HospitalInspections.org

Based on record review, interview, and observation, the hospital failed to ensure patients' rights to receive care in a safe environment for four of 15 patients (Patients #14, #15, #13, and #1).

1) At the time of survey suicidal Patients #14 and #15 had access to items potentially usable in self- harm. These items included a metal staple and a plastic fork, and hygiene solutions intended for external use only which had the potential for unintended ingestion.


2) At the time of survey Patient #13's close observational sheet was pre-timed.


3) Staff members who were authorized to monitor patients during restraint or seclusion incidents did not receive training and/or demonstrated competence in monitoring and recognizing their nutritional and hydration needs.



Findings included:


1) Observations on the hospital adult patient Unit II in Patient #14's room on 12/17/15 at about 14:50 reflected a plastic covered plastic fork and a stack of papers with a metal staple. The papers were identified by Hospital Employee #3 as the patient handbook. Hospital Employee #3 stated at that time that she had "never seen ...[stapled handbook] before on the unit."

Hospital Employee #22 was interviewed at that time regarding the plastic fork and stated she had not noticed it.

Record review of the hospital's adult unit daily safety inspection sheet dated 12/17/15 reflected for the 07:00 to 19:00 shift that the patient's rooms were "free of contraband i.e. any sharps..."

During observations on the hospital pediatric patient unit on 12/17/15 at approximately 15:20, containers with contact lens' solution, body wash, and body lotion marked "for external use only" were discovered in Patient #15's room and accessible to the patient. Hospital Employee #3 stated at that time that it was policy for patients to return hygiene products to unit staff after use.

Hospital Employee #21 stated on 12/17/15 at approximately 15:22, that the items "should have been turned in [to staff members]."


Record review of Patient #14's Integrated Psychiatric Assessment dated 12/10/15 at 08:21 reflected Psychosis as a primary reason for admission. Patient #14 had a history of suicide attempts, including cutting his wrists, and was assessed to be suicidal with "multiple" risk factors.

Record review of Patient #15's Psychiatric Evaluation dated 12/16/15 reflected the patient had overdosed on medication and was "a danger to self and others." The plan included to "keep the patient safe."

Patient #15's Physician Admit Examination Orders dated 12/16/15 noted the patient was on suicide precautions.


Record review of the hospital's policy NS 600.02 titled "Contraband" reflected the purpose to "provide a safe environment for all patients...by preventing the entry of dangerous items (...sharps...) into the patient care areas. Contraband items including "breakable plastic...should not be present."


2) Observations on the hospital adult patient Unit I on 12/17/15 reflected a close observation sheet for Patient #13 was completed for 15:00. Hospital Employee #3 was asked what time it was and stated it was 14:55.

Hospital Employee #23 was asked by the surveyor about completing the close observation sheet ahead of time and stated, "I always fill it out about two minutes early."

Patient #13's Psychiatric Evaluation dated 12/16/15 reflected he had a history of Depression, Anxiety, Alcohol Use Problems. His medical conditions included Diabetes Mellitus and Hypertension. Patient #13 had consumed 0.75 liters of liquor within two to three days prior to his admission and had been drinking almost daily during the past eight years. The document noted "significant alcohol withdrawal possible."


3) Hospital Employee #11 and #13's employee files were reviewed with Hospital Employee #25 on 12/17/15 at 12:00. There was no evidence of documented competency in monitoring and recognizing nutritional and hydration needs of patients in restraint or seclusion.

On 12/17/15 at approximately 12:00 Hospital Employee #25 identified Hospital Employees #11 and #13 as mental health technicians (MHTs) and denied the files contained documented competency in monitoring and recognizing nutritional and hydration needs of patients in restraint and/or seclusion.

On 12/17/15 at 16:15 Hospital Employee #3 stated that only registered nurses were presented with an in-service where hydration needs of a patient in restraint and seclusion were addressed.


Hospital Policy NS 400.16 dated 11/2014 and titled "Seclusion and Restraint" reflected that mental health technicians authorized to monitor patients in restraints and seclusion "receive additional training and demonstrate competence in...recognizing nutritional/hydration needs..."