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SPRING MOUNTAIN TREATMENT CENTER
PATIENT RIGHTS
Tag No.: A0115
Based on interview and documentation review, the facility had failed to protect and promote a safe environment for the patient.
Finding include:
Interview with facility staff and documentation review revealed that a safe environment and adequate processes were not present for the patient as required at:
? CFR 482.13(c)(2) (A144) Care in Safe Setting
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on observation, interview, and record review, the facility failed to ensure that the patient received individualized care and treatment in a safe setting.
Findings include:
On July 1, 2009, a Dodge Sprinter van was purchased with an order for safety locks. In an interview with Employee #1 and Employee #2, they indicated that safety locks were unable to be installed in the facility van. The van remained in service to transport patients to the Mental Health Court twice a week.
Patient #1's medical record revealed the patient had been placed on a Legal 2000 (State of Nevada's Involuntary Civil Commitment Process). The comprehensive assessment tool dated 6/30/10, documented the patient had been recently discharged from a mental health facility after a "...suicide attempt by jumping out of a car." The patient's father stated, "(the)patient (had) obsessive thoughts of jumping out of (a) car...(and) continues to be a danger to self." The adult nursing assessment dated 6/30/10, documented the patient had previously jumped from a vehicle in a suicide attempt.
On July 7, 2010, during transport, the patient leapt from the facility's above mentioned Dodge Sprinter van with no safety locks leading to her death.
Employee #6 and Employee # 7 were interviewed on 7/16/10. The employees indicated there was no report provided prior to transport of Patient #1 regarding any history of jumping from a moving vehicle.
On 7/16/10 at 11:10 AM, Employee #7 was interviewed and indicated that on the return trip to the facility Patient #1 requested to change her seat within the van because the air conditioning was too cold. She removed her seat belt and then changed seats so that she was closest to the door. Employee #7 indicated he was looking out the left window when he heard the van door open. Employee #7 indicated the van was traveling around 55 miles per hour when the Patient #1 jumped from the van.