HospitalInspections.org

Based on interview, record review, and observation, the facility failed to adequately direct, monitor, and evaluate the nursing care furnished, and thereby protect active sample patient L15 from self-injury while in seclusion on 5/7/11. After being placed in seclusion, he positioned himself in a "blind" corner of the seclusion room so that he could not be seen by the staff member monitoring from the window located in the seclusion room door. Review of this event via a camera recording revealed that while the patient was in the corner of the room, the patient injured himself, and sustained lacerations on his face. The staff member assigned to monitor the patient was seen on video visibly looking out towards the nurse's conference area rather than into the seclusion room while Patient L15 was harming himself out of view of the staff member. For over four minutes, Patient L15 was outside the line of sight of the staff monitor; during this time frame, the staff member did not call for assistance to see the patient, nor did the staff member physically get up out of the chair to look around the door in order to visualize the patient. The facility failed to provide a seclusion room that allowed constant staff monitoring, and failed to provide a staff member with sufficient training to immediately alert others when the patient could not be seen. These failures allowed patient L15 to seriously harm himself without staff intervening to protect the patient. In addition, observation revealed that the room had exposed door hinges on the inside, which could be used by a patient in self-harming actions. These failures place all patients on this unit who may require seclusion at similar risk for harm during episodes of seclusion. This situation was identified as an IMMEDIATE JEOPARDY to the health and safety of patients on the unit. The State Director of Mental Health and the facility's Chief Executive Officer were notified on 5/9/11 at 2:00 p.m. that a situation of IMMEDIATE JEOPARDY to patient health and safety existed. Subsequently, a plan of correction (POC) was submitted by the facility on 5/10/11 at 8:30a.m., but was not found to adequately address the identified problems and was not accepted. The situation of IMMEDIATE JEOPARDY continued at the time the survey concluded on 5/10/11. (Refer to B148)

Based on interview, record review and observation, the Director of Nursing failed to adequately direct, monitor, and evaluate the nursing care furnished, and thereby failed to protect patient L15, who was able to inflict self harm to his face while in a seclusion room on Unit 3 Lower within a "blind" spot area in the southwest corner of the north side seclusion room, located adjacent to the nurse's station. Review on 5/9/11 of a camera recording made on 5/7/11 revealed that on 5/7/11 at 6:54 PM, after Patient L15 was secluded, he positioned himself in the "blind" corner of the seclusion room, which meant that he could not be seen from the window in the seclusion room door, the door where a staff member sat to provide visual observation. The camera showed that while in the corner the patient used his fist to hit his nose and struck his head on the wall or door jamb causing injury to his face. The recording also showed that L15 sustained lacerations to his face. The staff member assigned to observe failed to observe the incident, failed to alert other staff that the patient could not be seen, and failed to act when the patient was injured. On video observation, the staff member seemed unaware of the gravity of the incident until the physician on call arrived and asked for assistance several times. The facility failed to provide a seclusion room that allowed constant staff monitoring, and failed to provide a staff member with sufficient training to immediately alert others when the patient could not be seen. These failures enabled patient L15 to seriously harm himself while in a setting which was supposed to protect him, and place other patients on the unit who require seclusion at risk of harm. Further interview revealed that seclusion rooms in other areas of the facility have similar configuration, which place patients housed on other units at similar risk.

Findings Include:

1. During an interview on 5/9/11 around 10:00 AM., the Director of Risk Management at Arkansas State Hospital (ASH) stated that over the previous weekend the facility had to submit a report of injury on a "Suspected Child Abuse Report" form to the Arkansas State Police. She stated that the report related to an incident on 5/7/11 when patient L15 managed to do bodily harm to himself while in a "blind" corner of the seclusion room. When asked if the seclusion room had a mirror in the room to avoid blind spots, the Risk Management Director said "No."

2. A review of the Seclusion and Restraint Report, dated 5/7/11 at 6:57 PM., stated that patient L15 "became angry for no apparent reason. He jumped up and assaulted a peer and bit a USO (unit security officer). Patient [pt] [L15]...threaten to hit staff and peers [sic]....Pt bit two staff. 15 min [minute] physical hold was applied and pt got a chemical restraint. Pt started self mutilating himself in seclusion and sent [sic] to ER [emergency room] for treatment."

3. The "Suspected Child Abuse Report" dated 5/7/11 stated, "resident [physician] on call gave order of close [sic] door seclusion and it was in the closed door seclusion that pt [L15] started using his fist to hit his nose. Pt sustained laceration and his face is [sic] full with blood. MD [doctor] ordered that pt should be transported to ACH [Arkansas Children's Hospital]. Pt injury was as a result of self mutilations, pt verbalizing 'I want to die and I want to kill myself.' Safety was provided and staff was monitoring pt, but pt went to the back of the door and in a hiding [sic] corner started the self harm bx [behavior]."

4. Observation on 5/9/11 at 12:15 PM of an audio/video recording dated 5/7/11 between 6:42 PM and 7:05 PM showed the circumstances leading up to the closed seclusion and the events that occurred in the seclusion room and adjacent nurse's conference room. Observation of the Unit 3 Lower dayroom camera recording validated the increasingly agitated behavior of Patient L15 leading up to the chemical restraint delivered in the day room and L15's "closed door" seclusion. As stated in the "Seclusion and Restraint Report," Patient L15 kept saying he wanted to die and banged his head against the wall several times prior to being placed in seclusion. The audio/visual recording from the nurse's station camera showed the BHA [Behavior Health Aide] seated outside of the seclusion room, using a window in the door to peer into the seclusion room; the BHA never alerted anyone that she could not see the patient when Patient L15 was in a "blind" corner of the seclusion room for several minutes. At 6:57 PM, visible on the north seclusion room camera recording but out of sight for the BHA, Patient L15 struck his face and then struck his head against the wall or door jamb. Patient L15 was clearly injured and remained in the "blind" corner for approximately 4 minutes while the recording showed the BHA sitting at the door looking away from the window and paying attention to the other 4 or 5 staff members in the nurse's conference room. The nurse's station camera recording then showed the resident physician, who had come to do a face-to-face evaluation of the patient after the patient had been placed in seclusion, arrive around 7:00 PM. The physician could be seen looking through the window in the seclusion room and then heard stating that he could not see Patient L15 and needed some help. He said this several times before nursing staff responded to his request. At about that time, the patient came to the door of the seclusion room, the physician saw the patient's bloody face, and ordered staff to remove the patient immediately from the seclusion room and send him to the hospital for evaluation.

5. A visit to the two seclusion rooms of Unit 3 Lower on 5/9/11 around 1:00 PM revealed that both rooms (north and south) had "blind" spots. The south side seclusion room had two doors leading into the seclusion room, each with a window in it. There were blind spots in two corners of the room, a different blind spot from each window used to view into the room. The seclusion room also had one door leading to a bathroom. All three doors opened inward: this is a potential danger to patients because the door hinges are inside, not outside, the seclusion room where patients could access them for self-harm. The other seclusion room was the same configuration. Maintenance men who were on Unit 3 Lower in the process of putting up mirrors in each seclusion room to eliminate the blind spots said they did not have enough new flush hinges to exchange all the existing ones on the two seclusion room doors. They also revealed that the seclusion rooms on the other patient units (3 Upper, 5 Lower, 5 Upper, 6 Lower and 6 Upper) had the same problem with hinges and blind spots (12 rooms total).

6. A review of seclusion and restraint reports of patients who had been subjected to seclusion and/or restraints was done for the period of April 15, 2011 to May 8, 2011. The reports revealed that there had been 10 incidents of locked seclusions on Unit 3 Lower during this period.

7. In an interview on 5/9/11 at 12:45 PM with the Asst DON, the surveyors looked at the configuration of the two seclusion rooms on Unit 3 Lower. The Asst DON agreed that protruding door hinges could cause harm to a patient who would strike his/her head or body against the hinges and that the hinges could pose a hanging hazard. The inward opening of the doors was also discussed. The Asst DON stated that the facility has had difficulty with this type of configuration on the adult forensic unit. He went on to describe power struggles staff has had in the past on the forensic unit with patients in seclusion, where the inwardly opening doors were used in attempts to self barricade or participate in a tug-of-war with staff.

8. The CEO (Chief Executive Officer) and the Director of Mental Health for the State of Arkansas were informed of the above circumstances, and the Immediate Jeopardy these circumstances present, on 5/9/11 at 2:20 PM. in the CEO's office. Both stated they wanted to submit a Plan of Correction (PoC) prior to the end of the survey on 5/10/11.

9. The facility submitted a PoC on 5/10/11 around 8:30 AM. The PoC contained the following:

a. "The seclusion room doors on units 3 Lower, 3 Upper, 5 Lower, 5 Upper, 6 Lower and 6 Upper will be modified by replacing the door frames and doors with doors that open outward and are flush fitting on the Inside of the seclusion room. The bathrooms inside the seclusion rooms will be blocked off and no longer used after the above referenced modifications are made.

b. "Effective May 9th, 2011, the seclusion rooms on units 3 Lower, 3 Upper, 5 Lower, 5 Upper, 6 Lower and 6 Upper will not be used for closed door seclusion until the existing doors are modified to open outward.

"No closed door seclusion will be used on these units until the existing doors are modified. Five-point restraint will be used if needed for patients who are dangerous or who exhibit threat of lethal behavior.

c. "By close of business May 9th, 2011, all nursing staff currently on duty will receive training on ASH Policy 05.01.07 specifically highlighting the constant visual one-hour observation rule applicable to instances of seclusion. Each oncoming shift of nursing staff will be trained in these procedures until all rotations and shifts are accounted for. Training will be verified by sign off sheets and confirmed by the NOD [Nurse on Duty] and the DON.

d. "Training Outline:

ASH seclusion policy overview

Direct observation required for the first hour

If patient cannot be seen, this must be immediately reported to the charge nurse and the seclusion room must be opened so that the patients can be seen and evaluated if needed."

10. The PoC focused primarily on assuring that all staff on the patient units were familiar with the correction made in the hospital seclusion/restraint policy (#05.01.07) - namely the constant one hour visual observation. The plan did not address staff training in the area of improving both physical and mental health assessments of patients while in seclusion and restraint to assure patients would be safe and their privacy would be protected. This specific training is necessary in order to have qualified staff providing active treatment. The IJ situation continued at the time the survey ended.