HospitalInspections.org

Based on interviews and records reviewed the Hospital failed to consistently provide care in a safe setting when staff who may be assigned to constant observation were not updated in a timely way of findings from an internal investigation to provide enhanced patient safety.

The Surveyor reviewed the Critical Incident Review worksheet at 10:00 A.M. on 7/7/2020. The document dated 2/24/2020 indicated an action plan to enhance patient safety after Patient #1 attempted to strangle herself while on a line-of-sight constant observation. The action plan indicated that Constant Observer Staff would be reminded about the Hospital's policy to visualize a patient's hands and face while being observed.

The Surveyor interviewed Certified Nursing Assistant (CNA#1) at 9:50 A.M. on 7/8/2020. CNA #1 said that she was on the line-of-sight watch for Patient #1 at the time of the attempted self strangulation. CNA #1 said that after the incident both the Emergency Department Director and her Manager, the Director of Nurses, had "advised" her about always being able to see a patient's hands and face.

The Surveyor interviewed the Risk Manager and the Director of Clinical Quality at 12:30 P.M. on 7/8/2020. The Risk Manager said the usual process to follow-up on a Critical Incident Review was to present the case to the Quality Committee and complete the action plan items. The Director of Clinical Quality said that the Quality Committee had ceased its' usual activities after the Massachusetts State of Emergency was announced. The Director of Clinical Quality said the Committee would be reconvening next week after the COVID hiatus and this case was to be presented and moved forward. Also, the Risk Manager said there were numerous work furloughs in the Risk/Quality Department during this timeframe.

The Surveyor reviewed the timeline associated with this event. The event occurred on 2/19/2020, the Critical Incident Review occurred on 2/24/2020 and the State of Emergency because of the COVID outbreak was announced in Massachusetts on 3/10/2020.

Based on interviews and records reviewed the Hospital failed to provide evidence of current restraint training for two of two contracted security staff sampled who would be involved in physical restraint application.

The Surveyor interviewed Security Officer #1 and #2 during a tour of the psychiatric holding area of the Emergency Department at 7:45 A.M. on 7/7/20. Both Security Officers said that they would participate in the application of restraints as needed.

The Surveyor reviewed the personnel records of both Security Officer #1 and #2 and neither record indicated restraint training as required.

The Surveyor interviewed the Director of Clinical Quality at 12:30 P.M. on 7/8/2020. The Director said that the Security Officers had been trained but their records failed to have the date of the training.