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Based on review of the medical record, physician and staff interviews, the Hospital failed to ensure that one of one applicable Patients, Patient #2, was maintained in a safe environment and not able to access sharps and other harmful contraband on 12/28/11, 01/04/12 and 01/24/12. Because Patient #2 was able to access contraband, multiple self-inflicted cuts were made on Patient #2's chest and abdomen which required 97 staples for closure.


Findings include:

1. Background: It was reported that Patient #2 was admitted to an inpatient psychiatric unit. Mental Health Counselor (MHC) #1 became concerned when Patient #1 spent considerable time in the bathroom. Patient #2 was observed to have multiple self-inflicted multiple lacerations to the chest and abdomen from a jagged disposable razor on 12/28/11 at 10:30 P.M. Patient #2 required the placement of 97 staples to close multiple superficial and deep lacerations on the chest and abdomen. Patient #1 also had superficial facial lacerations.

2. MHC #1 was interviewed in person on 02/06/12 from 3:16 P.M. to 3:34 P.M.and MHC #2 was interviewed in person on 02/06/12 from 3:36 P.M. to 3:58 P.M. respectively. Both said that Patient #2 was in the bathroom between 10 P.M. to 10:30 P.M. for two of the consecutive fifteen minute checks. When MHC #1 called out to ask if she/he was alright, Patient #2 reported to MHC #1 that he/she was fine. MHC #1 became suspicious and spoke to MHC #2 and Licensed Practical Nurse #1. Both MHC #1 and #2 returned to Patient #2's room and found him/her sitting on the bed, covered in blood from multiple lacerations on the face, chest and abdomen. A broken and jagged razor was found on the floor. Additional contraband including sharps, open paper clips, three plastic sharp tipped single use dental floss sticks and two razors were found in the room and within Patient #2's possessions. Patient #2 was evaluated by the Hospitalist and taken to the Emergency Department (ED) for treatment and closure of the wounds.

3 Patient #2 was observed to have self-inflicted chest and abdominal wounds measuring 90 centimeters in a criss cross pattern. Review of the ED Record indicated that Patient #2's wounds were closed with 97 staples. On 12/29/11 at 2:10 A.M., Patient #2 returned to the psychiatric unit.

4. Registered Nurse (RN) #1 was interviewed in person on 02/07/12 from 2:07 P.M. to 2:41 P.M. and RN #2 was interviewed in person on 02/07/12 from 4:00 P.M. to 4:25 P.M. respectively. RN #1 said that Patient #2's duffel bag had been given to him/her during the day. RN#1 said that sharp objects were found among the Patient's personal belongings and they were removed, documented on a list and the items were stored in pink plastic bins within a locked cabinet. RN #2 said that she offered Patient #2 the pink bin with the sharp items because Patient #2 requested to have a CD to listen to music with a headset. RN #2 said Patient #2 may have taken the razors at that time, but she did not recall the specific date.
There were no orders, nor specific directives for the use of CD's to listen to music with a headset. CD's were listed in the Hospital Center for Behavior Medicine Policy as a restricted item and required a physician's order for patients to use them.

5. Review of Patient #2's Valuables and Belongings List dated 12/19/11 on admission indicated that Patient #2 had 5 CDs, eight razors, a belt and styling gel. The sharp tipped, plastic dental floss container was not listed on the Valuables and Belongings List.

6. Review of both the Psychiatrist's Progress Note and Mental Health Clinician's Referral for Continued Care Note dated 01/04/12 indicated that Patient #2 was again found hoarding paper clips and tea bags for overconsumption of caffeine.

7. Review of the Nurses Note dated 01/10/12 indicated that "stay awake"caffeine pills were discarded as directed by the psychiatrist. The Nurses Note indicated Patient #2 had 29 out of 60 tablets remaining in the bottle. The documentation was unclear as to when Patient #2 had possession of the contraband. The "stay awake" caffeine pills were not listed on Patient #2's Valuables and Belongings List dated 12/19/11. On 01/23/12, Patient #2 signed a Treatment Plan to limit coffee consumption, to use the CD player in a public area and not hurt himself/herself or others. The Nurses Note dated 01/24/12 indicated that Patient #2 was suspected of having possession of a razor confiscated from another patient.

8. The Behavioral Health staff failed to ensure the safety of Patient #2 following an incident of self-inflicted injury by cutting because additional contraband continued to be found in Patient #2's possession despite documentation that Patient #2 had been assigned a one to one observer since 12/28/11.

9. The Behavioral Health staff failed to conduct an appropriate search of Patient #2's belongings on admission and failed to ensure that Patient #2 did not have access to additional contraband during his/her hospitalization.