HospitalInspections.org

Based on policy review, record reviews, document review, observations, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The deficient practices identified below had the potential to affect the physical safety and emotional well-being for all 39 inpatients at this facility.

The hospital failed to ensure patients received care in a safe setting related to not preventing patients from eloping and not inspecting patient environment for elopment risks (see findings in tag A0144).

Based on review of medical records, policies and other hospital documentation, staff interview, and observation, it was determined that the hospital failed to ensure the safety of 2 of 4 (50%) patients (Patient #'s 1 and 2) in the record sample and the remaining patient population.

Findings include:

Hospital policy titled "Environment of Care: Incident Reporting and Investigations" stated, "...All clients admitted to the hospital...are entitled to quality of care that is free of adverse preventable risks..."

Hospital policy titled "Risk Management: Abuse, Neglect, Mistreatment, and Significant Injury" stated, "...All care will be free from preventable risk..."

Hospital policy titled "Client Management: Nursing Environmental Rounds" stated, "...DPC provides a safe environment for clients, their families and staff...All shifts are responsible for conducting nursing environmental rounds..."

Review of hospital document titled "DPC [Delaware Psychiatric Center] Environmental Checklist: Sussex 1 Unit", dated 2/3/23, contained the following items for inspection: "...Doors...Ceiling...Walls...Floor...Other...". No problems were documented for any patient bedrooms, windows, or doors.


The hospital self-reported an incident that occurred on 2/8/23 at approximately 6:22 PM, where Patient #2 was able to elope from Unit Sussex 1, Room 40, through his room window utilizing a piece of metal obtained from his bed. Patient #2 was returned to the hospital at approximately 8:50 PM by police. No injuries were noted. He was searched for contraband and placed on 2:1 observation status.


Review of Patient #2's medical record revealed:

- "Nursing Narrative Note" by Employee #5, dated 1/31/23 at 10:26 PM stated, "...Client was very very agitated, wanting to leave the facility, He requested a 72 hour voluntary discharge..."

- "Psychiatry Ongoing Notes" by Employee #6, dated 2/1/23 at 4:12 PM stated, "...After lengthy discussion [Patient #2] recanted his 72 hrs [hours] and showed willingness to cooperate with his treatment..."

- "BH Progress Note" by Employee #7, dated 2/2/23 at 10:37 PM stated, "...[Friend of Patient #2] stated that client is planning to escape and has escaped in the past twice..."

- "Psychiatry Ongoing Notes" by Employee #8, dated 2/3/23 at 9:45 AM stated, "...Patient stated he could not be held at DPC and that he would leave if he weren't discharged...Patient was...encouraged not to elope and comply with treatment...He reassured that he will not make any effort elope (sic) and put that in writing..."

- "Nursing Narrative Note" by Employee #9 dated 2/3/23 at 11:46 PM stated, "...Precautions...special Q15 [every 15 minutes] checks with documentation for close monitoring for safety towards self and other...elopement risk..."

- "Nursing Narrative Note" by Employee #10 dated 2/6/23 at 2:08 PM stated, "...Client walked out on [treatment] team, became more agitated, was pacing back and forth the hallway and making verbal threat...Client is now on unit restriction..."

- "Psychiatry Ongoing Notes" by Employee #6 dated 2/8/23 at 10:44 PM stated, "...Per nursing staff, after his face check at 18:15, patient eloped through his bedroom window, he unhooked his bed off the wall and used the hinges from the bed to open the window. Campus security was notified, police were called, hospital was searched for the patient. Police eventually found patient...and returned him to the unit ~ [around] 20:40. Patient was searched and no contraband was found...he continued to threat (sic) about future elopement, 'I'll leave again.' Patient stated that he would leave whenever he'd feel like it, it could be done the easier way or the hard way..."

- "Psychiatry Ongoing Notes" by Employee #11 dated 2/9/23 at 12:15 PM stated, "...'I'm going to do the same thing I did last night but the only thing that's gonna be...different this time is I'm gonna get a...care this time, and cross state lines, and you're not gonna catch me this time'...He will be monitored on 2:1 observation due to elopement risk...Had extensive discussion regarding safety measures with hospital administration, agreed to have unit moved which might be much safer environmental wise..."

- "Nursing Weekly Note" by Employee #9 dated 2/10/23 at 11:52 PM stated, "...Nursing and Goals Progress...Goals...[Patient #2] will not attempt to elope from the facility..."

- "Psychiatry Ongoing Note" by Employee #6 dated 2/13/23 at 1:23 PM stated, "...He will be monitored on 1:1 observation due to elopement risk..."

During an interview with Employee #2 on 2/28/23 at 3:46 PM, it was confirmed that Patient #2 told psychiatry, nursing, family, and friend of plans to elope, and had done so previously at other psychiatric hospitals. Patient #2 was placed on elopement precautions and unit restrictions, but was still able to carry out the elopement plan on 2/8/23.


During an interview with Employee #1 on 2/27/23 from 10:30 to 10:38 AM, it was stated that, after the elopement on 2/8/23, Unit Sussex 1 was now considered a ligature risk, and all Sussex 1 patients were moved to Unit Sussex 3. The one patient (Patient #1) that was residing on Sussex 3 was moved to Sussex 1, Room 41. All other rooms on Sussex 1 were locked to bar entry.


During an environmental tour of Sussex 1 on 2/27/23 from 10:30 to 11:03 AM, the following was observed and confirmed with Employee #1:

- One (1) window in Room 40 (site of the elopement) secured with metal trim piece secured over ¼ to ½ inch gap between security window and wall frame.
- Six (6) windows in the hallway between nurses' station and main door entering the wing from the main building; windows observed with ¼ to ½ inch gap between metal security window and wall mounted frame.
- One (1) window in room 41; window observed with ¼ to ½ inch gap between security window and wall frame.
- Four (4) windows in day room; windows observed with ¼ to ½ inch gap between security window and wall frame.
- Seven (7) patient rooms doors without anti-ligature door handles; Room numbers 21, 25, 19, 35, 40, 41 and 43.


During a follow-up observation of Sussex 1 on 2/28/23 between 9:45 AM and 10:10 AM, the following was observed and confirmed with Employee #1:

- 1 of 2 patient beds in Room 41 not in good repair; wood separated from wooden box frame, approximately 12 inches from frame when pulled.

- Room 41 was still being utilized by Patient #1, the only patient on Sussex 1, yet was not repaired to prevent elopement.


During an interview on 2/28/23 at 2:51 PM, Employee #1 stated that Room 41 on Sussex 1 was being repaired. The bed was replaced by a plastic bed secured directly to floor. The window was to be secured by metal trim piece over the gap. Additionally, Patient #1 was ordered 1:1 observation status, with security also posted at the door of Room 41. Nursing was to check windows and doors of Sussex 1 every 1 hour until all windows were repaired with metal trim.


During a follow-up observation of Sussex 1 on 3/1/23 at 1:00 PM with Employee #1, the following was observed:

- Room 41 with plastic one-piece bed, bolted to floor.

- Room 41 window secured with metal trim piece over gap between window and frame.

- All windows in Sussex 1 secured with metal trim piece over gap between window and frame.

Based on observation, staff interview and facility documents and policy review, it was determined that the facility failed to maintain a safe and functional environment for patients in 3 of 6 wings at this facility on 2/27/23 and 2/28/23. Findings include:



A. The facility policy titled "Management of the Environment of Care" stated, "...General Expectations 1. The physical environment...and public areas are always to be kept clean, safe and in working order...Housekeeping provides cleaning and disinfecting for treatment unit environment and throughout DPC...include but are not limited to...vents, ceiling dust...furniture in common areas..."

The facility document titled "Sussex 1, 3 pm - 11 pm Schedule" stated, "... Laundry Room: High dust... dust..."

The facility document titled "Sussex 3, 7-3 Routine Schedule, C Worker" stated, "...Nurse Station #7 (Monday through Friday) clean daily. High dust wipe down all furniture..."

The facility document titled "Kent 3, 7-3 Routine Schedule, C Worker" stated, "...Floor Care...hallway must be cleaned daily..."

The facility document titled "DPC Environmental Checklist," listed the following items to be inspected on each Unit: "...Doors...Ceiling...Walls...Floor...Other..."

The facility policy titled "Chapter 2: Client Management, Section 4: Client Safety Rounds and Unit Rounds" stated, "...Any unusual occurrences or needed repairs to the structure or furnishing of the building are to be reported to the nurse. In cases where items appear to be missing or tampered, with an incident report must be completed..."

The facility document titled "May 1, 2022...Contract NO. GSS22080-PEST_CNTRL Pest Control Services" stated, "...RODENT CONTROL: During the first month of the contract period the pest control operator must establish rodent bait stations in all rodent-prone areas...SERVICE RESTRICTIONS...Rodent bait shall not used..."


B. During an environmental tour on 2/27/23 between 10:30 AM and 12:35 PM, the following was observed:

1. Between 10:30 AM and 11:00 AM; Wing, Sussex 1.

- Observed stained ceiling tile outside of room # 40; a tan colored, 6 inches by 3-inch stain.
- Observed dirt and debris at laundry room ceiling vent.

These items were confirmed on 2/27/23 at 10:52 AM, by Employee # 1.

2. Between 11:07 AM and 11:45 AM; Wing, Sussex 3.
- Observed dirt and debris on ceiling vents, ceiling vents in nurse station.

This item was confirmed on 2/27/23 at 11:39 AM, by Employee # 1.

3. Between 11:50 AM and 12:30 PM; Wing, Kent 3.
- Observed dirt and debris on ceiling vents; Vents in Kent 3, Pod A Day room
This item was confirmed on 2/27/23 at 12:00 PM, by Employee # 1.

C. During a follow up observation of Sussex 1 on 2/28/23 between 9:45 AM and 10:10 AM, the following was observed:
- Observed 1 of 2 patient beds in room # 41 not in good repair; wood separated from wooden box frame, approximately 12 inches from frame when pulled.
- Observed 3 of 15 chairs not in good repair; Three (3) chairs have rips in leather upholstery.

This item was confirmed on 2/28/23 at 10:00 AM, by Employee # 1.

D. Between 10:30 AM and 12:35 PM on 2/27/23, Rodent bait stations observed at 3 of 3 entrances into building.
- Observed at main entrance between Sussex 1 and Sussex 3; two (2) residential rodent bait stations observed on the ground.
- Observed at the entrance located Infront of the cafeteria; two (2) residential rodent bait stations observed between set of double doors.
- Observed at entrance of Kent 3, behind soda vending machine; one (1) residential rodent bait station on the ground.

These items were confirmed on 2/27/23 between 10:30 AM and 12:35 PM at time of discovery, by Employee # 1.

Based on observation, staff interview and facility documents and policy review, it was determined that the facility failed to maintain a safe and functional environment for patients at this facility for 7 of 7 months. Findings include:


A. The facility policy titled "Fire Safety Management Plan 2022" stated, "...The Division of Management Services Security Department conducts monthly fire drills on each unit for each shift..."

B. Record review of 7 months of fire drill and safety data, June 2022 thru December 2022, revealed:
- Fire drills are not being conducted once per month for each shift.
- Observed from June 2022 thru December 2022; one (1) inspection was conducted for each wing of the hospital each month.

This finding was confirmed on 3/1/23 at 12:47 PM by Employee #3.

Based on observation, staff interview and facility documents and policy review, it was determined that the facility failed to maintain a safe and functional environment for patients at this facility. Findings include:

A. The facility policy "Medical Equipment Management Plan 2016" stated, "...The hospital inspects, test, and maintains all high-risk equipment...medical equipment is monitored weekly by Central Supply Department and is documented on the Medical Emergency Equipment Weekly Log..."

The facility policy titled "DPC Environmental Checklist" stated, "...Doors...Ceiling...Walls...Floor...Other..."

The state regulation "State of Delaware food code 2019" stated, "...cleaned EQUIPMENT...and SINGLE-SERVICE and SINGLE- USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor..."

Surveyors requested a policy for expired medical supplies; facility was unable to provide such policy.

The facility job description for "Supply, Storage and Distribution Technician I" stated, " ...Conducts various detailed inventories to comply with stock rotation schedules, periodic inventory audits..."

B. Between 11:07 AM and 11:45 AM; Wing, Sussex 3, Medication room, Room number 35

1. Observed expired medical supplies inside cabinet under hand wash sink:
- Four (4) bottles of Calvicide, Lot # 20-1262, expired 22-09-01, Manufacturer Metrex.

2. Observed items being stored in cabinet under hand wash sink:
- Four (4) bottles of Calvicide, Lot # 20-1262, expired 22-09-01, Manufacturer Metrex.
- Eight (8) bottles (8 Fluid Ounces), Hand Sanitizer, Sanitect Hand Sanitizer, Manufacturer Aquagenics Tech

3. Observed items being stored directly on the floor:
- Five (5) one (1) Gallon jugs of Deer Park water
- Eight (8) ounce foam drinking cups being stored in a cardboard box on the ground; Approximately 125 foam cups, manufacturer Dart.
- Four (4) plastic storage containers being stored on the ground, containing foam drinking cups and disposable pill cups.

4. Observed personal dishes being stored next to hand wash sink:
- Light blue coffee mug
- Multicolored metal water bottle
- Disposable plastic fast food container

These findings were confirmed at time of discovery on 2/27/23 between 11:07 AM and 11:45 AM, by Employee #1.

C. Between 11:50 AM and 12:30 PM; Wing, Kent 3.

1. Observed expired medical supplies in medication room:
- Eight (8) Vacutainers, UA Preservative Tube, Reference # 364992, lot# 9260333, expired 21/3/31, Manufacture BD.
- Eight (8) Vacutainers, Urine C&S Preservative, Reference # 364951, expired 21/6/30, Manufacture BD.
- Six (6) Vacutainers, Urine C&S Preservative, Reference # 36495, expired 21/6/30, lot# 9344853, Manufacturer BD.

These items were confirmed at time of discovery on 2/27/23 between 11:50 AM and 12:30 PM, by Employee # 1.