HospitalInspections.org

Based on observation, record reviews and staff interviews, the facility failed to provide a safe setting when Patient #1 was able to harm self while on increased levels of supervision. Patient #1's orders did not specify interventions and instructions to protect wounds and provide supervision, especially when in the bathroom when:
A. Patient #1's precaution folder (a red folder provided to direct care staff describing Patient #1's supervision requirements) did not specify nursing interventions to protect wounds or dressings while in the shower. A poncho, intended for use by staff to cover their own clothes while in shower area, was used to cover Patient #1's wounds
B. Staff of the opposite gender as the patient (or as clinically appropriate as decided by the RN) were assigned when the patient was in any state of undress (bathing, dressing (toileting, etc.).

The findings were:

A. Patient #1 was admitted to the facility 1/25/24 with diagnoses including major depressive disorder, posttraumatic stress disorder, and borderline personality. Patient #1 was placed on 1:1 level of observation (one staff to patient ratio) for self-injurious behavior. On 2/8/24, Patient #1 observation level was increased to 2:1 (two staff to patient ratio) close proximity continuous for self-injurious behavior.

Since 2/8/24, Patient #1 had 22 incidents, 18 of which were self-harm related. Patient #1's incidents involving body injury area included:
*2/8/24, Reopened wound on FA; transferred to hospital and placed on 2:1
*2/10/24, pulled tile and put into wound; transferred to hospital to remove foreign body
*2/19/24, attempted to remove stitches with teeth; declined assessment
*2/21/24, Used finger to reopen laceration L FA; staff intervened immediately, declined assessment then let MD assess on 2/22/24, transferred to hospital, noted foreign body in arm from previous incident with surgery
*3/6/24, injured outer thigh with an earring in the shower; staff cleansed
*3/13/24, pulled sutures out of Left FA wound while in the shower
*3/25/24, pulled hair; no treatment required
*3/29/24, pulled hair; no injury noted, refused ice pack
*3/31/24, punched door 4 times with hand; staff intervened immediately, pain meds declined
*4/1/24, bit R middle finger cuticle; scant bleeding with minor first aid
*4/3/24, punched window with hand; staff intervened immediately, offered ice pack and med clinic referral
*4/4/24, pt pulled hair out, attempted to rub wrist wound on chair; staff intervened immediately, redness and bald spot noted, small scratch to wrist
*4/12/24, pulled picture from the wall which exposed a screw, patient #1 scratched Left wrist; staff intervened immediately, first aid, MD assessed wound and applied steri-strips with wound covering
*4/21/24, while in bathroom, used metal piece obtained earlier from shower area and reopened L FA wound, 3-inch laceration noted; staff intervened immediately, refused treatment, assessment, and pain meds by RN, sent to hospital on 4/22/24 for removal of foreign body with sutures applied.
***No observation sheet was found for 4/21/24 for Patient #1***
*4/29/24, pt pulled own hair; refused ice pack and pain meds
*5/2/24, pt removed a piece of grout by window while showering and cut L Antecubital (AC); staff jumped into shower with clothes on, pt sustained several scratches, minor first aid given
*5/5/24, pt reopened L FA wound with chewy tool; cleaned, med clinic order placed, Chewy removed from pt and reminded staff that both hands need to be observed at all times
*5/6/24, pt reopened L FA wound; staff intervened immediately

Physician orders for wound care did not specify nursing interventions to protect wounds or dressings while in the shower.

Nursing interventions to protect wounds or dressings while in the shower were not specified in Patient #1's precaution folder (a red folder provided to direct care staff describing Patient #1's supervision requirements).

On 5/14/24, Staff #7, Program Director, verified pages in red folder were too numerous for assigned staff to quickly familiarize themselves with Patient #1's supervision needs.

In an interview on 5/14/24, Staff 14, PNA, reported sometimes "staff fall behind in updating the red folder" and the 2:1 sheet, patient information sheet, and warning signs should be in the red folder, but stated, "The problem is that [Patient #1] has so much in her folder."

In an interview on 5/14/24, Staff #12, PNA [psychiatric nursing assistant], stated, "[Patient #1's] order in red folder (for her 2:1). Info was not kept up to date in red folder. Sometimes there was no doctors' order for 2:1, what patient can/can't have; gives you all the detail you need. At times, would not be updated or even in the folder. For the last 1 ½ to 2 months, now have updated information and order." Staff #12 went on to say, "[Patient #1] wanted to wear the poncho, instead of using the poncho as a wrap for her arm in the shower." Some staff used a poncho to cover Patient #1's wounds during a shower.

In interview on 5/16/23 at 11:55 AM, in a facility conference room, Staff #15 reported the red folder had levels of precautions, along with orders (orders state what she can't have). Nurses would put the poncho on Patient #1 before showering. On 3/13/24, Patient #1 wanted to run around the unit with the poncho. Staff #19, RN, would not give the poncho and said it was okay to get dressing wet. Patient #1 was showering and all of a sudden, Staff #11, PNA (assigned 2:1) yelled, "She's bleeding!" Called a code, Staff #19, took a look at it and determined she could finish showering. Patient #1 completed shower, got dressed, came out, told staff to call a "Code 10" and then Patient #1 took her finger and opened up wound.

On 5/16/24, Staff #17, Infection Preventionist, stated, "Typically, there are sleeves now a days to cover patient's dressing. Sleeve ordered by building manager but cannot remember specifically if Patient #1 had sleeve."

On 5/16/24, Staff #7, Program Director, reported "unit ordered protective sleeves that were intended for reuse, but staff used once and disposed. Ponchos were intended to be used by staff to protect their clothes when in shower area with patient."

In an interview on 5/16/24, Staff # 4, Assistant Chief Nurse Executive, while reviewing video footage of the incident on 4/21/24, verified Patient #1 was not wearing a dressing to LFA when entering the bathroom.

On 5/17/24, Staff #1, Superintendent, confirmed staff should be able to quickly familiarize themselves with Patient #1's supervision requirements and verified numerous pages with conflicting information could make that difficult.

Facility-based policy No. 4.05.01, Topic: Precautions, reviewed 5/2021, documented: " ... based on assessment and perceived level of risk, a staff person may be assigned to a patient as 1:1, 1:2, 2:1, etc. to provide for increased supervision and increased ability to intervene if necessary. 5. Assignment 5.1 All 1:1's must have a safety plan in place ... to clearly and concisely tell direct care staff what the interventions for the 1:1 are to be ... Specific directions / interventions will be identified on the safety plans ... 6. Levels of Supervision ... 6.4 2:1 - two staff members will be within ten (10) feet or less of the patient during waking hours ... Management of the Patient on Precautions ... 9.4.2 Patients on precautions for suicide or self-injury will shower with the curtain open and will have the stall door or restroom door open while toileting."

B. In an interview on 5/14/24, Staff #13, Clinical Coordinator, reported Patient #1 was suggestive and sexualized male staff, making it uncomfortable for them.

In an interview on 5/16/24, Staff # 4, Assistant Chief Nurse Executive, while reviewing video footage of the incident on 4/21/24 verified male staff assigned as 2:1 were monitoring Patient #1 in the bathroom.

Facility-based policy No. 4.05.01, Topic: Precautions, reviewed 5/2021, documented: " ... 12. Implementation of Precautions ... 12.3 Staff of the same gender as the patient (or as clinically appropriate as decided by the RN) will be assigned whenever the patient is in any state of undress (bathing, dressing (toileting, etc.) or when alone will assigned staff in any isolated location (bedroom, etc.) ..."