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Based on observation, policy and procedure review, documentation review, patient and staff interviews; the facility failed to implement systems that assured a safe, functional, and private environment for patients with a psychiatric diagnosis. The Mental Health Unit identified a census of 7 patients. The following examples confirm this determination.

Although facility staff was aware of some conditions that posed a risk to patients with psychiatric diagnoses, the facility failed to:

Provide care in a safe setting for 2 of 7 patients with suicidal ideation or past histories of suicide attempts. (refer to A 144)

Provide care in a safe setting for 3 patients (as reported in variance reports from 2010-2012) with suicide attempts/self harm during their in-patient stay. (refer to A 144)

Identify, remove or replace non-breakaway hardware from patient bedroom doors. (refer to A 144)

Maintain a safe environment for suicidal patients by failing to minimize risk factors available in patient bedrooms, associated to the electrical outlets. (refer to A 144)

Identify, remove or replace standard loopable handicap grab bars in the patient rooms. (refer to A 144)

Identify, remove or replace non-breakaway sink faucets in patient rooms and shower rooms. (refer to A 144)

Identify, remove or replace the telephone cord in the central hallway. (refer to A 144)

Educate patients on the unit of the camera monitoring and recording in public hallways and seclusion room. (refer to A 143)

The cumulative effect of these systemic failures and deficient practices resulted in the facility's inability to ensure the safe care and monitoring of patients, with psychiatric diagnoses who may also be suicidal, in a safe environment.

Based on observation, review of policy and procedures, and Mental Health staff interviews, the facility failed to educate the Mental Health patient's regarding their use of camera monitoring and recording to observe patient's activities in public areas and the seclusion room. The administrative staff identified a census of 7 patients on the Mental Health Unit.

Failure to provide Mental Health Unit patients with information and explanation regarding use of camera monitoring and recording could potentially violate patient's right to privacy if patients were unaware of the camera locations and/or where patients could go to ensure privacy.

Findings include:

Observation on 2/18/13 at 2:00 PM, during the initial tour of the Mental Health Unit, with the Director of Mental Health revealed, camera monitoring in the seclusion room and public areas of the unit. The Director reported approximately 2 weeks ago, the facility began recording the camera monitoring and they plan to store the recordings for 6-12 months.

1. Review of facility policy titled Mental Health Capability, Capacity, Suitability, and Admission Policy, undated, showed the policy lacked information regarding camera monitoring and recording.

2. Review of facility policy titled Patient Rights and Responsibilities Policy, undated, showed the policy lacked information regarding camera monitoring and recording.

3. Review of the Mental Health Unit Information form, welcoming patients to the Mental Health Unit undated, showed the form lacked information regarding camera monitoring and recording.

4. During an interview on 2/18/13 at 3:45 PM, Staff L, CNA (Certified Nursing Assistant), revealed she does not explain the camera monitoring and recording to mental health patients.

5. An interview on 2/18/13 at 4:00 PM, Staff M, RN (Registered Nurse), revealed only nurses do the admission assessment. No mention of camera monitoring and recording at the time of admits, and it is not mentioned in the admission packet. Patients are not made aware of the camera monitoring and recording during their stay.

An interview on 2/18/13 at 4:00 PM, Staff M, RN (Registered Nurse), revealed only nurses do the admission assessment. No mention of camera monitoring and recording at the time of admits, and the admission packet does not include this information. Staff does not inform Patients of the camera monitoring and recording during their stay.


6. An interview on 2/18/13 at 4:15 PM, with Staff N, RN (Registered Nurse) revealed, sometimes she explains camera monitoring in public areas and the seclusion room to patients that are paranoid or for safety reasons. She was unaware of the recording of the camera monitoring.

7. During an interview on 2/21/13 at 10:00 AM, Director of Mental Health verified the camera monitors have only been recording for approximately 2 weeks. My mentor recommended this for safety purposes.

I. Based on observation, review of policies and procedures, and psychiatric staff interviews, the facility failed to establish and maintain a safe environment for 2 of 7 patients with a previous diagnosis of suicide attempts or suicide ideation.
Failure to establish and maintain a safe environment for psychiatric patients could potentially result in patient deaths, injuries, or other life threatening conditions.

Findings include:

1. Observations on 2/18/13 at 2:00 PM, with Director of Mental Health, revealed the following.

-Entrance doors to 8 of 8 patient rooms opened inward. Three visible hinges attached the door to the frame. Closure of the door revealed the exposure of the 3 hinges, to the patient residing in the room. The hinges (made of metal) extended approximately 1-inch from the door frame. The extension of the hinges provided a sufficient area for the attachment of a hanging device and produced an unsafe environment in the patient rooms.

The Director of Mental Health confirmed the extensions of the hinges produced an unsafe environment for psychiatric patients at the time of the observation.

-Five sets of electrical outlets in 8 of 8 patient rooms. All electrical outlets were live with electrical current and readily available for patient use. The electrical outlets produced an unsafe environment in the patient rooms.

-Seven of 8 patient rooms that contained toilets had a metal handicap grab bar beside the toilet that was approximately 30 inches from the floor. Eight of 8 bathrooms contained pocket doors to allow patients privacy while using the facilities. Five of 8 grab bars mounted on the side wall were open between the bar and the wall, and projected approximately 3 inches from the wall. The grab bars provided a sufficient area for attachment of a hanging device and produced an unsafe environment in the patient bathroom.

The Director of Mental Health confirmed the exposed area between the grab bars produced an unsafe environment for psychiatric patients at the time of the observation.

-Eight of 8 patient rooms contained 2 sinks; the men and women's shower rooms contained 1 sink each. All sinks contained non-break away faucets (ligature resistant) and lacked testing for weight resistance (the amount of weight, when applied, would cause the fixture to break away.). The faucets provided an extension that provided a sufficient area for the attachment of a hanging device.

The Director of Mental Health was unaware if anyone had tested the faucets for weight breakaway points or if the faucets were ligature resistant approved.

-A fixed, wall mounted telephone with an approximately 36 inch metal cord attached from the receiver to the hand set, in the central hallway. The metal cord provided a sufficient area for hanging and produced an unsafe environment.

The Director of Mental Health confirmed Patients could potentially use the metal cord on the phone as a hanging device and produced an unsafe environment for psychiatric patients.

2. Review of facility policy titled, Mental Health Unit Safety Policy, undated, revealed in part. Policy Purpose: Provide a process to ensure a safe and secure environment. Any potential safety hazard will be addressed immediately by an on-duty staff to the director or designee and addressed in a patient variance report.

3. Review of the policy titled, Suicide Precautions Policy, undated, revealed in part. Policy Purpose: Provide a process to ensure the safety of patients at risk for self-harm. Assess the patient room frequently for potentially harmful objects. Remove all potentially harmful patient care objects from bedside.

4. During an interview on 2/19/13 at 9:00 AM, Director of Plant Operations confirmed the electric outlets found in the psychiatric patient rooms were live with electric current and lacked tamper resistant properties. Also during this interview, the Director of Plant Operations confirmed the faucets lacked testing for weight break away points and failed to be ligature resistant.

II. Based on review of documents and medical records, the facility failed to establish and maintain a safe environment for 2 of 7 (Patients #6 and 7) active patients identified by psychiatric nursing staff with a history of suicidal thoughts on the admission nursing assessment and a potential for injury on the care plan. Census at the time of the recertification survey was 7.

Failure to establish and maintain a safe environment for patients with a psychiatric diagnosis could potentially result in patient deaths or other life-threatening conditions. Although there were no active attempts of self-harm for either Patient #6 or #7 at the time of the survey, they were identified on the admission nursing assessment with a history of suicidal thoughts, and the care plan for potential injury, placing both at a greater risk for self-harm.

Findings include:

1. Review of Patient #6's medical record showed admission to the psychiatric unit on 1/30/13 for manic-bipolar disorder (a psychiatric diagnosis for a mood disorder typically alternating with episodes of a frenzied state known as manic and episodes of depression).

An admission nursing assessment, dated 1/30/13, at 4:42 PM, revealed the patient had a history of suicidal thoughts.

A daily care plan identified the patient was at risk for injury and the facility would ensure no injury occurred while hospitalized.

2. Review of Patient #7's Psychiatric medical record showed admission to the psychiatric unit on 2/8/13 for schizophrenia versus bipolar disorder.

An admission nursing assessment, dated 2/8/13, at 5:15 PM, revealed the patient had a history of suicidal thoughts.

A daily care plan identified the patient was at risk for injury and the facility would ensure no injury occurred while hospitalized.



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III. Based on review of documents, medical records, and staff interviews, the facility identified 3 patients (Patients #'s 1, 2, and 3) in variance reports as suicide attempts/self-harm, for the review period of 2010-2012. Psychiatric census at the time of the recertification included 2 of 7 patients identified on the admission nursing assessment with a history of suicidal thoughts.

Failure to establish and maintain a safe environment for patients with a psychiatric diagnosis could potentially result in patient deaths, injuries, or other life-threatening conditions.

Findings include:

Review of variance reports dated 2010-2012 revealed 3 suicide attempts in the Psychiatric Unit (Patients #'s1, 2, and 3), 2 hangings and 1 strangulation.

1. Review of Patient #1's medical record showed admission to the psychiatric unit on 5/11/10 for bipolar mood disorder, mixed with psychotic features (a psychiatric diagnosis for a mood disorder typically alternating with episodes of a frenzied state known as manic and episodes of depression and loss of contact with reality).

An admission nursing assessment, dated 5/11/10 at 6:00 PM, revealed the Patient was an involuntary court committal and complaining of bipolar condition was cycling and having thoughts of hurting self and others (suicidal ideation).

The admission physician orders dated 5/11/10, revealed a diagnosis of bipolar mood disorder, mixed with psychotic features and presenting problem suicidal and homicidal threats and included suicidal precautions.

The Precautions Flow Sheet, dated 5/11-12/10, and completed by Psychiatric nursing staff, revealed completion of 15 minute checks.

The Progress Notes Report dated 5/12/10, completed by Psychiatric nursing staff, revealed Patient #1's roommate reported the Patient was trying to hang him/herself and Patient #1 was found with the tubing from a C-Pap (a machine that assists Patients while, they sleep, with apnea symptoms and breathing disorders) wrapped around the Patient's neck twice tightly. Staff removed the tubing from the Patient's neck and administered Seroquel (medication to decrease anxiety). Much assurance given and the Patient made a commitment to the nurse not to self-harm and to call the nurse if those feelings occurred again.

Physician Progress Notes, dated 5/13/10 revealed an attempt of self-harm by wrapping C-Pap tubing around the neck and pulling it tightly.

2. Review of Patient #2's Medical record showed admission on to the psychiatric unit 1/14/11 for schizoaffective disorder (combination of psychosis and mood changes that causes both a loss of contact with reality (psychosis) and mood problems.).

An admission nursing assessment, dated 1/14/11, at 5:45 PM, revealed the Patient was an involuntary court committal with suicidal thoughts of riding a bike in front of a semi, walking in front of traffic, or jumping out of window.

The Physician admission orders, dated 1/14/11, revealed a diagnosis of schizoaffective disorder, and presenting problem Patient is threatening harm to self.

The Precautions Flow Sheet dated 1/14-15/11, and completed by Psychiatric staff, revealed completion of 15 minute checks.

The Progress Notes Report dated 1/15/11; completed by Psychiatric nursing staff, revealed the Patient was found hanging from the handicap bar in the Patient ' s bathroom. The Patient had torn a tie from the robe, the tie was knotted several times around the bar and around the Patient's neck, very tightly-it took 3 staff members to loosen the tie enough to cut it off-once we did, we assisted the Patient to bed, and Ativan was given (a medication to decrease anxiety). Staff notified the doctor and unit director.

The Physician Progress Notes dated 1/16/11, revealed. Yesterday the Patient had a serious suicide attempt. The Patient wrapped the gown around his/her neck in the bathroom. The Patient was turning blue when found. Staff cut the gown from the Patient's neck, gave Ativan, and the Patient rested quietly.

3. Review of Patient #3's Medical record showed admission to the psychiatric unit on 3/26/12 for schizoaffective disorder.

An admission nursing assessment dated 3/26/12 at 4:54 PM, revealed an involuntary court committal with suicide attempt and reports of increased hallucinations, depression.

The Physician admission orders dated 3/26/12, revealed a diagnosis of schizoaffective disorder and presenting problem of auditory hallucinations, and included suicidal precautions.

The Precautions Flow Sheet dated 3/26-27/12, completed by Psychiatric staff, revealed completion of 15 minute checks, with 1:1 observation initiated on 3/27/12.

The Progress Notes Report dated 3/27/12, completed by Psychiatric nursing staff, revealed Patient #3's roommate was on the phone in the hall and called to me that the roommate was making some funny noise. The Patient was sitting on the bed, bent over, face was purple, and the Patient was moving minimal air. The Patient had torn the bedding, wrapped it numerous times around the neck, and knotted it in several places; staff called a Code Green (all hospital alert for help). Staff had to cut the bedding from the neck in several places before we got it all cut away.

The Physician Progress Notes dated 3/28/12, revealed later in the evening, the Patient was in the room alone while the Patient ' s roommate was on the phone. Patient #3's roommate told the nursing staff that the Patient was making funny noises and the nursing staff checked on the Patient. Staff found Patient #3 sitting on the bed bent over, face was purple. The Patient had minimal air moving. The Patient had torn the bedding, wrapped it numerous times around the neck, and knotted it. Staff called a Code Green and cut the bedding away from the Patient. The Patient became angry with the nursing staff, and given Geodon (medication to reduce anxiety), Ativan, and taken to the seclusion room.

4. Review of Patient #1's variance report titled Patient Tried to Harm Self dated 5/12/10 showed the following:

- A diagnosis of Bipolar disorder.

- The Detailed Description Patient revealed Patient #1's roommate came to nurse's station and told us the Patient was attempting to hang themself. The Patient was in the room with the tubing from the C-PAP machine wrapped twice around the neck tightly. Staff easily removed the tubing and took the tubing out of the room.

- The Director's Follow-up Note dated 5/13/10 at 11:32 AM revealed the Director discussed the incident with the assigned nurse. Patient was on suicide precautions with every 15 minute checks. The Patient had received a PRN (as needed) Ativan at 11:00 for anxiety. The Patient denied suicidal ideation on morning assessment. After the incident, the nurse visited with the Patient. The Patient voiced concerns about feeling staff at the waiver home was out to get him/her. The Patient reported thoughts of being sexually molested as a child and has sexually molested a staff member. ARNP (Advanced Registered Nurse Practitioner) felt this was delusional in nature. The Patient did contract with nurse not to self-harm and agreed to talk with staff if he/she feels this way. The Patient received another PRN medication after the incident. I am investigating whether they make breakable tubing and plan to implement removal of C-PAP machines from patient rooms during Patient awake hours.

- The Director's Change Notes dated 5/13/10 at 11:32 AM revealed an Email sent to staff to remind them to remove this type of equipment during patient awake hours.

- The Outcome: has a slight imprint around Patient's neck from the tubing.

- The Subject Harm: 3-Minimum patient harm

5. Review of Patient #2 ' s variance report titled Suicide Attempt, dated 1/15/12 showed the following:

- A diagnosis of schizoaffective disorder.

- The Detailed Description revealed the Patient had been in his/her room on the floor with pillows and blanket at 4:25 PM when I checked. At 4:50 PM when the CNA (Certified Nursing Assistant) went to distribute sodas to the patients, he could not find Patient #2. Patient #2 was found hanging from the handicap bar in the bathroom-with torn the ties from the robe, the Patient had tied them over and over around the bar and then very tightly around the neck. Patient #2 was blue when found. It took 3 staff to get the ties loose enough to be able cut them with a scissors. Staff assisted Patient #2's to bed and administered 4mg (milligram) IM (Intramuscular. Staff stayed with the Patient until he/she fell asleep. Staff moved the Patient to room #21, across from the nurse's station for better observation.

- The Director's Follow-up Notes dated 1/25/11 at 12:40 PM, review of the situation, handled appropriately by staff.

- Director's Change Notes dated 1/25/11 at 12:40 PM, revealed a discussion regarding the bar with the Plant Operations Director. We are looking into a different style of bar, this bar is located in only two rooms of the unit, those directly across the office.

Outcome: good

Subject Harm: 3-Minimum patient harm

6. Review of Patient #3 variance report titled Suicide Attempt dated 3/27/12 showed the following:

- A diagnosis of schizoaffective disorder and borderline personality disorder.

- The Detailed Description revealed staff had checked on the Patient about 5 minutes before the Patient s roommate was on the hall phone and reported their roommate was making funny noises. Upon going into the Patient's room, staff found the Patient on the bed slumped over on the side and the Patient ' s face was purple. The Patient had torn the bedding and wrapped strips tightly around the neck with it knotted in several places-Code Green called.

- The Director's Follow-up note dated 11/9/12 at 4:52 PM, revealed the following. Reviewed with the nurse, this was Patient behavior issue, and the Patient is attention seeking, need close observation to prevent self-injury.

-Director's Change note dated 11/912 at 4:52 PM, revealed one to one observation ordered to keep Patient safe

-Outcome: staff cut the bedding from the Patient's neck; staff took the Patient to seclusion.

-Subject Harm: 3-Minimum patient harm

7. Review of the Variance Reporting Form revealed the recorder could make a subject harm selection at level 3 minimum patient harm based on the following levels documented on the Variance Reporting Form:

- 1. Caught before it reached the patient
- 2. Reached patient, but no harm caused
- 3. Minimum patient harm
- 4. Temporary patient harm
- 5. Patient hospitalized/extended stay
- 6. Permanent harm
- 7. Death

8. Review of facility policy titled Variance and Sentinel Event Reporting Policy, undated, lacked information related to suicide attempts and stated its purpose was to document and report variances to appropriate individuals within the organization.

-Review of facility Patient Safety Steering Committee Meeting notes dated 6/20/10, showed the notes lacked information related to Patient #1's suicide attempt on 5/12/10.

-Review of the Committee for Safe Patient Care Meeting notes dated 2/10/11, showed the notes lacked information related to Patient #2's suicide attempt on 1/14/11.

-Review of the Committee for Safe Patient Care Meeting notes dated 4/12/12, showed the notes lacked information related to Patient #3's suicide attempt on 3/27/12, documentation showed Director of Mental Health attended the meeting.

9. An interview on 2/20/13 at 9:00 AM, with Quality Services Coordinator revealed she has access to the variance reports, and edits them. The Quality Services Coordinator was aware of all 3 attempts of suicide. Staff members completing the report assign the variance levels of harm and Quality re-evaluates. Staff reports the variances at monthly safety meetings. Usually the Safety Committee only discusses variances above level 4. Quality is not made aware of individual variances below or including a level 3.

-An interview on 2/21/13 at 8:10 AM, with CNO (Chief Nursing Officer) verified that she was aware of all 3 incidents, but the incidents did not rise to a level of significance that required additional action.

-During an interview on 2/21/13 at 10:00 AM, Director of Mental Health revealed she has been the Director of Mental Health since 11/2/11, two of the suicide attempts occurred prior to this date. All variances are taken to the patient safety committee, which meets quarterly, and are only discussed if they are above a level 3. Patient #3's variance report failed to rise above a level 3 (minimal harm) and did not require additional action.

The Director reported having a mentor who is the Director of a nearby hospital based Mental Health Unit. The Director said she has failed to develop a plan defining her needs as the new Director of Mental Health with her mentor. The Director's mentor has made one on-site visit, toured the Mental Health Unit, and discussed general safety concerns related to the addition of a security room, securing the beds to the floor, and camera monitoring of the room; recording of the existing camera monitoring, staffing, and additional activities.

Based on document review, and staff interview, Quality Assurance and Safety Committee staff failed to develop a variance profile coding system that triggered tracking, analyzing, and implementing preventative actions for 3 of 3 attempted suicides by hanging or asphyxiation on the psychiatric (Psych) unit. The Mental Health unit Director identified an average daily census of approximately 8 patients.

Failure to develop a variance profile coding system to track all relevant data, irrespective of harm level, prevented the Quality Services and Safety Committee staff from implementing specific interventions targeted at identifying causes of attempted suicide by hanging or asphyxiation in order to prevent or minimize the potential for another patient attempting to commit suicide by hanging or asphyxiation which may be avoidable.
Findings include:

1. Review of variance reports from 5/2010 to 3/2012 revealed in part:

- On 5/12/2010 at 8:08 PM, Patient #1 attempted to hang him/herself with c-pap (a ventilation device that blows a gentle stream of air into the nose during sleep to keep the airway open) tubing. Psych nursing staff were able to remove the tubing from the patient's neck then documented there were slight imprints around the patient's neck from the tubing and coded the event at 3 (minimum patient harm).

On 5/13/10 at 11:32 AM the psychiatric nursing director reviewed the incident with the assigned nurse and documented on the variance report the c-pap device would be removed from the patient's room during waking hours.

During an interview on 2/20/13 at 2:50 PM, Quality Program Coordinator A acknowledged they were aware of the variance report but it would not be necessary for them to be involved because it did not result in injury or death of a patient.

- On 1/15/11 at 5:43 PM, Patient #2 attempted to hang him/herself from a handicap bar in the bathroom with ties from a bathrobe. Psych nursing staff cut the ties with a scissors and coded the event at 3.

On 1/17/11 at 11:11 AM, the Quality Program Coordinator sent a response to the psych nursing director, inquiring whether a closed type of handicap bar would be appropriate in the bathrooms or anywhere on the unit.

On 1/25/11 at 12:40 PM, the Psych nursing director documented that they had discussed the handicap bar with the Plant Operations Director and they were looking into a different style of bar. The variance report lacked additional follow up after the 1/25/11 entry.

During an interview on 2/20/13 at 2:50 PM, the Quality Program Coordinator A acknowledged they were aware of the variance report but it would not be necessary for them to be involved because it did not result in injury or death of a patient.

- On 3/27/12 at 9:11 PM, Patient #3 attempted to hang him/herself with strips torn from bedding. Psych nursing staff cut the bedding from the patient's neck and documented the patient's face was purple and a Code green was called (staff including security are to report to the location immediately where a patient had a serious and potentially life-threatening change in medical condition). The event was coded at 3.

On 11/9/12, the psych nursing director reviewed the event with the nurse and documented that this was a patient behavior issue, the patient is attention seeking, and needed close observation to prevent self-injury.

During an interview on 2/20/13 at 2:50 PM, the Quality Program Coordinator A acknowledged they were aware of the variance report but it would not be necessary for them to be involved because it did not result in injury or death of a patient.

2. Review of the facility's "Policy for Variance and Sentinel Event Reporting," undated, revealed the following in part, "...An intranet electronic variance report shall be completed any time an incident or event occurs...an event is an occurrence that is not consistent...with the routine care of a particular patient...the following events should be considered a sentinel event if there was no serious injury or death: suicide or suicide attempt of anyone receiving care or treatment."

During an interview on 2/20/13 at 2:50 PM, the Director of Quality Services B acknowledged all three suicide attempts were not identified as sentinel events.

3. Review of "Variance Statistical Profile/Patient Safety Committee Review" reports for May 2010, January 2011, and March 2012, found it did not include any data on the suicide attempts on the psych unit. The report lacked evidence that Quality and Safety staff analyzed the causative events surrounding the suicide attempts and implemented preventative actions that include feedback and learning throughout the hospital.

4. Review of the facility's "Quality Assessment and Performance Improvement Plan (QAPI) for 2012, revealed the following in part, "...The purpose of QAPI...is to ensure the delivery of the best possible care for patients. This is accomplished by assessing patient care...in a systematic manner in order to identify and act upon opportunities for improvement...to use quality indicator data to monitor the effectiveness and safety of services...and identify changes that will lead to improvement...in addition to indicator measurement, opportunities for improvement may be identified through other means, including but not limited to...adverse patient events."

5. During an interview on 2/20/13 at 2:50 PM, Director of Quality Services B explained, staff completing the variance report would assign a number for harm levels and the department directors would review the reports to determine if the number assigned was appropriate and if follow up actions were necessary. The Director of Quality Services B stated the quality assurance committee would not be involved with these processes unless the specific department asked for their assistance. The Director of Quality Services B said each department in the hospital is responsible for completing their own quality assurance initiatives and submitting them to the quality assurance committee. Additionally, the quality assurance committee staff met with the departments on several occasions to review what they are monitoring and measuring but this would not be documented, it would be "consultative" basis. The Director of Quality Services B acknowledged the hospital failed to follow up on the suicide attempts by hanging and the committee for safe patient care should have addressed the attempts by hanging as well. The Director of Quality Services B said the incident should have been addressed in these committees and they were not.
(Refer to A-144 for additional patient informatin)

Based on review of documents and administrative staff interview the Board of Trustees failed to ensure the Quality Assurance Program and Safety Committee staff developed and implemented a plan to correct environmental hazards that created an unsafe environment for patients with a psychiatric diagnosis who may also be suicidal. These hazards were present on the PPS excluded Psychiatric Unit. Additionally, Quality Assurance Program and Safety committee staff failed to communicate quality and patient safety concerns to the Board of Trustees.

Variance reports for 1 of 3 suicidal attempts by hanging identified environmental hazards impacting the safety and well being of patients on the certified patient care area.

Failure to implement a corrective action to eliminate the environmental hazards resulted in 1 patient, in the PPS excluded Psychiatric Unit, who attempted suicide by hanging in 2011. Failure to recognize and correct the environmental hazards following this attempt inhibited the facility's ability to provide a safe environent and avoid subsequent similar attempts.

Findings include:

1. Review of "Quality Program Coordinator-Quality Services" Job summary revealed in part, "...Assist Director of quality services as needed with...risk management...communicate with hospital staff regarding...patient safety...manage the hospital variance reporting system...promote and assist with hospital-wide patient safety...responsibility for reporting variance and patient safety related risk issues and participating in safety-enhancing projects."

-Review of Board of Trustees Bylaws, dated 4/14/11, revealed in part, "...The hospital Board of Trustees is responsible for effective governance which includes...the provision of quality services...the Board of Trustees shall provide for the management, control, and government of the hospital."

- The Quality Management Committee Meeting notes from 5/2010 to 11/2012 lacked evidence of Quality Activity/Safety Committee tracking, analyzing and implementing preventative actions for 3 of 3 attempted suicides by hanging on the psychiatric unit, 1 of 3 that involved environmental hazards.

During an interview on 2/20/13 at 3:45 PM, the Director of Quality Services B acknowledged the findings.

-The Board of Trustees Meeting Minutes from 2010 to 2012 lacked evidence of the Quality Activity/Safety Committee tracking, analyzing and implementing preventative actions for 3 of 3 attempted suicides by hanging on the psychiatric unit, 1 that involved environmental hazards.

During an interview on 2/20/13 at 3:45 PM, the Director of Quality Services B acknowledged the findings.

2. During an interview on 2/21/13 at 8:20 AM, the Chief Executive Officer (CEO) said the quality and planning committees have monthly meetings that include two board members. The CEO stated their strategic planning process included patient safety. The CEO confirmed the Director of Quality presented information regarding patient safety concerns at the Board of Trustees meetings and said essentially, all ongoing quality assurance activities would be reported by various disciplinary work groups in all departments of the hospital. The CEO stated they were not aware of the suicide attempts by hanging and the discussions or concerns with the removal of a handicap bar on the psychiatric unit. The CEO said because none of the incidents resulted in harm or injury to the patients and it would not be necessary for them to be apprised of the information. The CEO stated that, going forward, he should be aware of any type of activity like this.

(Refer to A-144 and A-286 for additional patient and quality information)

Based on review of medical records and staff interview, the hospital failed to ensure the patient's medical record included physician hemodialysis orders, hemodialysis treatment information, physician progress notes, and nursing communication that documented the patients' progress and status during the hemodialysis treatments throughout the patients' hospital admission.

Failure to maintain the physician hemodialysis orders, progress notes, along with hemodialysis treatment information, and nursing communication in the patient's medical record could potentially prevent hospital staff from assessing the patient's hemodialysis treatment and providing the care the dialysis patient required to receive optimal post dialysis care.

The medical record must contain documentation to support and describe the response to the patient's hemodialysis treatments received during the hospitalization. The hemodialysis treatment information is a reflection of how the patient tolerated the treatment. It includes information regarding the hemodialysis machine safety checks, pre and post patient assessments, treatment prescription, medications given, and the patient's status during the treatment (blood pressure, pulse, fluid removed, arterial and venous pressures, blood flow rates, dialysate flow rates, and ultrafiltration rates), patient concerns, and hemodialysis staff comments and/or concerns.
Findings for 4 of 4 closed medical records for Patients who received hemodialysis treatments during hospitalization. (Patient #'s 1, 2, 3, and Patient 4) The hospital reported no inpatient hemodialysis patients at the time of the survey.

1. Review of documentation received from the Dialysis Director showed Patient #1 received hemodialysis treatments on 11/28/12 and 11/29/12 during hospitalization. However, review of Patient #1's medical record showed it failed to include the physician ' s hemodialysis treatment order, progress note, hemodialysis treatment information, and documentation of communication between the RN (Registered Nurse) from the hospital and the RN from the dialysis unit indicating the patient received dialysis those days. Documentation related to the dialysis treatment should include, a brief dialysis synopsis, post dialysis weight, medications, intake during dialysis, fluid removed during dialysis, vital signs post treatment, and the patient's current condition and level of consciousness post treatment.

-Review of documentation received from the Dialysis Director showed Patient #2 received hemodialysis treatments on 5/2/12 during hospitalization. However, review of Patient #2's medical record showed it failed to include the physician ' s hemodialysis treatment order, progress note, hemodialysis treatment information, and documentation of communication between the RN from the hospital and the RN from the dialysis unit indicating the patient received dialysis those days. Documentation related to the dialysis treatment should include, a brief dialysis synopsis, post dialysis weight, medications, intake during dialysis, fluid removed during dialysis, vital signs post treatment, and the patient's current condition and level of consciousness post treatment.

-Review of documentation received from the Dialysis Director showed Patient #3 received hemodialysis treatments on 11/5/12, 2/8/13, and 2/11/13 during hospitalizations. However, review of Patient #3's medical record failed to include the physician ' s hemodialysis treatment order, progress note, hemodialysis treatment information, and documentation of communication between the RN from the hospital and the RN from the dialysis unit indicating the patient received dialysis those days. Documentation related to the dialysis treatment should include, a brief dialysis synopsis, post dialysis weight, medications, intake during dialysis, fluid removed during dialysis, vital signs post treatment, and the patient's current condition and level of consciousness post treatment.

-Review of documentation received from the Dialysis Director showed Patient #4 received hemodialysis treatments on 4/20/12, 4/23/12, and 4/25/12 during hospitalization. However, review of Patient #4's medical record failed to include the physician ' s hemodialysis treatment order, progress note, hemodialysis treatment information, and documentation of communication between the RN from the hospital and the RN from the dialysis unit indicating the patient received dialysis those days. Documentation related to the dialysis treatment should include, a brief dialysis synopsis, post dialysis weight, medications, intake during dialysis, fluid removed during dialysis, vital signs post treatment, and the patient's current condition and level of consciousness post treatment.

2. During an interview on 2/12/13 at 9:00 AM, the CNO (Chief Nursing Officer) reported the facility did not provide acute dialysis at the hospital. The CNO reviewed the hospital application for licensure and reported the acute dialysis section was marked in error. The CNO reported the inpatients receive hemodialysis treatments at the hospital chronic outpatient unit during their hospitalization.

-During an interview on 2/12/13 at 1:30 PM, with the Dialysis Director and the CNO, the Dialysis Director stated, "All the documentation is kept in my chronic unit. The inpatient records come with the patient to dialysis but we do not document in the inpatient record." The surveyor asked about the physician hemodialysis orders and progress notes. The Dialysis Director reported the physician writes the patient hemodialysis order one time a year and the changes to the order would be in the progress notes. The Dialysis Director stated, "We would call the Dr, when the patient is hospitalized, for orders. " The Dialysis Director agreed the documentation in the medical record and/or the documentation the Dialysis Director provided did not show the staff notified the physician of Patient # ' s 1, 2, 3, and 4 hospitalizations and/or received hemodialysis treatments during the hospitalization. The Dialysis Director agreed the physician's hemodialysis order did need written for the patient's admission to the hospital. The CNO reported a lack of knowledge regarding the need for hemodialysis treatment information, physician orders, communication record and dialysis treatment I & O's in the hospital records.

Based on medical record review and staff interview, the facility failed to ensure each dialysis patient ' s medical record included a hemodialysis order for each dialysis treatment. Nursing staff failed to include the amount of fluid removed during the patients' hemodialysis treatment when calculating the patients I&O (Intake and Output) at the end of the shift for 4 of 4 closed dialysis patient medical records (#'s 1, 2, 3, and 4). The hospital reported no inpatient hemodialysis patients at the time of the survey.


Failure to ensure patients had a hemodialysis order and an accurate account of the dialysis patient's output could potentially result in the hospital staff not identifying a patient with an incorrect hemodialysis order and inhibits the hospital staffs ability to know when too much or too little fluid was removed. Too much fluid removed could potentially cause low blood pressure, cramping, and/or dizziness. Too little fluid removed could cause volume overload, fluid retention, and shortness of breath.

A medical record is complete if it contains sufficient information to identify the patient's hemodialysis order, course, and results of treatments to promote continuity of care among staff.

Findings include:

1. Review of the patient closed medical records revealed the following:

-Review of Patient #1's medical record revealed a document titled, "INTAKE/OUTPUT RECORD," dated 11/26/12 through 12/1/12, that reflected documentation regarding the amount of urine the patient voided, the amount of fluids taken orally, and the amount of fluids that were administered intravenously. However, further review of the document failed to show the amount of fluid removed during the dialysis treatment.

The Dialysis Director provided a document for Patient #1 titled, "CHRONIC HEMODIALYSIS ORDERS" dated 1/11/12. The Dialysis Director reported this was the order used for Patient #1's hemodialysis treatments on 11/26/12, 11/28/12, and 11/29/12.

The Dialysis Director provided documents for Patient #1 titled, "HEMODIALYSIS TREATMENT INFORMATION." (HDTI)

The HDTI dated 11/26/12, showed staff used a UF Profile (A method to use pressure to remove excess fluid weight from a patient during the hemodialysis treatment.) during the dialysis treatment. The amount of fluid removed (UF amount), based on the patient's pre weight equaled 3.1 kg (kilograms).

The HDTI dated 11/28/12 showed staff used a UF Profile during the treatment. The amount of fluid removed, based on the patient's pre weight equaled 4.2 kg.

The HDTI dated 11/29/12 showed staff used a UF Profile during the treatment. The amount of fluid removed, based on the patient's pre weight equaled 1.5 kg.

-Review of Patient #2's medical record revealed a document titled, "INTAKE/OUTPUT RECORD," dated 5/2/12 through 5/5/12, that reflected documentation regarding the amount of urine the patient voided, and the amount of fluids taken orally and the amount of fluids that were administered intravenously. However, further review of the document failed to show the amount of fluid removed during the dialysis treatment.

The Dialysis Director provided a document for Patient #2 titled, "CHRONIC HEMODIALYSIS ORDERS" dated 1/10/12. The Dialysis Director reported this was the order used for Patient #2's hemodialysis treatments on 5/2/12.

The Dialysis Director provided a document for Patient #2 titled, "HEMODIALYSIS TREATMENT INFORMATION" dated 5/2/12, that showed staff used a UF Profile during the treatment. The amount of fluid removed; based on the patient's pre weight equaled 0.8 kg.

-Review of Patient #3's medical record revealed a document titled, "INTAKE/OUTPUT RECORD," dated 2/8/13 through 2/13/13, that reflected documentation regarding the amount of urine the patient voided, and the amount of fluids taken orally and the amount of fluids that were administered intravenously. However, further review of the document failed to show the amount of fluid removed during the dialysis treatment.

The Dialysis Director provided a document for Patient #3 titled, "CHRONIC HEMODIALYSIS ORDERS" dated 1/9/13. The Dialysis Director reported this is the order used for Patient #3's hemodialysis treatments on 2/8/13 and 2/11/13.
The Dialysis Director provided a document for Patient #3 titled, "HEMODIALYSIS TREATMENT INFORMATION" dated 2/8/13, that showed staff used a UF Profile during the dialysis treatment. The amount of fluid removed based on the patient's pre weight, equaled 0.4 kg.

The document dated 2/11/13; showed staff used a UF Profile during the treatment. The amount of fluid removed based on the patient's pre weight, equaled 0.1 kg.

-Review of Patient #4's medical record revealed a document titled, "INTAKE/OUTPUT RECORD," dated 4/20/12 through 4/26/12, that reflected documentation regarding the amount of urine the patient voided, the amount of fluids taken orally, and the amount of fluids that were administered intravenously. However, further review of the document failed to show the amount of fluid removed during the dialysis treatment.

The Dialysis Director provided a document for Patient #4 titled, "CHRONIC HEMODIALYSIS ORDERS" dated 4/20/12. The Dialysis Director reported this was the order used for Patient #4's hemodialysis treatments on 4/23/12 and 4/25/12.

The Dialysis Director provided a document for Patient #4 titled, "HEMODIALYSIS TREATMENT INFORMATION." dated 4/23/12, that showed staff used a UF Profile during the treatment. The amount of fluid removed based on the patient's pre weight, equaled 3.4 kg. However, review of the documents dated 4/20/12 and 4/25/12 showed staff failed to acquire Patient #4's pre and post weight in order to obtain the amount of fluid removed during the dialysis treatment.

2. During an interview on 2/11/13 at 2:20 PM, the Dialysis Director reported the hospital medical record and the Chronic Dialysis Unit medical records do not cross over in the computer system. The Dialysis Director stated, "We call report to each other. My staff may not document it but I know they call the nurse with a report after the patient is done with their treatment." The surveyor asked about the physician's order for the hemodialysis treatment. The Dialysis Director reported the dialysis staff contacts the physician to update the physician and receive a new order if there are changes in the patient's condition. The Dialysis Director stated, "I know my staff calls the Dr. It may not get wrote in the record but I am there and I know it gets done." The Dialysis Director continued to report the dialysis unit maintained all the documentation for every dialysis treatment. The surveyor questioned the treatment type (inpatient or outpatient) on the hemodialysis treatment information document. The Dialysis Director stated, "We enter outpatient." However, the patients are inpatient at the time of the treatment.

-During an interview on 2/12/13 at 8:25 AM the Chief Nursing Officer (CNO) stated, "We only do Chronic Outpatient Dialysis. I have no idea who marked the Acute Dialysis." The CNO reported the hospital would be removing the Acute Dialysis from the hospital application.

-During an interview on 2/12/13 at 1:30 PM with the Dialysis Director and the CNO, the Dialysis Director stated, "All the documentation is kept in my chronic unit. The inpatient records come with the patient to dialysis but we do not document in the inpatient record." The Dialysis Director reported when the patients are in the hospital and if the physician were evaluating the patients in the Chronic Unit, the physician would evaluate the inpatient in the Chronic Unit. The CNO agreed the physician did not evaluate the inpatient hemodialysis patients at the hospital bedside. The CNO reported a lack of knowledge regarding the need for the patient's hemodialysis treatment information and I & O's documentation to be in the hospital records. The CNO agreed the hospital staff did not comply with the regulation to provide sufficient information in the patient's inpatient medical record to support the results of the patient's hemodialysis treatments, and/or documentation that shows continuity of care among staff.

Based on review of policy and procedure, medical records, and staff interview, hospital staff failed to obtain an informed consent for hemodialysis treatments patients received during their hospitalization. The hospital reported no inpatients receiving hemodialysis at the time of the survey. Four of 4 closed medical records reviewed for Patients who received hemodialysis treatments during their hospitalization (Patient # ' s 1, 2, 3, and 4) lacked evidence of a signed Informed Consent prior to receiving dialysis treatment.

Failure to obtain an informed consent from the patient regarding the hemodialysis treatments could potentially prevent the patient from receiving knowledge regarding the purpose of the treatment, expected benefits, effects of risks, and possible complications.

1. Review of the hospital policy titled, "INFORMED CONSENT POLICY" stated in part, "...B. If the recommended treatment involves the performance of "non-routine" care, the practitioner must explain to the patient the nature and purpose of the treatment or procedure and disclose the risks, possible complications, and expected benefits or effects of the risks and benefits...H. Unless incapacitated, adult patients have the sole right to consent or refuse recommended treatment...I. Regardless of documentation, if a member of the nursing staff is unsure whether informed consent has been obtained from a patient, he or she may raise the question with the responsible practitioner or with the nursing supervisor on duty..."

2. The hospital provided hemodialysis treatments to their inpatients. When a patient requiring hemodialysis is in the hospital, staff reportedly transports patients via wheelchair to the chronic dialysis unit located on the third level of the hospital. Upon completion of the dialysis treatment, hospital staff transported the patients back to their hospital room.

3. Review of the patient's medical records revealed the following:

-Review of Patient #1's medical record showed the patient required hospitalization on 11/26/12, and while in the hospital the patient received hemodialysis treatments on 11/28/12 and 11/29/12. However, further review of the medical record failed to show Patient #1 signed an Informed Consent for the hemodialysis treatment procedures.

-Review of Patient #2's medical record showed the patient required hospitalization on 5/2/12, and while in the hospital the patient received hemodialysis treatments on 5/2/12. However, further review of the medical record failed to show Patient #2 signed an Informed Consent for the hemodialysis treatment procedures.

-Review of Patient #3's medical record showed the patient required hospitalization on 2/8/13, and while in the hospital the patient received hemodialysis treatments on 2/8/13 and 2/11/13. However, further review of the medical record failed to show Patient #3 signed an Informed Consent for the hemodialysis treatment procedures.

-Review of Patient #4's medical record showed the patient required hospitalization on 4/20/12, and while in the hospital the patient received hemodialysis treatments on 4/20/12, 4/23/12, and 4/25/12. However, further review of the medical record failed to show Patient #4 signed an Informed Consent for the hemodialysis treatment procedures.

4. During an interview on 2/12/13 at 10:30 AM, the Chief Nursing Officer (CNO) reported a lack of knowledge regarding the need for informed consents for hemodialysis treatments received during the patient ' s hospitalization. The CNO stated, " We've never had to have them before." The CNO agreed the hospital policy clearly stated that staff is required to document an informed consent from the patient before they receive a treatment.

Based on observation, document review, and staff interviews, the facility failed to ensure the pharmacy staff maintained oversight of the receipt and distribution of sample medications in 1 of 1 area of the hospital that had sample medications. (Medical Oncology Clinic) The Medical Oncology Clinic had an average of 100-135 patient visits per month.

Failure of pharmacy staff to provide oversight of sample medications could potentially result in expired medications being available for patient use.

Findings include:

1. Observation during tour of the Medical Oncology Clinic on 2/20/13 at 10:40 AM, with the Medical Oncology Clinic Clinical Coordinator, revealed a locked storage cupboard that contained 1 sample medication - 9 bottles of Femara 2.5 mg - 30 tablets per bottle.

2. Review of Pharmacy policies/procedures revealed the lack of a policy/procedure related to the receipt and distribution of sample medications in the hospital.

3. During an interview on 2/20/13 at 10:40 AM, at the time of the tour, the Medical Oncology Clinic Clinical Coordinator acknowledged the sample medications kept in the Medical Oncology Clinic and further stated Pharmacy staff do not have any oversight of those sample medications.

During an interview on 2/20/13 at 12:40 PM, the Director of Pharmacy stated there were no sample medications in the hospital, the hospital does not allow sample medications. The Director of Pharmacy further stated the only policy the Pharmacy had is that the hospital will not use sample medications.

During an additional interview on 2/20/13 at 1:15 PM, the Director of Pharmacy reported the Pharmacy does not have a policy/procedure regarding sample medications. The Director of Pharmacy further stated the pharmacy follows the Iowa Administrative Code for Hospital Pharmacies that sample medication use is prohibited for hospital inpatient use. The Director of Pharmacy stated she was not aware the Medical Oncology Clinic had any sample medications.

Based on observation, review of documentation, policies/procedures, and staff interview, the facility failed to ensure current safety inspection occurred for 3 of 3 steam sterilizers, used to sterilize all clinic instruments, in the only sterile processing area and 3 of 3 main boilers used to heat water for patient and staff use during daily hospital activities. The facility reported approximately 4 loads of clinic instruments sterilized per day in the steam sterilizer. The facility performed 4-5 equipment sterilizations in the large autoclave a day, 5 flash equipment sterilizations a day and 5-6 equipment sterilizations in the Sterad.

Failure to ensure current safety inspections of the steam-sterilizers and general boilers could potentially result in the sterilizers failing to kill bacteria on clinic instruments and could result in infections to patients. In addition, the lack of safety inspection of the pressure vessel could potentially result in harm to the operator if the steam sterilizers or boilers would malfunction.

Findings include:

1. Tour of the sterile processing area on 2/19/13 at 1:20 PM, with Staff F, Director of Surgery, revealed sterile processing had 3 steam sterilizers. Staff F stated the director of plant operations would have the current steam sterilizer boiler certificates of inspection and produce them when asked.

2. Tour of the hospital environment on 2/20/13 at 9:30 AM, with Staff G, Director of Plant Operations revealed 3 boilers with expired inspection certificates. Two boiler inspection certificates expired 9/2012 and 1 expired 1/20/13.

3. Review of the steam sterilizer and boiler inspection certificates revealed steam sterilzer #1, 2, and 3 expired 1/2013 and boilers #1 and 2 expired 9/2012, boiler #3 expired 1/2013.

4. Review of the hospital policy titled Preventative Maintenance Policy, no review date, revealed in part. Systems included in the program are essential for life safety or used in diagnosing or monitoring any physiologic condition of the patient. These include: 4. Boiler and Heating Systems.

5. During an interview on 2/21/13 at 12:00 PM, Staff G stated the hospital insurance inspector failed to inspect the boilers and steam sterilizers on time. Staff G said the hospital staff should have identified this and had the inspections completed on time.

Based on medical record review, policy/procedure review and staff interviews, the facility failed to provide ongoing activity programs developed according to the comprehensive assessment and activity interest for 2 of 2 current Swing Bed (SWB) patients (Patient #'s 8 and 9) and 5 of 5 discharged skilled patients (Patient #'s 10, 11, 12, 13, and 14).

The hospital had a census of nine SWB inpatients at the time of the survey.

Failure to develop ongoing activities according to the interest and needs of the CAH patients could interfere with the continuity of care of the patient while hospitalized.

Findings include:

1. Review of the medical records for Patients #'S 8, 9, 10, 11, 12, 13, and 14 revealed a lack of documentation for an initial activity assessment, documentation activities were offered and/or provided, or documentation activities were care planned.

2. During an interview on 2/14/13 at 9:45 AM, Staff H, Director of Medical/Surgical Units stated the 2 open medical records for current SWB patients lacked all documentation for the ongoing activity program.

3. During an interview on 2/20/13 at 7:30 AM, Staff I, Activity Coordinator stated the medical record lacked documentation for an initial activity assessment, activities were offered and/or provided and the care plan did not include activities.

4. During an interview on 2/21/13 at 10:50 AM, Staff J, Assistant Director of Medical/Surgical Units stated the 5 closed medical records for discharged SWB patients lacked all documentation for the ongoing activity program.

I. Based on observation, review of policies and procedures, and psychiatric staff interviews, the facility failed to establish and maintain a safe environment for 2 of 7 patients with a previous diagnosis of suicide attempts or suicide ideation.
Failure to establish and maintain a safe environment for psychiatric patients could potentially result in patient deaths, injuries, or other life threatening conditions.

Findings include:

1. Observations on 2/18/13 at 2:00 PM, with Director of Mental Health, revealed the following.

-Entrance doors to 8 of 8 patient rooms opened inward. Three visible hinges attached the door to the frame. Closure of the door revealed the exposure of the 3 hinges, to the patient residing in the room. The hinges (made of metal) extended approximately 1-inch from the door frame. The extension of the hinges provided a sufficient area for the attachment of a hanging device and produced an unsafe environment in the patient rooms.

The Director of Mental Health confirmed the extensions of the hinges produced an unsafe environment for psychiatric patients at the time of the observation.

-Five sets of electrical outlets in 8 of 8 patient rooms. All electrical outlets were live with electrical current and readily available for patient use. The electrical outlets produced an unsafe environment in the patient rooms.

-Seven of 8 patient rooms that contained toilets had a metal handicap grab bar beside the toilet that was approximately 30 inches from the floor. Eight of 8 bathrooms contained pocket doors to allow patients privacy while using the facilities. Five of 8 grab bars mounted on the side wall were open between the bar and the wall, and projected approximately 3 inches from the wall. The grab bars provided a sufficient area for attachment of a hanging device and produced an unsafe environment in the patient bathroom.

The Director of Mental Health confirmed the exposed area between the grab bars produced an unsafe environment for psychiatric patients at the time of the observation.

-Eight of 8 patient rooms contained 2 sinks; the men and women's shower rooms contained 1 sink each. All sinks contained non-break away faucets (ligature resistant) and lacked testing for weight resistance (the amount of weight, when applied, would cause the fixture to break away.). The faucets provided an extension that provided a sufficient area for the attachment of a hanging device.

The Director of Mental Health was unaware if anyone had tested the faucets for weight breakaway points or if the faucets were ligature resistant approved.

-A fixed, wall mounted telephone with an approximately 36 inch metal cord attached from the receiver to the hand set, in the central hallway. The metal cord provided a sufficient area for hanging and produced an unsafe environment.

The Director of Mental Health confirmed Patients could potentially use the metal cord on the phone as a hanging device and produced an unsafe environment for psychiatric patients.

2. Review of facility policy titled, Mental Health Unit Safety Policy, undated, revealed in part. Policy Purpose: Provide a process to ensure a safe and secure environment. Any potential safety hazard will be addressed immediately by an on-duty staff to the director or designee and addressed in a patient variance report.

3. Review of the policy titled, Suicide Precautions Policy, undated, revealed in part. Policy Purpose: Provide a process to ensure the safety of patients at risk for self-harm. Assess the patient room frequently for potentially harmful objects. Remove all potentially harmful patient care objects from bedside.

4. During an interview on 2/19/13 at 9:00 AM, Director of Plant Operations confirmed the electric outlets found in the psychiatric patient rooms were live with electric current and lacked tamper resistant properties. Also during this interview, the Director of Plant Operations confirmed the faucets lacked testing for weight break away points and failed to be ligature resistant.

II. Based on review of documents and medical records, the facility failed to establish and maintain a safe environment for 2 of 7 (Patients #6 and 7) active patients identified by psychiatric nursing staff with a history of suicidal thoughts on the admission nursing assessment and a potential for injury on the care plan. Census at the time of the recertification survey was 7.

Failure to establish and maintain a safe environment for patients with a psychiatric diagnosis could potentially result in patient deaths or other life-threatening conditions. Although there were no active attempts of self-harm for either Patient #6 or #7 at the time of the survey, they were identified on the admission nursing assessment with a history of suicidal thoughts, and the care plan for potential injury, placing both at a greater risk for self-harm.

Findings include:

1. Review of Patient #6's medical record showed admission to the psychiatric unit on 1/30/13 for manic-bipolar disorder (a psychiatric diagnosis for a mood disorder typically alternating with episodes of a frenzied state known as manic and episodes of depression).

An admission nursing assessment, dated 1/30/13, at 4:42 PM, revealed the patient had a history of suicidal thoughts.

A daily care plan identified the patient was at risk for injury and the facility would ensure no injury occurred while hospitalized.

2. Review of Patient #7's Psychiatric medical record showed admission to the psychiatric unit on 2/8/13 for schizophrenia versus bipolar disorder.

An admission nursing assessment, dated 2/8/13, at 5:15 PM, revealed the patient had a history of suicidal thoughts.

A daily care plan identified the patient was at risk for injury and the facility would ensure no injury occurred while hospitalized.



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III. Based on review of documents, medical records, and staff interviews, the facility identified 3 patients (Patients #'s 1, 2, and 3) in variance reports as suicide attempts/self-harm, for the review period of 2010-2012. Psychiatric census at the time of the recertification included 2 of 7 patients identified on the admission nursing assessment with a history of suicidal thoughts.

Failure to establish and maintain a safe environment for patients with a psychiatric diagnosis could potentially result in patient deaths, injuries, or other life-threatening conditions.

Findings include:

Review of variance reports dated 2010-2012 revealed 3 suicide attempts in the Psychiatric Unit (Patients #'s1, 2, and 3), 2 hangings and 1 strangulation.

1. Review of Patient #1's medical record showed admission to the psychiatric unit on 5/11/10 for bipolar mood disorder, mixed with psychotic features (a psychiatric diagnosis for a mood disorder typically alternating with episodes of a frenzied state known as manic and episodes of depression and loss of contact with reality).

An admission nursing assessment, dated 5/11/10 at 6:00 PM, revealed the Patient was an involuntary court committal and complaining of bipolar condition was cycling and having thoughts of hurting self and others (suicidal ideation).

The admission physician orders dated 5/11/10, revealed a diagnosis of bipolar mood disorder, mixed with psychotic features and presenting problem suicidal and homicidal threats and included suicidal precautions.

The Precautions Flow Sheet, dated 5/11-12/10, and completed by Psychiatric nursing staff, revealed completion of 15 minute checks.

The Progress Notes Report dated 5/12/10, completed by Psychiatric nursing staff, revealed Patient #1's roommate reported the Patient was trying to hang him/herself and Patient #1 was found with the tubing from a C-Pap (a machine that assists Patients while, they sleep, with apnea symptoms and breathing disorders) wrapped around the Patient's neck twice tightly. Staff removed the tubing from the Patient's neck and administered Seroquel (medication to decrease anxiety). Much assurance given and the Patient made a commitment to the nurse not to self-harm and to call the nurse if those feelings occurred again.

Physician Progress Notes, dated 5/13/10 revealed an attempt of self-harm by wrapping C-Pap tubin