence of the Chief Nursing Officer, used her finger to flick off a piece of black sharp material.

The Facility's Chief Operating Officer later informed the Surveyor that the material on the male's bathroom flooring on station #5 was epoxy.

Interview and observation on 10/28/2020 at 12:40 p.m. in the male bathroom on station #5, with Patient #2, in the presence of the Facility's Chief Nursing Officer, Patient #2 stated that she had given the sharp object to Patient #1 and she had used it to cut herself.

Patient #2 then pointed to the black hard material with sharp edges on the floor and told the Surveyor and Chief Nursing Officer that she had taken the sharp object given to patient #1 from the black material on the bathroom flooring.


Patient #1

Reviewed Patient #1's clinical record. Review of the patient's demographic data revealed she was admitted to the 10/14/2020. The record revealed she was discharged from the facility on 10/13/2020 and while being transported by a staff from Child Protective Services to a residential living facility, she attempted to kick out the vehicle's window to jump off the vehicle. She was then readmitted to the facility.

Review of a History and Physical completed on 10/13/2020 revealed patient presented with chief complaint of homicidal ideation, suicidal ideation; 12-year-old patient with history of depression who presents for suicidal ideation. Patient was assessed at another facility then transferred to the current facility.

Review of a Nurse to Nurse Transfer Form, dated 10/14/2020 documented "Pt discharged from WOH today, and tried to jump out of the case worker's car. And threatened to kill self and others. Sad for several months. Screaming and kicking the car window, wants to kill self by cutting to bleed to death. Threatened to kill kids at her placement."

Review of the patient's visual skin/body assessment completed on 10/14/2020 revealed documentation of body piercing on the patient's ears but no other skin impairment.

Review of a nurse's notes, dated 10/26/2020 at 2301, revealed the following documentation: "PT admitted for SI/HI. Assessed for SI/HI P - Q 15 minutes monitoring in progress. Patient noted with a cut to her right arm at 1925 hrs. Writer asked what happened, stated: "Another patient on the unit picked a piece of tile on the floor in the bathroom, gave it to me and I used it to cut my right arm." Superficial cut noted. Dr-informed about the incident, new orders received for Q 5 minutes, UR SSH, Supervisor notified about the new orders"


Reviewed Patient#2's clinical record

Review on 10/29/2020 of Patient #2's clinical record (progress notes) dated 10/26/2020 revealed the following documentation: "New order received to place Pt on UR because another patient stated she gave her piece of tile found on the floor in the bathroom to cut self. Dr notified about incident and new order received for UR."


Observation and record review of Patient #4's clinical record

On 10/29/2020 at 2:58 p.m. Patient #4 was observed on station #7. The Patient was alert and oriented to person, place, and time. Interview with the Patient at that time, in the presence of the Facility's Chief Nursing Officer, revealed, she had cut herself many times. When asked what she had used to cut herself she refused to answer. Observation of the patient at that time revealed a laceration to the patient's left wrist measuring approximately 4 cm in length, which was partially scabbed over.


Patient #4

Review of Patient #4's clinical record (nurse's notes) dated 10/27/2020 at 0900 revealed the following documentation: "Pt very agitated, impulsive oppositional, rude to staff and threatening to fight peers because she verbalized that Pt gave her a broken tile from the bathroom to cut herself, but the patient did not use it"

Review of a Psychiatrist daily progress notes dated 10/27/2020 at 2:15 p.m. revealed the following entry" "Cut self with broken pieces of tile."


Interviews:

Registered Nurse (D)

Interview on 10/28/2020 at 12:46 p.m. with Registered Nurse (D) revealed, Patient #1 told her that a patient gave her a piece of tile but she did not tell her where she got the tile from. She said an incident report was made by a nurse and that she had observed that the patient had bruises and cuts to her arms which she had used the tiles to self -inflict.


Registered Nurse (I)

Interview via the telephone on 10/29/2020 at 9:18 a.m. with Facility's Registered Nurse (I) revealed, on arriving to work on 10/26/2020 on the night shift, a mental health technician told her that she noticed some cuts on the patient's arm. She said patient told her that one of the patients gave her the "tile" that she found on the floor in the male bathroom. She said she noticed superficial cuts on the patient's arm. She then called the doctor and told him what happened. She also informed the supervisor and made out the incident report. She said the physician ordered every 5 minutes monitoring and the mental health technician was instructed to accompany the patient to the bathroom. Registered Nurse (I) said she did not check the bathroom for sharp objects or contraband, because she was told it was given to to the patient by another patient. She said she had just arrived on duty when she was made aware of the incident and that the incident did not happen on her shift.


Director of Risk Management

Interview on 10/29/2020 at 11:54 a.m. with the Facility's Director of Risk Management revealed, typically when there is an injury to patients, staff would call her or the risk manager on call. She said on the day of the alleged incident on Patient #1 she was the Risk Manager on call. She said, she tracks injury of patients and staff by the incident report which is also in the computer system, but because the system was in a down time the hard paper copy was used.

The Surveyor notified her that there was no documentation on the incident report indicating that the patient had superficial cuts and scratches to her arm. She said, based on this report she would conclude that the patient did not have an injury due to self- harm. She said this is an outlier which retraining is being provided by the Chief Nursing Officer.

Subsequent interview on 10/29/2020 11:50 a.m. with the Facility's Director of Risk Management revealed, a contraband search was conducted on all patients on the unit 10/28/2020, after the threat was identified by the Surveyor and "they did get pieces of the epoxy from them." referring to the patients.


Psychiatrist J

During an interview on 10/29/2020 at 3:10 p.m. with Psychiatrist (J) who was present in the facility on station 5, revealed, the Surveyor informed her that she had reviewed Patient #4's clinical record, and there was an entry by her which indicted that Patient #4 had cut herself with "tiles" from the bathroom.

She stated " they do not want me to write it in the chart" so she personally went over and spoke with the Facility's Chief Nursing Officer, "that the patients are getting the tiles from the bathroom and use it to cut themselves and they have to do something about it".

She said the Chief Nursing Officer assured her that he would take care of it. She said, she told him this on the date she wrote the notes on patient #4 on 10/ 27/2020.

The Facility's Chief Nursing Officer was present on station #5 during the interview with the psychiatrist and validated that he was told this by the Psychiatrist, that patients were using the tiles from the bathroom to cut themselves.

Review of the facility's current policy and procedure on Integrated Policy for Patient Search and property Management # AIM 109 directed staff as follows: "Hospital strives to provide our patients with safe environment. Therefore, potentially dangerous items will be removed as contraband Prohibited items - possessions that may create a safety risk for self or others "Shaving razors, sharp items including scissors knives tweezers, etc.

Review of a Healthcare Peer Review Report, dated 10/26/2020 at 7:00 p.m. revealed documentation of "self-inflicted injury" by Patient #1. The report had no documentation of what type of injury was self- inflicted.

The section for type of injury/ outcome, documented "examined" The section for injury was blank.

Review of the record revealed no documentation that the facility investigated how and where the sharp object was secured by the patients, and that the facility had implemented systems to remove the threat. There was no evidence documented that the patients and surroundings were searched for contraband or the object used to self-inflict the scratches on patient #1 and 4.