HospitalInspections.org

Based on observations and interviews, the hospital failed to ensure psychiatric patients were provided care in a safe setting. This deficient practice was evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety for patients admitted to the inpatient psychiatric hospital for being a danger to themselves and/or others.

On 03/07/19 at 8:00 a.m. a tour of Room "A" with S1Admin revealed two windows with plexiglass to all four panes screwed on with both tamper-resistant and non-tamper resistant screws.
The plexiglass was not securely fastened in place as evidenced by:
1. One pane on the left was missing two screws to the bottom corners.
2. One pane on the right was missing three screws to the bottom.
3. There was a 1 inch gap between the frame and the piece of plexiglass exposing the sharp edges of the plexiglass and allowing enough room for ones' finger to grab the plexiglass and bend the plexiglass.

On 03/07/19 at 8:00 a.m. S1Adm verified the above findings and stated they were testing out the plexiglass to see how it would work.

Based on policy review, record review, and interview, the hospital failed to provide 24-hour nursing services supervised by a Registered Nurse and have a Licensed Practical Nurse or Registered Nurse on duty at all times.
Findings:

Review of the hospital policy titled Rest/Meal Periods presented as current policy revealed in part: Direct Patient Care employees are not permitted to leave the facility's premises during their meal periods....A meal period may be interrupted by management when it is necessary for employees to return to work.

Review of the hospital policy titled Staffing Plan presented as current policy revealed in part: A registered nurse is physically present and on duty at all times when a patient is present on the unit...A registered nurse is responsible to supervise all License Practical Nurses and Mental Health Techs...The facility will be staffed with a minimum of 2 nursing staff, one of which is a registered nurse with one additional direct patient care staff (LPN or MHT) to maintain a therapeutic milieu and a safe environment....Criteria for staffing: minimum of one RN and whenever possible utilize LPN as second licensed staff under the RN charge.

Review of the Staffing Matrix reveals the Geriatric Psychiatric Unit staffing was to have 1 RN, 1LPN, and 1 MHT for every 6 patients.

On 03/07/19 at 9:45 a.m. review of the Medical Executive Committee 3rd Quarter and Annual Meeting Minutes dated 11/14/18 revealed in part:
Current Hospital Staff: Discussion: Staffing ratio remains the same with no changes. Geri Unit 1:6 ratio MHT, 1RN, and 1LPN 24/7.
Current Hospital Staff: Action: Approved will submit to Governing Board for Approval for 2019
Current Hospital Staff: Responsible Party: Medical Staff


Patient #2
Review of the medical record for Patient #2 revealed a 68 year old male admitted on 01/18/19 at 2:00 a.m. under a Physician's Emergency Certificate for hostile behavior towards his social worker and an admitting diagnosis of unspecified dementia with behavioral disturbance.

Review of the incident report for Patient #2 revealed on 01/18/19 at 5:30 a.m. Patient #2 broke the window in his room and eloped. Patient #2 was transferred to an Acute Care Hospital at 6:00 a.m.

Review of the LDH Hospital Abuse/Neglect Initial Report, the EMS supervisor stated Patient #2 had injuries from the broken glass to his hands, arms, and stomach.


On 03/06/19 at 3:15 p.m. in an interview with S4LPN revealed she left for lunch on 01/18/19 at approximately 5:00 a.m.; she left the hospital for her lunch break; and she returned to the hospital after the incident.

On 03/06/19 at 2:25 p.m. in an interview with S7MHT revealed on 01/18/19 at approximately 5:30 a.m. Patient #2 broke his window and left the hospital. S7MHT and S6MHT left the hospital and followed Patient #2 in their car until the police and ambulance arrived.

On 03/06/19 at 3:00 p.m. in an interview with S6MHT revealed on 01/18/19 at approximately 5:30 a.m. S6MHT and S7MHT left the hospital to follow Patient #2 in S7MHT's car. They called the police and followed the patient in the car with their hazards on as directed by the police because Patient #2 was walking across and down the street to Starbucks.

On 03/07/19 at 12:50 p.m. in an interview with S5MHT revealed on 01/18/19 at approximately 5:00 a.m., S4LPN left the hospital for her lunch break as she usually does. The incident involving Patient #2 took place at approximately 5:30 a.m. S6MHT and S7MHT followed Patient #2 in a car while S5MHT and S3RN stayed on the unit to watch the remaining patients.

On 03/06/19 at 1:50 p.m. in an interview with S3RN revealed on 01/18/19 at approximately 5:30 a.m., during the incident involving Patient #2, she remained on the unit with S5MHT to care for 17 patients. She stated she did not recall how long they were alone on the unit with 17 patients.