HospitalInspections.org

Based on facility policy review, medical record review, review of facility documentation, observation, and interview, the facility failed to ensure care was provided in a safe setting for 1 patient (#2) of 4 patients reviewed for safety.

The findings included:

During the survey it was found Patient #2 was admitted to the facility on 10/4/16 with a diagnosis of Bipolar Disorder and Self-Inflicted Laceration to the Left Wrist. Continued review revealed the facility failed to ensure unsafe objects were not available to Patient #2 and failed to maintain 1 to 1 (1:1) observation of Patient #2 allowing the patient to self-injure.

The facility was found to not be in compliance with Condition for Participation, Patient Rights 482.13.

Please refer to A142 and A144.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure care was provided in a safe environment for 1 patient (#2) of 4 patients reviewed for safety.

The findings included:

Review of a facility policy Behavioral Health Suicide Prevention Plan last revised 3/2016, revealed "...will foster the accurate identification and successful management of patients who are at an increased risk...self-destructive behaviors. Patient at risk for...self-destructive behavior require...close observation...protective measures for their emotional and physical well-being at all times...1:1 monitoring and observation...staff responsibilities: The patient is NEVER to be out of arms reach or the assigned and dedicated staff member...patients on...heightened observation levels for...self-destructive behaviors may have the following restrictions...plastic eating utensils...collect at end of meal...staff are to be continually aware of the environment and immediately correct or report any identified risks..."

Medical record review revealed Patient #2 was admitted to the facility on 10/4/16 with the diagnosis of Bi-Polar Disorder and Self-Inflicted Laceration to the Left Wrist. Continued review revealed the patient was
"...depressed & suicidal..."

Medical record review of a nursing shift assessment dated 10/7/16 at 7:02 PM revealed "...Patient presented to nurses station after having gone to bathroom and presented to staff with self-inflicted deep lacerations on left and right forearms. Blood on fingers. Patient reports using fingernails to dig into arms..."

Medical record review of a transfer form dated 10/7/16 revealed the patient was transferred to the emergency room (ER) due to "...self-inflicted wound..."

Medical record review of a physician's order dated 10/8/16 revealed "...suicide risk precautions...monitoring frequency: One to One [1:1]..."

Medical record review of a Psychiatric Evaluation Note dated 10/8/16 revealed "...cut open old wounds on arm yesterday...cuts were sutured yesterday in the ER...agitation/anxiety, depression, hallucinations, irritability..."

Medical record review of a nurse's shift assessment dated 10/13/16 at 7:34 PM revealed "...was found in bathroom shower sitting on the floor at approximately 1820 [6:20 PM] covered in blood on hands, arms and clothes from cutting self with a staple she stated she found on the floor..."

Medical record review of a nurse's shift assessment dated 10/17/16 at 7:17 PM revealed "...Pt on 1:1 but finding ways to harm self with plastic instruments on unit...Patient had a plastic fork in the MPR [multi-purpose room] and used it to tear open wounds on her arm. The plastic fork had been left in the MPR..."

Medical record review of a transfer form dated 10/17/16 revealed the patient was transferred to the ER due to "...self-inflicted wound..."

Interview with the Quality Director (QD) and the Market Regulatory Director (MRD), on 1/4/17 at 2:40 PM, in the conference room, confirmed "...tech did not maintain 1:1..."

Interview with Registered Nurse (RN) #1 on 1/4/17 at 3:30 PM, at the 300 nursing station, confirmed "...1:1 is within arm's reach at all times..."

Observation on 1/4/17 at 3:30 PM, of the MPR, revealed the nursing station is diagonally across the hallway from the MPR and the MPR cannot be seen from the nursing station.

Interview with Mental Health Technician (MHT) #1 on 1/5/17 at 9:50 AM, in the conference room, confirmed "...it was about pass off time [shift change 2:45 PM to 3:00PM]...I stepped away to get a cup of coffee...have to step behind the nursing station to get coffee...she [Patient #2] wore a coat...when I came back I noticed a change in her demeanor...had her back to me, she had been looking out the window...I couldn't see it but she was actually digging inside her coat...couldn't see the fork because of the coat...I went out to tell the charge nurse [about the change in demeanor]...she [patient] came out into the hallway without her coat...I saw the fork sticking out...normally forks are kept out up on the counter on a tray...1:1 is arm's length...I stepped away probably not within arm's length...I got a feeling about her something was wrong, a definite change..."

Interview with QD and MRD on 1/5/17 at 10:50 AM, in the conference room, confirmed "...[MHT #1]...couple of times not in close proximity...couple of times out of room...forks were delivered with supplies for the unit and put in the multi-purpose room and not supposed to be in there...we don't keep them there..."

Interview with MHT #2 on 1/5/17 at 1:15 PM, in the conference room, confirmed "...no do not leave them alone except when they go to the bathroom and I leave the door open a crack..."

Interview with the QD and MRD on 1/5/17 at 1:30 PM, in the conference room, confirmed the facility failed to provide care in a safe setting and the facility failed to follow facility policy.

Based on review of facility policy review, medical record review, and interview, the facility failed to provide care per the care plan for 1 patient (#2) of 4 patients reviewed.

The findings included:

Review of a facility policy Behavioral Health Suicide Prevention Plan last revised 3/2016 revealed "...will foster the accurate identification and successful management of patients who are at an increased risk...self-destructive behaviors. Patient at risk for...self-destructive behavior require...close observation...protective measures for their emotional and physical well-being at all times...1:1 monitoring and observation...staff responsibilities: The patient is NEVER to be out of arms reach or the assigned and dedicated staff member...patients on...heightened observation levels for...self-destructive behaviors may have the following restrictions...plastic eating utensils...collect at end of meal...staff are to be continually aware of the environment and immediately correct or report any identified risks..."

Medical record review revealed Patient #2 was admitted to the facility on 10/4/16 with the diagnosis of Bi-Polar Disorder and Self-Inflicted Laceration to the Left Wrist.

Medical record review of a physician's order dated 10/8/16 revealed "...suicide risk precautions...monitoring frequency: One to One [1:1]..."

Medical record review of a nurse's shift assessment dated 10/14/16 at 8:55 PM revealed "...1:1 observation in place per orders..."

Medical record review of a nurse's shift assessment dated 10/15/16 at 6:11 AM revealed "...continuing 1:1 observation..."

Medical record review of a nurse's shift assessment dated 10/17/16 at 7:17 PM revealed "...self-inflicted injuries...Pt on 1:1 but finding ways to harm self with plastic instruments on unit..."

Medical record review of a transfer form dated 10/17/16 revealed the patient was transferred to the emergency room at a sister facility due to "...self-inflicted wound..."

Interview with Quality Director (QD) and Market Regulatory Director (MRD) on 1/4/17 at 2:50 PM, in the conference room, confirmed "... tech did not maintain 1:1..."

Interview with MHT #1 on 1/5/17 at 9:50 AM, in the conference room, confirmed "...it was about pass off time [shift change, 2:45 PM to 3:00PM]...I stepped away to get a cup of coffee...have to step behind the nursing station to get coffee...she [Patient #2] wore a coat...when I came back I noticed a change in her demeanor...had her back to me, she had been looking out the window...I couldn't see it but she was actually digging inside her coat...couldn't see the fork because of the coat...I went out to tell the charge nurse [about the change in demeanor]...she [patient] came out into the hallway without her coat...I saw the fork sticking out...normally forks are kept out up on the counter on a tray...1:1 is arm's length...I stepped away probably not within arm's length...I got a feeling about her something was wrong, a definite change..."

Interview with QD and MRD on 1/5/17 at 10:50 AM, in the conference room, confirmed "...[MHT #1]...couple of times not in close proximity...couple of times out of room...forks were delivered with supplies for the unit and put in the multi-purpose room and not supposed to be in there...we don't keep them there..."