HospitalInspections.org

Based on observations, record reviews, and interviews the hospital failed to meet the requirements for the Condition of Participation (CoP) for Patients' Rights. The deficient practice was evidenced by failing to ensure all staff members were re-educated to prevent future occurrences after a patient elopement from the hospital for 1 (#2) of 3 (#1, #2, #3) patients reviewed and failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for ligature risks and safety risks (see findings under Tag A0144).

Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by:

1.) failing to ensure all staff members were re-educated to prevent future occurrences after a patient elopement from the hospital for 1 (#2) of 3 (#1, #2, #3) patients reviewed; and

2.) failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for ligature risks and safety risks.

Findings:

1.) Failing to ensure all staff members were re-educated to prevent future occurrences after a patient elopement from the hospital for 1 (#2) of 3 (#1, #2, #3) patients reviewed.

Review of Patient #2's medical record revealed an admission date of 04/27/2024. Review of the nurse's note dated 04/27/2024 at 11:38 a.m. by S4RN revealed in part, Patient #2 wanted to smoke while he was being admitted and said he had money in his wallet. Patient #2 did not have a wallet or cell phone in his property. Patient #2 became irritated and started yelling and screaming. S4RN called hospital "B" ED to see if his property was still there. Hospital "B" ED said they did not have it. Patient #2 continued to escalate. S5Physician notified. Patient #2 began disrobing and wrapped his top around his fist and punched the wall at the end of the hall twice. He banged on the nurse's station then hit and put a hole in the wall by the staff lounge. Patient #2 then went into his room and pulled the nightstand from the wall and threw it at the window. The nightstand shattered, it did not break the glass. Patient #2 then went and picked up a chair, pulled the tennis balls from the legs of it and shattered the glass door to the patio. Patient #2 threw the chair and ran onto the patio and jumped the fence just as the police arrived. The police ran after Patient #2 but did not find him. Review of the nurse's note dated 04/27/2024 at 5:51 p.m. by S4RN revealed in part, nursing received a call from hospital "B" ED and the nurse told S6LPN that Patient #2 was back in the ED and sheriff deputy brought him there. Patient #2 was safe.

In an interview on 05/14/2024 at 1:09 p.m. - 1:14 p.m. while observing the patio area S3DQ stated Patient #2 broke the patio door and was able to get into the patio area. S3DQ stated there was a trash can near the fence. S3DQ stated the trash can was turned over because the staff cleaned the trash can and put it there to dry. S3DQ stated Patient #2 jumped onto the trash can and then jumped over the fence and eloped from the hospital. S3DQ stated the trash can should have been on the other side of the fence and not in the patient patio area but that day the trash can was in the patient patio area.

Review of the incident report dated 04/30/2024 revealed in part, Follow up and education: Education of all staff included appropriate location of the garbage can per S2DON. Education to all staff including ensuring that nothing is left on the patio per S2DON.

In an interview on 05/14/2024 at 12:24 p.m. S2DON stated there was no documentation of this provided education. She stated there was no documentation of staff sign-in sheets on who received and understood the education. She stated she met with each shift and verbally educated the staff.

In a phone interview on 05/14/2024 at 2:07 p.m. S7MHT stated she was not provided education after this incident occurred.

In an interview on 05/14/2024 at 2:15 p.m. S8RN stated she did not attend the mandatory meeting. She stated she was not provided education after this incident occurred.

In an interview on 05/14/2024 at 2:19 p.m. S6LPN stated she did not receive education regarding this incident.

S2DON later presented a staff sign-in sheet with 10 nurse signatures. S2DON also presented a weekly update sheet dated 04/30/2024 which revealed in part, 7. Do not leave anything on the patio that can be used by a patient to harm self, use as a weapon or use to scale the fence (trash cans or bags, boxes, lighters, etc).

In an interview on 05/14/2024 at 2:59 p.m. S2DON stated this was the education presented to staff and the sign-in sheet.

Review of the hospital's staff list revealed in part, there were 22 nurses and 20 MHTs on staff.

In an interview on 05/14/2024 at 3:10 p.m. S2DON stated she sent the education information via their communication system to the nurses and techs. S2DON verified because she sent the education information via their communication system there was no documentation of the staff receiving the education.

2.) Failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for ligature risks and safety risks.

In an observation on 05/13/2024 at 10:10 a.m. - 10:52 a.m. of the hospital revealed a gap between the toilet and the wall creating a potential ligature risk and the toilet seat was able to be lifted exposing the hinge creating a potential ligature risk in the bathroom of patient rooms "b" and "d".

In an observation on 05/14/2024 at 2:47 p.m. - 2:58 p.m. of the hospital revealed a gap between the toilet and the wall creating a potential ligature risk and the toilet seat was able to be lifted exposing the hinge creating a potential ligature risk in the bathroom of patient room "a". There was one nightstand in patient room "a" that was not secured to the wall and the surveyor was able to move the nightstand making the nightstand a potential safety risk.

In an interview on 05/14/2024 at 2:53 p.m. S1Adm and S3DQ verified all 10 patient room bathrooms were the same and had a gap between the toilet and the wall and all 10 toilet seats were able to be lifted exposing the hinge. S1Adm and S3DQ verified the nightstand in patient room "a" was not secured to the wall.

Based on observation and interview, the hospital failed to ensure facilities, supplies, and equipment were maintained to an acceptable level of safety and/or quality. This deficient practice was evidenced by failing to ensure expired supplies were not available for patient use.

Findings:

In an observation on 05/13/2024 at 10:10 a.m. - 10:52 a.m. of the hospital revealed the following expired supplies located in the medication room:
a) Zepto Metrix - NatTrol Flu/RSV/SARS-CoV-2 Negative Control with an expiration date of 03/27/2024
b) Zepto Metrix - NatTrol Flu/RSV/SARS-CoV-2 Positive Control with an expiration date of 05/01/2024
c) 4 - BD Insyte Autoguard IV Catheter 22GA 1.00in with expiration dates of 05/31/2021

In an interview during the observation S3DQ verified the above stated findings.