HospitalInspections.org

Based on observation, staff interview, record review and document review it was determined the facility failed to maintain a safe environment free from strangulation and smothering risks associated with the placement of a flexible plastic barrier wall in a patient hallway (A 144). As a result of this failure, Immediate Jeopardy (IJ) was identified and the facility was notified on 6/16/21 at 3:16 p.m. The facility submitted and implemented an acceptable plan to remove the IJ, that was verified by the State Survey Agency on 6/16/21 at 6:22 p.m.

The following interventions were implemented to resolve the IJ: Behavior Health Staff (BHS) immediately trained on monitor plastic barrier wall. On 06/16/21 at 2:55 p.m. the plastic barrier wall was removed. Director of Plant Operations will monitor all patient care units to ensure plastic barrier wall is not placed back on units. This will occur daily and a report will be given to the interim Chief Executive Officer to ensure 100% of compliance for 4 weeks and then monitoring will be decreased to monthly. Cross-reference 482.13 (c)(2) Patient Rights: Care in a Safe Setting.

A. Based on observation, medical record review, staff interview and document review it was determined the Director of Operations failed to ensure the physical environment was maintained to prevent harm to all patients. A plastic barrier, which posed a strangulation and smothering risk, was placed in a patient hallway. This failure has the potential for all suicidal ideation/suicide risk patients to be at risk for an increased risk of suicide.

Findings include:

Review of the medical record for patient #1, revealed upon admission on 05/21/21, the patient had a diagnosis of suicidal threats and was placed on every fifteen (15) minute safety checks. On 06/07/21, the patient had a paper clip and had an intent to self-harm. On 06/09/21 and 06/11/21, the patient was aggressive punching the walls and causing self-harm to hand.

Review of the medical record for patient #2, revealed upon admission on 05/21/21, the patient had a history of feelings of hopelessness and tried to cut themself by breaking a bottle to self-cut. The patient was placed on every fifteen (15) minute safety check.

Review of the medical record for patient #3, revealed upon admission on 05/21/21, the patient had a diagnosis of depressive symptoms with suicidal ideation's. The patient was placed on every fifteen (15) minute safety checks.

A review of the medical record for patient #4, revealed upon admission on 06/10/21, the patient had a history of self-injury by cutting their wrist. The patient was placed on every fifteen (15) minute safety checks.

A review of the medical record for patient #5, revealed upon admission on 05/17/21 and until discharge on 06/16/21, the patient had a diagnosis of suicidal ideation, homicidal ideations and major depressive disorder. The patient had a plan to cut themself and to stab their parents. The patient was on every fifteen (15) minute checks.

Review of the medical record for patient #7, revealed upon admission on 06/10/21, the patient had a diagnosis of suicidal ideations with a plan to commit suicide from an overdose of heroin. The patient has a history of suicide attempts. The patient was placed on every fifteen (15) minute checks.

Review of the medical record for patient #10, revealed upon admission on 06/10/21, the patient had a diagnosis of suicidal ideations and major depressive disorder with a plan to cut and hang themself (patient had looked up how to tie a noose). The patient was placed on every five (5) minute safety checks and on 06/17/21, an order was written to complete safety checks every fifteen (15) minutes.

Observation conducted on 6/16/21 at 11:10 a.m. on 2 East, Hallway 1 revealed a plastic barrier, held in place on the floor, walls and ceiling by tape, completely divided the front and back sides of the hallway. Staff were observed in the front of Hallway 1 and in the nurse's station. No staff were monitoring the cameras at the nursing station and no staff was monitoring halls or the plastic wall.

Observation on 6/16/21 at 11:10 a.m. showed there were five (5) unquarantined patients and one (1) patient (patient #1) who tested positive for Coronavirus-19 (COVID-19) on 06/10/21 and three (3) patients (patients #5, 7, and 9), who were suspected of having COVID-19 on Hallway 1 (behind the plastic barrier).

An interview was conducted with anonymous staff member #5 on 6/16/21 at 1:34 p.m. They stated the wall was put in place under the direction of the ICEO and was intended to prevent the spread of COVID-19. When asked why they never put the unexposed patients on an empty unit they stated in part, "We didn't consider it."

An interview was conducted with the Medical Director on 6/16/21 at 2:15 p.m. The Director stated they knew a plastic barrier was going to be placed on unit 2 East, but thought it was being placed inside the nurse's station. The Director was unaware the plastic barrier had been placed in the hallway and had not gone to the unit to see the wall.

An interview was conducted with the Corporate Quality Director on 6/17/21 at 11:55 a.m. The ICNO was asked if any of the patients on unit 2 East were diagnosed with suicidal ideation. The Corporate Quality Director responded, "Yes".

An interview was conducted with anonymous staff member #7 on 6/17/21 at 1:18 p.m. They stated in part the understanding was the wall would be monitored at all times ... although if the Behavioral Health Technicians and nurses were busy, a patient could take the opportunity to seriously harm themselves with the plastic barrier wall. They also stated the barrier wall could only be pulled down by someone with extreme strength or someone who had knowledge of how the wall was constructed. Gorilla tape and a roll was used on each wall, ceiling and floor. They further stated, "A patient would not be able to get the wall down."

Review of a document titled "Environment of Care/Safety Audit Date 6/14/21," revealed in part: "Barrier wall installed at 1:11 p.m."

An interview was conducted with the ICEO on 6/18/21 at 12:55 p.m. The ICEO stated in part, "We respect that the barrier presented a strangulation risk and we took it down."

B. Based on record review, staff interview and document review it was determined the facility failed to ensure patient observations were being conducted in accordance with physicians' orders via a computerized system (ObservSmart-used for recording observations and notifying administration of lapses of observations) which was not functioning correctly. This deficient practice was identified in six (6) of ten (10) records reviewed (Patients #2, 6, 7, 8, 9 and 10). This failure to promote and protect patient safety places all patients at risk for harm.

Findings include:

Review of the clinical record for Patient #2 revealed the patient was admitted on 5/21/21 with diagnoses of suicidal ideation and depression, with physician orders for staff to observe (every fifteen (15) minutes). On 5/24/21, physician ordered staff observations were not completed between 4:52 p.m. and 6:00 p.m. On 6/14/21, physician ordered staff observations were not completed between 10:32 p.m. and 11:00 p.m. (patient's room was located off a hallway behind a flexible plastic barrier wall on that date).

Review of the clinical record for Patient #6 revealed the patient was admitted on 6/8/21 with a diagnosis of severe major depression, with physician orders for staff to observe (every fifteen (15) minutes). On 6/14/21, physician ordered staff observations were not completed between 8:45 p.m. and 9:07 p.m. and between 9:44 p.m. and 10:06 p.m. (patient's room was located off a hallway behind a flexible plastic barrier wall on that date).

Review of the clinical record for Patient #7 revealed the patient was admitted on 6/10/21 with a diagnosis of suicidal ideation with a plan, with physician orders for staff to observe (every fifteen (15) minutes). On 6/14/21, physician ordered staff observations were not completed between 8:22 p.m. and 8:46 p.m. and between 9:45 p.m. and 10:57 p.m.

Review of the clinical record for Patient #8 revealed the patient was admitted on 4/1/21 with a diagnosis of major depressive disorder, with physician orders for staff to observe (every fifteen (15) minutes). On 6/14/21, physician ordered staff observations were not completed between 8:45 p.m. and 9:07 p.m. and between 10:34 p.m. and 11:00 p.m. (patient's room was located off a hallway behind a flexible plastic barrier wall on that date).

Review of the clinical record for Patient #9 revealed the patient was admitted on 6/12/21 with a diagnosis of severe oppositional defiant disorder, with physician orders for staff to observe(every fifteen (15) minutes). On 6/14/21, physician ordered staff observations were not completed between 8:25 p.m. and 9:46 p.m. and between 9:46 p.m. and 10:58 p.m.

Review of the clinical record for Patient #10 revealed the patient was admitted on 6/10/21 with a diagnosis of major depressive disorder, with physician orders for staff to observe (every fifteen (15) minutes). On 6/14/21, physician ordered staff observations were not completed between 8:20 p.m. and 9:08 p.m.

Review of the website for ObserveSmart states in part: ObservSMART has designed real-time alerts into the software to account for safety concerns, missed observations, and 1:1 observation proximity failure. Supervisory staff is proactively notified of any potential issues so they can immediately assist and correct the problem real-time...Coordinated, supervisory escalation process...Missed observations, 1:1 out of range, and off-unit lateness notifications.

An interview was conducted with Corporate Quality (CQ) on 6/17/21 at 11:55 a.m. When asked about (2) lapses in observations on Patient #2, one (1) lasting twenty-nine (29) minutes and one (1) lasting sixty-eight (68) minutes, CQ stated the tablets used during observation should have alarmed them; if the observation wasn't done an alarm would have been sent to an Administrator. CQ stated, "That shouldn't have happened." CQ stated they would check with the ICEO about the lapses.

An interview was conducted with CQ on 6/17/21 at 4:06 p.m. CQ stated the ObservSmart alerts were not configured correctly and tablets were still audibly sounding, but reports to management did not occur, and they were reconfiguring the system today. The correct sequence of events for the ObservSmart should be: The system will pre-alert the staff five (5) minutes prior for the need of safety checks. One (1) minute past the fifteen (15) minute check an alert is given to the Nursing Supervisor. Five (5) minutes past the fifteen (15) minute check an alert is given to the Director of Nursing. Ten (10) minutes past the fifteen (15) minute check an alert is given to the Chief Executive Officer. Each time Administration is alerted the ObserveSmart is also alerted to the person assigned to complete fifteen (15) minute safety checks.

An interview was conducted with the ICEO on 6/18/21 between 12:55 p.m. and 1:18 p.m. The ICEO stated there was no way to tell how long the ObservSmart system was not notifying management of lapses in patient observations. The system was reconfigured during this survey after the state surveyors brought lapses to the attention of CQ.

Review of a document titled "Title of Policy ... Patient Monitoring," revised 10/2020, revealed in part: "Hospital staff closely monitor all patients at a minimum of 15 minute intervals."

An interview was conducted with the ICEO on 6/18/21 between 12:55 p.m. and 1:18 p.m. The ICEO concurred lapses beyond fifteen (15) minutes, or the time specified by the physician, are unacceptable. The ICEO stated, "My expectation is that fifteen (15) minute checks will be done within the fifteen (15) minutes."