HospitalInspections.org

Based on medical record review, review of hospital policy, observations, and staff interview, the Hospital's administrative staff failed to protect and promote the rights of each patient to receive care in a safe setting. The Hospital's administrative staff failed to:

1. Ensure the Hospital's adult inpatient (IP) behavioral health unit/ward (BHU) was appropriately staffed at all times to ensure the safety of all patients (Please refer to A-0144).

2. Develop and implement a plan to minimize opportunities for patients prone to self-harming behaviors (Please refer to A-0144).

The cumulative effect of these systemic failures and deficient practices resulted in the Hospital's administrative staff's inability to ensure that patients received adequate nursing supervision to meet the safety needs of all patients which resulted in a patient, Patient #3, causing significant injury to themselves and could have resulted in injury to other patients, and/or staff.

Based on medical record review, hospital policy review and staff interviews, the Hospital's administrative staff failed to ensure hospital staff followed policies and procedures for supervision of the patients and failed to ensure hospital staff developed and implemented a plan to reduce opportunities for self-harm for 1 of 20 patients (Patient #3) sampled residing in the adult inpatient (IP) behavioral health unit/ward (BHU).

Failure to ensure hospital staff followed policies and procedures related to supervision and ensure hospital staff implemented and developed a plan to reduce opportunities for self-harm resulted in Patient #3 causing significant self-inflicted injuries to them self, requiring transfer to another hospital for treatment on 6/14/24, and could have resulted in death of Patient #3 and/or injuries to other patients and/or staff working. The hospital identified a census of 20 patients on the adult IP BHU at the time of the survey.

Findings include:

1. Review of the policy "Nursing Department Scope of Service," Last Reviewed 2022, revealed in part:

a. " ...The unit staff is comprised of Registered Nurses (RN), Licensed Practical Nurses (LPN), Resident Treatment Technicians (RTT), and Resident Treatment Workers (RTW) ... The minimum number of Registered Nurses (RN) on each unit is one, on all shifts ..."

2. Review of the policy "Nursing Department Staffing Plan," Last Revised 7/2024, revealed in part:

a. " ...Minimal staffing levels and mixes are based on patient care needs and standard benchmarks. Factors considered are: census, patient acuity, and unit maintenance responsibilities. The nurse Supervisor makes adjustments for any unusual increase or decrease in census or patient acuity, unusual event or circumstance, or special planned activities ..."

b. "Unit R: 20-bed Adult Co-ed Unit ... Baseline Staffing Day/Evening (for Average Daily Census of 20: 6 Staff: RN + Direct Care Staff). 1:4 Staff/Patient Ratio. 1-2 Registered Nurse(s) and/or 1 - LPN, 4 non-licensed staff.

c. " ...The staff/patient ratio excludes one RN who manages the Unit. Staffing is adjusted each shift by the Nurse Supervisor based on patient acuity, patient census, mix and experience of the staff."

d. "Night shift is staffed with a minimum of ...five (5) staff on Ward R." (Adult IP BHU)

3. Review of Patient #3's medical record revealed:

a. On 7/13/17 at 6:35 PM, Patient #3 was admitted to Ward R at the Hospital. He remained at the hospital until an incident of self-harm on 6/14/24. The patients plan of care revealed the patient was a high acuity patient that frequently required a 2:1 ratio for (2 staff to 1 patient) interactions with the patient.

b. On 6/14/24 at 8:05 PM, 3 of 5 staff from Ward R responded to an emergency code on another ward, which left 2 staff (RN A and RTW B) to supervise 20 patients for an undetermined amount time, but potentially up to 15 minutes. The staffing ratio requirement on the ward was 1 staff person to 4 patients.

c. On 6/14/24 at 8:20 PM, another patient reported to RTW B that Patient #3 had something under their shirt. RN A, RTW B, and RTW D went to check on Patient #3 who was in the bathroom. Staff called out to Patient #3, but Patient #3 didn't answer, so RTW D looked over the curtain and saw Patient #3 held a large white piece of metal in their hand, and had a large laceration to Patient #3's throat. Patient #3 had a very deep laceration over the trachea with minimal bleeding.

d. On 6/14/24 at 8:29 PM, RN A called an emergency code due to the severity of the laceration. ARNP C responded and assessed Patient #3. The switchboard operator called for an ambulance.

e. On 6/14/24 at 8:40 PM an ambulance transported Patient #3 to Hospital B's emergency department (ED) for care. Hospital B's ED physician noted the patient ' s injury required surgical exploration and treatment and transferred the patient to Hospital A for a trauma evaluation.

f. On 6/15/24 at 1:05 AM, an Ear, Nose, and Throat specialist at Hospital A completed an exploration, washout, and closure of patient # 3 ' s neck wound.

g. On 6/14/24 at 8:45 PM, RN A documented (late entry) Patient #3 had been asking for "a shot of Ativan," because they were feeling overwhelmed and their medications didn't help. RN A noted patient #3 was calm, and not showing signs of agitation at that time, but also noted Patient #3 spit out half of their bedtime medication. Patient #3 was given an oral PRN medication for anxiety at an unknown time, prior to the incident that occurred on 6/14/24 at approximately 8:20 PM.

h. On 6/15/24 (at an undocumented time), hospital staff identified the metal piece Patient #3 used to self-harm was from an exit sign located on Ward R. The sign was removed by maintenance. Hospital staff noted in their investigation conclusion that patient #3 required close monitoring with need for safety precautions and suicide precautions ordered many times over the past year. Hospital staff identified Patient #3 used an opportunity of staff responding to an emergency event on another ward to self-harm.

4. During an interview on 7/1/24 at 4:00 PM, RTW B recalled working on 6/14/24 when Patient #3 used the metal piece of exit sign to cause the self-inflicted neck laceration. RTW B reported another patient told them Patient #3 had something under their shirt. RTW B reported going to the bathroom, knocked on the door, opened the door, asked Patient #3 if they were okay, and Patient #3 responded without distress (no known time for when this occurred; not documented in the record). RTW B recalled doing a check of the area, checking outlet covers, which were all accounted for, then RTW B went to report to RN A what was reported to them. RTW B reported going back to the bathroom where Patient #3 was located with RN A and RTW D, and found Patient #3 with the self-inflicted throat laceration from a piece of metal. RTW B reported only having two staff present on Ward R on 6/14/24 when Patient #3 caused the self-inflicted throat laceration.

5. During an interview on 7/2/24 at 11:30 AM, RN A described Patient #3 as unpredictable. RN A recalled on 6/14/24 Patient #3 wanted an Ativan (medication used to treat anxiety) shot, and didn't get what they wanted. RN A reported giving Patient #3 an oral PRN anxiety medication, and Patient #3 returned to their room and seemed calm. RN A recalled a Code Blue (emergency code) being called on another hospital ward, and two staff from Ward R initially responded leaving three staff for twenty patients, and then a third staff responded leaving only two staff.

6. During an interview on 7/1/24 at 3:17 PM, RTW D described Patient #3 as pretty clever, sneaky, and a med seeker. RTW D recalled leaving Ward R to respond to the code on the other hospital ward when Patient #3 caused their self-inflicted throat laceration.

7. During an interview on 7/1/24 at 1:20 PM, Advanced Registered Nurse Practitioner (ARNP) Q recalled being on-call, and responded to assess Patient #3 after their self-inflicted neck laceration on 6/14/42. ARNP Q reported Patient #3 had a significant history of substance abuse, had the tendencies to seek medication, and frequently wanted to go into restraints. ARNP Q reported Patient #3 would go to extremes if they wanted something bad enough. ARNP Q recalled receiving a call from the nurse on 6/14/24 prior to Patient #3's incident, reporting Patient #3 had increased agitation and anxiety, they spit out half of their evening medication, and wanted to know what to give Patient #3. ARNP Q recalled instructing the nurse to administer Patient #3 their oral PRN anxiety medication. ARNP Q reported responding around 8:00 PM to a Code Blue on another hospital ward, and while attending to that code a Code Blue was called for Patient #3. ARNP Q responded, assessed Patient #3, ordered them to be transferred by ambulance to the ED for evaluation, and ordered SSP and 1:1 monitoring (within arm's reach of staff).

8. During an interview on 7/1/24 at 2:00 PM, Physician J reported Patient #3 had a long history of psychiatric hospitalization and problems, and tried several different medications for Patient #3. Physician J reported Patient #3 had manipulating and demanding behavior, illogical thoughts, and delusions. Physician J reported Patient #3 assaulted several staff members, tried to harm them self, demanded restraints, and sometimes demanded medications. Physician J reported Patient #3 would hide things to use to cause self-harm. Physician J reported Patient #3 couldn't be kept indefinitely on safety precautions and restrictions, precautions are kept in place as long as necessary, and then gradually decreased as able, but if Patient #3 acted out, they were placed back on precautions depending on the behavior. Physician J reported Patient #3 was frequently placed on safety precautions, more than most of the other patients due to Patient #3's unstable behaviors.

9. During an interview on 7/2/24 at 10:30 AM, Nursing Supervisor (NS) E reported being the supervisor for Ward R, and was working on 6/14/24 when Patient #3 caused the self-inflicted laceration to their throat. NS E reported Ward R was usually staffed between six to seven staff during the day, and the night shift was staffed with four to five. NS E reported Patient #3 inflicted a lot of harm to them self when given the opportunity, assaulted staff, and had injured their neck several times. NS E reported Patient #3 became progressively worse over the past six months to a year. NS E recalled having minimal staff on Ward R when Patient #3 cause the self-inflicted throat laceration. NS E described Patient #3 as an opportunist, and reported Patient #3 saw an opportunity during the code on another hospital ward and took it. Finally, NS E recalled Ward R only had two staff present at one point on 6/14/24 during the code, and one staff member was sitting with patients in the day area and the other staff member was doing 15-minute safety rounds.

10. During an interview on 7/2/24 at 10:44 AM, RN F described Patient #3 as unpredictable. RN F reported Patient #3 was constantly on and off different safety precautions. RN F recalled on 6/14/24 when Patient #3 caused the self-inflicted throat injury there were only two staff on Ward R, and reported Ward R being left with only 2 staff was not safe.

11. During an interview on 7/1/24 at 3:15 PM, LPN M reported Patient #3 recently had slowly worsened, and would say or do anything to get out of the Hospital. LPN M reported the IP BHU's should have at a minimum of four staff at all times, and if a ward did not have that minimum, then staff from that ward should not respond to a code. LPN M reported with Patient #3, "if there is a will, there is a way."

12. During an interview on 7/1/24 at 2:02 PM, RN G reported Patient #3 was on 2:1 with interactions a majority of the time, and would attack staff randomly without signs of escalation or agitation.
13. During an interview on 7/2/24 at 10:03 AM, RTW H recalled two staff members being left on the adult IP BHU at the time Patient #3 caused their self-inflicted throat laceration.

14. During an interview on 7/2/24 at 4:47 PM, RTW P recalled Patient # 3 was on restricted to ward precautions on 6/14/24 when they caused the self-inflicted throat laceration. RTW P recalled leaving Ward R to respond to a code on another ward, and three staff members remained on Ward R.

15. During an interview on 7/2/24 at 4:07 PM, Superintendent couldn't say what the minimum staff to patient ratio should be on Ward R during a code on another ward. Superintendent acknowledged when they have a patient who may be an opportunist, they could have established a plan to make sure the patient was taken care of in the event of a crisis situation.

16. Review of the Hospital's administrative investigation and corrective action plan revealed the hospital had not yet developed and implemented a plan to minimize opportunities for patients prone to self-harming behaviors. Hospital staff failed to develop a plan to ensure patient's continuously received care in a safe setting in the event of an emergency, such as a code to another ward.

Based on medical record review, review of hospital policy, and staff interviews, the Hospital's administrative staff failed to ensure that an appropriate number of nursing staff were present on the adult inpatient (IP) behavioral health unit/ward (BHU) to provide care and safety to all patients (Please refer to A-0392).

The cumulative effect of this systemic failure and deficient practice resulted in the Hospital's administrative staff's inability to ensure that patients received adequate nursing supervision to meet the safety needs of all patients which resulted in Patient #3 causing significant injuries to themselves.

Based on medical record review, hospital policy review, and staff interviews, the Hospital's administrative staff failed to ensure that hospital staff adhered to all hospital policies and procedures by ensuring that there were an adequate number of nursing staff to meet the safety needs for 1 out of 20 patients (Patient #3) sampled.

Failure to ensure there were an adequate number of nursing staff present on the adult inpatient behavioral health unit during an emergency code response on another unit resulted in Patient #3 causing significant self-inflicted injuries to them self, requiring transfer to another hospital for treatment, and could have resulted in death of Patient #3 and/or injuries to other patients and/or staff working.

The hospital identified a census of 20 patients on the adult inpatient (IP) behavioral health unit/ward (BHU) at the time of the survey.

Findings include:

1. Review of the policy "Nursing Department Scope of Service," Last Reviewed 2022, revealed in part:

a. " ...The unit staff is comprised of Registered Nurses (RN), Licensed Practical Nurses (LPN), Resident Treatment Technicians (RTT), and Resident Treatment Workers (RTW) ... The minimum number of Registered Nurses (RN) on each unit is one, on all shifts ..."

2. Review of the policy "Nursing Department Staffing Plan," Last Revised 7/2024, revealed in part:

a. " ...Minimal staffing levels and mixes are based on patient care needs and standard benchmarks. Factors considered are: census, patient acuity, and unit maintenance responsibilities. The nurse Supervisor makes adjustments for any unusual increase or decrease in census or patient acuity, unusual event or circumstance, or special planned activities ..."

b. "Unit R: 20-bed Adult Co-ed Unit ... Baseline Staffing Day/Evening (for Average Daily Census of 20: 6 Staff: RN + Direct Care Staff). 1:4 Staff/Patient Ratio. 1-2 Registered Nurse(s) and/or 1 - LPN, 4 non-licensed staff.

c. " ...The staff/patient ratio excludes one RN who manages the Unit. Staffing is adjusted each shift by the Nurse Supervisor based on patient acuity, patient census, mix and experience of the staff."

d. "Night shift is staffed with a minimum of ...five (5) staff on Ward R." (Adult IP BHU)

3. Review of Patient #3's medical record revealed:

a. On 7/13/17 at 6:35 PM, Patient #3 was admitted to Ward R at the Hospital. He remained at the hospital until an incident of self-harm on 6/14/24. The patients plan of care revealed the patient was a high acuity patient that frequently required a 2:1 ratio for (2 staff to 1 patient) interactions with the patient.

b. On 6/14/24 at 8:05 PM, 3 of 5 staff from Ward R responded to an emergency code on another ward, which left 2 staff (RN A and RTW B) to supervise 20 patients for an undetermined amount time, but potentially up to 15 minutes. The staffing ratio requirement on the ward was 1 staff person to 4 patients. c. On 6/14/24 at 8:20 PM, another patient reported to RTW B that Patient #3 had something under their shirt. RTW B summoned addition, and RN A, RTW B, and RTW D went to check on Patient #3 who was in the bathroom. Staff called out to Patient #3, but Patient #3 didn't answer, so RTW D looked over the curtain and saw Patient #3 held a large white piece of metal in their hand, and had a large laceration to Patient #3's throat. Patient #3 had a very deep laceration over the trachea with minimal bleeding.

d. On 6/14/24 at 8:29, RN A called an emergency code due to the severity of the laceration. ARNP C responded and assessed Patient #3. The switchboard operator called for an ambulance.

e. On 6/14/24 at 8:40 PM an ambulance transported Patient #3 to Hospital B's emergency department (ED) for care. Hospital B's ED physician noted the patient ' s injury required surgical exploration and treatment and transferred the patient to Hospital A for a trauma evaluation.

f. On 6/15/24 at 1:05 AM, an Ear, Nose, and Throat specialist at Hospital A completed an exploration, washout, and closure of patient # 3 ' s neck wound.

g. On 6/14/24 at 8:45 PM, RN A documented (late entry) Patient #3 had been asking for "a shot of Ativan," because they were feeling overwhelmed and their medications didn't help. RN A noted patient #3 was calm, and not showing signs of agitation at that time, but also noted Patient #3 spit out half of their bedtime medication. Patient #3 was given an oral PRN medication for anxiety at an unknown time, prior to the incident that occurred on 6/14/24 at approximately 8:20 PM.

h. On 6/15/24 (at an undocumented time), hospital staff identified the metal piece Patient #3 used to self-harm was from an exit sign located on Ward R. The sign was removed by maintenance. Hospital staff noted in their investigation conclusion that patient #3 required close monitoring with need for safety precautions and suicide precautions ordered many times over the past year. Hospital staff identified Patient #3 used an opportunity of staff responding to an emergency event on another ward to self-harm.

4. During an interview on 7/1/24 at 4:00 PM, RTW B recalled working on 6/14/24 when Patient #3 used the metal piece of exit sign to cause the self-inflicted neck laceration. RTW B reported another patient told them Patient #3 had something under their shirt. RTW B reported going to the bathroom, knocked on the door, opened the door, asked Patient #3 if they were okay, and Patient #3 responded without distress (no known time for when this occurred; not documented in the record). RTW B recalled doing a check of the area checking outlet covers, which were all accounted for, then RTW B went to report to RN A what was reported to them. RTW B reported going back to the bathroom where Patient #3 was located with RN A and RTW D, and found Patient #3 with the self-inflicted throat laceration from a piece of metal. RTW D reported only having two staff present on Ward R on 6/14/24 when Patient #3 caused the self-inflicted throat laceration.

5. During an interview on 7/2/24 at 11:30 AM, RN A described Patient #3 as unpredictable. RN A recalled on 6/14/24 Patient #3 wanted an Ativan (medication used to treat anxiety) shot, and didn't get what they wanted. RN A reported giving Patient #3 an oral PRN anxiety medication, and Patient #3 returned to their room and seemed calm. RN A recalled a Code Blue (emergency code) being called on another hospital ward, and two staff from Ward R initially responded leaving three staff for twenty patients, and then a third staff responded leaving only two staff.

6. During an interview on 7/1/24 at 3:17 PM, RTW D described Patient #3 as pretty clever, sneaky, and a med seeker. RTW D recalled leaving Ward R to respond to the code on the other hospital ward when Patient #3 caused their self-inflicted throat laceration.

7. During an interview on 7/1/24 at 1:20 PM, Advanced Registered Nurse Practitioner (ARNP) Q recalled being on-call, and responded to assess Patient #3 after their self-inflicted neck laceration on 6/14/42. ARNP Q reported Patient #3 had a significant history of substance abuse, had the tendencies to seek medication, and frequently wanted to go into restraints. ARNP Q reported Patient #3 would go to extremes if they wanted something bad enough. ARNP Q recalled receiving a call from the nurse on 6/14/24 prior to Patient #3's incident, reporting Patient #3 had increased agitation and anxiety, they spit out half of their evening medication, and wanted to know what to give Patient #3. ARNP Q recalled instructing the nurse to administer Patient #3 their oral PRN anxiety medication. ARNP Q reported responding around 8:00 PM to a Code Blue on another hospital ward, and while attending to that code a Code Blue was called for Patient #3. ARNP Q responded, assessed Patient #3, ordered them to be transferred by ambulance to the ED for evaluation, and ordered SSP and 1:1 monitoring (within arm's reach of staff).

8. During an interview on 7/2/24 at 10:30 AM, Nursing Supervisor (NS) E reported being the supervisor for Ward R, and was working on 6/14/24 when Patient #3 caused the self-inflicted laceration to their throat. NS E reported Ward R was usually staffed between six to seven staff during the day, and the night shift was staffed with four to five. NS E reported Patient #3 inflicted a lot of harm to them self when given the opportunity, assaulted staff, and had injured their neck several times. NS E reported Patient #3 became progressively worse over the past six months to a year. NS E recalled having minimal staff on Ward R when Patient #3 cause the self-inflicted throat laceration. NS E described Patient #3 as an opportunist, and reported Patient #3 saw an opportunity during the code on another hospital ward and took it. Finally, NS E recalled Ward R only had two staff present at one point on 6/14/24 during the code, and one staff member was sitting with patients in the day area and the other staff member was doing 15-minute safety rounds.

9. During an interview on 7/2/24 at 10:44 AM, RN F described Patient #3 as unpredictable. RN F reported Patient #3 was constantly on and off different safety precautions. RN F recalled on 6/14/24 when Patient #3 caused the self-inflicted throat injury there were only two staff on Ward R, and reported Ward R being left with only 2 staff was not safe.

10. During an interview on 7/1/24 at 3:15 PM, LPN M reported Patient #3 recently had slowly worsened, and would say or do anything to get out of the Hospital. LPN M reported the IP BHU's should have at a minimum of four staff at all times, and if a ward did not have that minimum, then staff from that ward should not respond to a code. LPN M reported with Patient #3, "if there is a will, there is a way."

11. During an interview on 7/1/24 at 2:02 PM, RN G reported Patient #3 was on 2:1 with interactions a majority of the time, and would attack staff randomly without signs of escalation or agitation.

12. During an interview on 7/2/24 at 10:03 AM, RTW H recalled two staff members being left on the adult IP BHU at the time Patient #3 caused their self-inflicted throat laceration.

13. During an interview on 7/2/24 at 4:47 PM, RTW P recalled Patient #3 was on restricted to ward precautions on 6/14/24 when they caused the self-inflicted throat laceration. RTW P recalled leaving Ward R to respond to a code on another ward, and three staff members remained on Ward R.

14. During an interview on 7/2/24 at 4:07 PM, Superintendent couldn't say what the minimum staff to patient ratio should be on Ward R during a code on another ward. Superintendent acknowledged when they had a patient who may be an opportunist, they could have established a plan to make sure the patient was taken care of in the event of a crisis situation.