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Based on observation, record review and staff interview, the hospital failed to meet the Condition of Participation for Patient Rights as evidenced by failing to ensure patients received care in a safe setting for 6 of 8 sampled patients in a total sample of 9 (#1, #2, #3, #4, #7, #8) by failure to ensure patients, who were committed by Physician's Emergency Certificate (PEC) for suicidal ideations/danger to self, did not reside in rooms with windows that were accessible for egress and failure to ensure staff providing care for patients who were PEC'd (Physician Emergency Certificate) followed the hospital's policy and procedure for Observation Guidelines as evidenced by Patient #7 jumping from easily opened window for egress and landed on the roof of the first floor sustaining a complex, comminuted and multi-displaced fracture to the distal tibia with disruption of the ankle mortise and extended into the tibiotalar joint with disruption of the ankle mortise (the hinge of the ankle) while being monitored by the Licensed Practical Nurse, (LPN), S1 one to one observation on 05/20/12 at 11:25 p.m. (2325). (See deficiency cited at A0144).

Based on observation, record review and interview the hospital failed to ensure patients received care in a safe setting for 6 of 8 sampled patients in a total sample of 9 (#1, #2, #3,
#4, #7, #8) as evidenced by:

a. Failure to ensure patients, who were committed by Physician's Emergency Certificate (PEC) for suicidal ideations/danger to self, did not reside in rooms with windows that were accessible for egress.

b. Failure to ensure staff providing care, for patients who were PEC'd, followed the hospital's policy and procedure for Observation Guidelines.

Findings:

Patient #7:

Review of the medical record for Patient #7 revealed the patient was a 28 year old female admitted for an overdose of Ambien and Xanax medications on 05/20/12. The patient was admitted to the Med/Surg Unit, room "h" and was ordered 1:1 observation status by the admitting physician on 05/20/12 at 6:56 p.m. (1856). Review of the "Physician Emergency Certificate" dated/timed 05/20/12 at 6:15 p.m. (1815) revealed Patient #7 was a harm to self.

Further review of the record reflected the patient (#7) resided in room "h" on the 3rd floor for one (1) hour and twenty (20) minutes. This room had windows that were able to be easily opened for egress. On 05/20/12 at 11:25 p.m. (2325), the patient jumped from the window and landed on the roof of the first floor. Patient #7 sustained a complex, comminuted and multi-displaced fracture to the distal tibia with disruption of the ankle morise and extended into the tibiotalar joint with disruption of the ankle mortise (the hinge of the ankle).


Review of the medical record for Patient #7 revealed there were no forms noted in the record for staff members (S3LPN, S4LPN) assigned to provide one to one observation for the patient on 05/20/12.

Interview with S3, Licensed Practical Nurse (LPN) on 5/25/12 at 12:30 p.m. revealed she was the LPN who presented to duty on the night shift on 5/20/12. S3 stated she was scheduled to work from 11:00 p.m. to 7:00 a.m. and was assigned to provide one to one observation for Patient #7. S3 further revealed she was sitting inside of the patient's room ("h") at the "doorway" and was not within arm's length of patient as per policy. S3 stated she was not aware that she was suppose to be within arm's length of the patient at all times until after the incident occurred. S3 further revealed she had not been informed, prior to sitting with the patient, that she was supposed to sign a form describing (one to one observation), as per the hospital's policy.

Interview with S4, LPN on 5/29/12 at approximately 12:10 p.m. revealed she provided one to one observation for patient #7 on 5/20/12 during the evening shift. S4 stated she began sitting with the patient on 5/20//12 at approximately 6:30 p.m.or 7:00 p.m. while the patient was in the emergency department, and she continued to provide one to one observation when the patient was transferred to the 3rd floor. S4 stated she was not made aware that she was supposed to sign a form prior to sitting with patients who were PEC'd and on one to one observation. S4 further revealed she did not know the hospital's policy regarding Observation Guidelines prior to the incident concerning patient #7, and she revealed she was not aware that staff was suppose to remain within arm's length of a patient when providing one to one observation. S4 confirmed she was not within arms length of the patient when she provided care to the patient on the 3rd floor.


Patient #1:


Review of the medical record for Patient #1 revealed he was a 19 year old male admitted for overdose (OD) of Prozac; Major Depression, Suicidal Attempt (SA); and Hypertension (HTN). Review of the "Physician Emergency Certificate" dated/timed 02/08/12 at 4:55 p.m. (1655) revealed Patient #1 was suicidal, dangerous to self, and unwilling. The patient was admitted to the Med/Surg Unit, room "e" and was on one to one (1:1) observation status as ordered by the admitting physician on 02/08/12 at 7:18 p.m. (1918).

Further review of the record reflected the patient resided in room "e" on the 3rd floor for one (1) day from 02/08/12 at 3:53 p.m. (1553) through 02/09/12 at 6:27 p.m. (1827). This room had windows that were able to be easily opened for egress.
Review of the medical record for Patient #7 revealed there were no forms noted in the record for staff members assigned to provide one to one observation for the patient.


Patient #2:


The medical record for Patient #2 reflected the patient was a 32 year old female admitted for overdose of Tramadol medication on 02/10/12. The patient was admitted to the Med/Surg Unit, room "f" and was on line of sight (LOS) observation status as ordered by the admitting physician on 02/10/12 at 3:18 a.m. (0318). Review of the "Physician Emergency Certificate" dated/timed 02/09/12 at 9:53 p.m. (2153) revealed Patient #2 was suicidal, dangerous to self, and unwilling.

Further review of the record reflected the patient resided in room "f" on the 3rd floor for 1 day from 02/09/12 at 9:32 p.m. (2132) through 02/10/12 at 10:41 p.m. (2241). This room had windows that were able to be easily opened for egress.


Patient #3:


Review of the medical record revealed the patient (#3) was a 23 year old female admitted for a medication overdose, suicidal ideation (SI), and urinary tract infection (UTI) on 03/15/12. Patient #3 was admitted to the Med/Surg Unit and was ordered line of sight (LOS) observation status by the admitting physician on 03/15/12 at 2:30 p.m. (1430). Review of the "Physician Emergency Certificate" dated/timed 03/15/12 at 3:03 p.m. (1503) revealed Patient #3 was suicidal, dangerous to self, gravely disabled, and unable to seek voluntary admission.

Further review of the record reflected the patient (#3) resided in room located on the 3rd floor for two (2) days from 03/15/12 through 03/17/12. This room had windows that were able to be easily opened for egress.


Patient #4:

The medical record for Patient #4 revealed the patient was a 25 year old male admitted for major drug overdose, major depression, and abscess to bilateral buttocks on 04/16/12. Patient #4 was admitted to the Med/Surg Unit, room "g" and was ordered line of sight (LOS) by the admitting physician on 04/16/12 at 1:00 p.m. (1300). Review of the "Order of Protective Custody" dated/timed 04/16/12 at 8:55 a.m. (0855) revealed Patient #4 had suicidal ideation and was violent. Review of the "Physician Emergency Certificate" dated/timed 04/16/12 at 3:56 p.m. (1556) revealed Patient #4 was dangerous to self, unwilling, and gravely disabled. Review of the "Coroner Emergency Certificate" dated/timed 04/19/12 at 5:30 p.m. (1730) revealed Patient #4 had psychosis, depression, paranoia, and belligerent.

Further review of the record reflected the patient (#4) resided in room "g" on the 3rd floor for fourteen (14) days from 04/16/12 through 04/30/12. This room had windows that were able to be easily opened for egress.


Patient #8:

Review of the medical record reflected Patient #8 was a 54 year old female admitted for abdominal pain, and OPC (Office of Protective Custody) for being non-compliant with medications and reports nausea and vomiting for one (1) month and room mate reports not eating for days on 05/14/12. The patient was admitted to the Med/Surg Unit, room "i" on 05/14/12 at 8:00 p.m. (2000). Review of the "Office of Protective Custody" revealed Patient #8 was suicidal, danger to self, unwilling, and gravely disabled on 05/14/12 at 11:45 p.m. (2345).


Further review of the record reflected the patient (#8) resided in a room on the 3rd floor for 3 days from 05/14/12 through 05/17/12. This room had windows that were able to be easily opened for egress.


A tour of the Med/Surg Unit was conducted on 05/25/12 from 2:50 p.m. through 2:57 p.m. with the CEO (chief executive officer), S1 and CNO (chief nursing officer), S2. During this tour, room "a" and room "b" were both observed with two (2) small aluminum strips mounted on top of the window that secured the right windows shut. This was confirmed by both CEO and CNO. Further observation revealed room "c" had a window with a metal latch. At 2:50 p.m., the surveyor unlatched the window and it opened outward. Further observation revealed there was a roof noted below the window.


The CEO, S1 and CNO, S2, both observed the surveyor open the window at this time. The CEO, S1 indicated that is the first floor' s roof. S1CEO stated it is sixteen (16) feet from the window to the roof. S1CEO reported all 31 rooms on this unit have windows that can be opened. S1 indicated that as of this evening there has been three (3) rooms ("a", "b", and "d") designated for patients admitted to the unit who are PEC. S1 reported room "d" and the four (4) ICU beds' windows will be secured by maintenance tonight. The CEO S1 indicated all patients who have been PEC and admitted to the hospital will be admitted to the three designated rooms (a, b, or d) and/or on the ICU that have secured windows.


Review of the policy titled, "Suicide Precautions" effective date of 3/14/07, revised date of 1/2010, revealed it is the policy of the hospital to provide direct supervision for persons who are at high risk during the time of admission. There are three (3) suicide precaution levels, one to one, close observation, and line of sight. The procedure for the one to one criteria is as follows: a patient that has recently made a suicide attempt prior to admission. A patient voicing a suicidal ideation. A patient voicing feelings of hopelessness and helplessness and has a history of suicide attempts in the past. A patient voicing suicidal ideation and unwillingness to accept treatment. A patient expressing feelings of hopelessness. The definition of "One to One Observation" is keeping the patient at arms length and under direct observation at all times which includes the use of the bathroom and bathing. The patient must have staff at arms length at all times, whether the patient is in bed, in a chair, ambulating in the hall, in the bathroom or bathing. The patient is to never be left alone. One to One Guidelines must be signed by all staff that is sitting with the patient. Close Observation is defined as visual observation of the patient at all times, including bathroom and bathing. The definition of Line of Sight is when patients are potentially, but not immediately, at risk. Patients should be kept within site at all times, by day and by night.


Interview with S2, CNO on 5/29/12 at 11:00 a.m. revealed employees review the policies and procedures when they are hired. S2 further stated that if an employee has never provided care for a patient on one to one observation, then staff would review the policy with the staff member prior to the staff member sitting with the patient. S2, CNO stated that an employee sitting with a patient on one to one observation is required to sign a form prior to sitting with the patient. S2 stated that when a patient is placed on one to one observation, the staff member assigned to the patient is expected to remain at arm's length of the patient at all times.

















25059

25059


Based on record review and interview, the hospital failed to track adverse patient events as evidenced by failure to include a suicide attempt and elopement on the list of patient incidents tracked on the performance improvement.
Findings:

There was documented evidence of the adverse event regarding Patient #7 jumping from room "h" located on the 3rd floor of the Med/Surge Unit on 05/20/12 was being monitored, tracked/trended. Further review revealed there was no documentation the Med/Surge Unit regarding the windows were locked from 05/20/12 through 05/29/12. There was no documented evidence Patient #7 ' s incident that occurred on 05/20/12 was identified as an area that needed to be monitored, tracked and/or trended.

Review of Patient #7's medical record revealed she jumped from the window located on the 3rd floor of the Med/Surge Unit, room "h" and fractured her right ankle while ordered one to one observation that was not implemented by S3LPN on 05/20/12 at 11:25 p.m. (2325).


Review of the hospital's incident report log for the month of May of 2012 revealed Patient #7 jumped from the window of room "h" on 05/20/12 at 11:25 p.m. (2325) and fractured her right ankle.

In an interview on 05/29/12 at 2:45 p.m., QAPI (quality assessment performance improvement) S8 indicated there was no monitoring, tracking and/or trending of the Med/Surge Unit without locked windows from the day of the incident on 05/20/12 through 05/29/12. S8 further indicated there was no monitoring, tracking and/or trending of the adverse event regarding Patient #7 as of today, 05/29/12.

During an interview on 05/29/12 at 3:00 p.m., S2CNO (chief nursing officer) indicated there was no tracking/trending of the adverse event with Patient #7 from 05/20/12 through 05/29/12. The CNO further indicated there was no documented evidence of the monitoring, tracking and/or trending of the unlocked windows from 05/20/12 through 05/29/12. S2CNO stated this will be implemented as of today, 05/29/12.

25059

Based on record review and interview, the Registered Nurse failed to ensure the Nursery Nurses, S3 Licensed Practical Nurse, (LPN) and S4LPN were trained and experienced to provide ongoing assessment of the patient to remain in direct observation and in arms length at all times while providing one to one observation to Patient #7 as per the "Suicide Precaution" policy as evidenced by Patient #7 jumping from the window of room "h" located on the Med/Surge Unit, (3rd floor of the hospital) and sustained a complex, comminuted and multi-displaced fracture to the distal tibia with disruption of the ankle mortise (the hinge of the ankle) while S3LPN (Licensed Practical Nurse), was monitoring the patient on 05/20/12 at 11:25 p.m. (2325) for 1 of 9 sampled patients.

Findings:

Interview with S3, Licensed Practical Nurse (LPN) on 5/25/12 at 12:30 p.m. revealed she was the LPN who presented to duty on the night shift on 5/20/12. S3 indicated she works as a nursery nurse but the nursery did not have any patients on 05/20/12. The LPN, S3 stated she was scheduled to work from 11:00 p.m. to 7:00 a.m. and was assigned to provide one to one observation for Patient #7 on 05/20/12. S3 further revealed she was sitting inside of the patient's room ("h") at the "doorway" and was not within arm's length of patient as per policy. S3 stated she was not aware that she was suppose to be within arm's length of the patient at all times until after the incident occurred. S3 further revealed she had not been informed, prior to sitting with the patient, that she was supposed to sign a form describing (one to one observation), as per the hospital's policy.

Interview with S4, LPN on 5/29/12 at approximately 12:10 p.m. revealed she provided one to one observation for Patient #7 during the evening shift from 3:00 p.m. through 11:00 p.m. on 05/20/12. S4 stated she was a nursery nurse but the unit did not have a patient, so she began sitting with the patient on 5/20//12 at approximately 6:30 p.m. or 7:00 p.m. while the patient was in the emergency department, and she continued to provide one to one observation when the patient was transferred to the 3rd floor. S4 stated she was not made aware that she was supposed to sign a form prior to sitting with patients who were PEC'd and on one to one observation. S4 further revealed she did not know the hospital's policy regarding Observation Guidelines prior to the incident concerning patient #7 and she revealed she was not aware that staff was suppose to remain within arm's length of a patient when providing one to one observation. S4 confirmed she was not within arms length of the patient when she provided care to the patient on the 3rd floor on 05/20/12.

During a telephone interview with S6, RN on 5/29/12 at approximately 1:20 p.m., she revealed that she was the Charge Nurse on the night shift for 5/20/12. S6RN stated she worked from 11:00 p.m. to 7:00 a.m. but she had not received report prior to Patient #7's incident. S6RN revealed that whenever a staff member is assigned to sit with a patient who is on one to one observation, then the staff member is required to sign a form regarding observation procedures/guidelines prior to sitting with the patient. S6 confirmed she did not give S3 the form to sign pertaining to one to one observation for Patient #7.

Attempts were made to interview the evening shift Charge Nurse, S9, RN but the attempts were unsuccessful.

Review of the policy titled, "Suicide Precautions" effective date of 3/14/07, revised date of 1/2010, revealed it is the policy of the hospital "to provide direct supervision for persons who are at high risk during the time of admission. The definition of "One to One Observation" is keeping the patient at arms length and under direct observation at all times which includes the use of the bathroom and bathing. The patient must have staff at arms length at all times, whether the patient is in bed, in a chair, ambulating in the hall, in the bathroom or bathing. The patient is to never be left alone. One to One Guidelines must be signed by all staff that is sitting with the patient".

Interview with S2, CNO on 5/29/12 at 11:00 a.m. revealed employees review the policies and procedures when they are hired. S2 further stated that if an employee has never provided care for a patient on one to one observation, then staff would review the policy with the staff member prior to the staff member sitting with the patient. S2, CNO stated that an employee sitting with a patient on one to one observation is required to sign a form prior to sitting with the patient. S2 stated that when a patient is placed on one to one observation, the staff member assigned to the patient is expected to remain at arm's length of the patient at all times.

Further review of the medical record for Patient #7 revealed there were no forms noted in the record for staff members (S3LPN, S4LPN) assigned to provide one to one observation for the patient on 05/20/12.

25059


Based on record review and interview, the Registered Nurse failed to ensure the nursing care of each patient had competent nursing staff (S3LPN, S4LPN) assigned to provide one to one observation as per policy as evidenced by Patient #7 jumping from a window that was easily opened for egress and landing on the roof of the first floor sustaining a complex, comminuted and multi-displaced fracture to the distal tibia with disruption of the ankle mortise and extended into the tibiotalar joint with disruption of the ankle mortise (the hinge of the ankle) while being monitored by the Licensed Practical Nurse, (LPN), S3 on 05/20/12 at 11:25 p.m. (2325) for 1 of 9 sampled patients.
Findings:

Patient #7:

Review of the medical record for Patient #7 revealed the patient was a 28 year old female admitted for an overdose of Ambien and Xanax medications on 05/20/12. Review of the "Physician Emergency Certificate" dated/timed 05/20/12 at 6:15 p.m. (1815) revealed Patient #7 was a harm to self. The patient was admitted to the Med/Surg Unit, room "h" and was ordered 1:1 observation status by the admitting physician on 05/20/12 at 6:56 p.m. (1856).

Further review of the record reflected the patient (#7) resided in room "h" on the 3rd floor for one (1) hour and twenty (20) minutes. This room had windows that were able to be easily opened for egress. On 05/20/12 at 11:25 p.m. (2325), the patient jumped from the window and landed on the roof of the first floor. Patient #7 sustained a complex, comminuted and multi-displaced fracture to the distal tibia with disruption of the ankle mortise and extended into the tibiotalar joint with disruption of the ankle mortise (the hinge of the ankle).


Review of the personnel file for S3LPN revealed a hire date of 3/11/99. Review of the "Annual Evaluation" dated 04/25/12 revealed S3LPN's performance exceeds expectations under the section titled, "...V. Professional Expectations and Leadership...B. Demonstrates knowledge of Hospital and Nursing Policies and Procedures...2. Performs within limits of hospital policies and procedures...". Further review revealed the CNO (chief nursing officer), S2 reviewed the evaluation of S3LPN and strongly agreed that her job performance exceeded the expectations of the hospital on 04/03/12.


Review of the "Job Description for the Licensed Practical Nurse" for S3LPN revealed her job duties and responsibilities were to assists in providing nursing care to patient through use of the nursing process and functioned within limits of hospital and nursing department policies and procedures on 04/25/12.


Review of the personnel file for S4LPN revealed she was hired on 5/19/11. Review of the "Annual Evaluation" dated 12/03/11 revealed her "performance exceeds expectations under the section titled, "V. Professional Expectations and Leadership...B. Demonstrates knowledge of Hospital and Nursing Policies and Procedures...2. Performs within limits of hospital policies and procedures". Further review revealed S2CNO (chief nursing officer), reviewed the annual evaluation of LPN and strongly agreed that S4LPN's performance exceeded the expectations of the hospital on 11/15/11.


Review of the "Job Description for the Licensed Practical Nurse" for S4LPN revealed her job duties and responsibilities were to assists in providing nursing care to patient through use of the nursing process and functioned within limits of hospital and nursing department policies and procedures on 12/03/11.


Review of the policy titled, "Suicide Precautions" effective date of 3/14/07, revised date of 1/2010, revealed it is the policy of the hospital "to provide direct supervision for persons who are at high risk during the time of admission. The definition of "One to One Observation" is keeping the patient at arms length and under direct observation at all times which includes the use of the bathroom and bathing. The patient must have staff at arms length at all times, whether the patient is in bed, in a chair, ambulating in the hall, in the bathroom or bathing. The patient is to never be left alone. One to One Guidelines must be signed by all staff that is sitting with the patient".

Interview with S3, Licensed Practical Nurse (LPN) on 5/25/12 at 12:30 p.m. revealed she was the LPN who presented to duty on the night shift on 5/20/12. S3 stated she was scheduled to work from 11:00 p.m. to 7:00 a.m. and was assigned to provide one to one observation for Patient #7. S3 further revealed she was sitting inside of the patient's room ("h") at the "doorway" and was not within arm's length of patient as per policy. S3 stated she was not aware that she was suppose to be within arm's length of the patient at all times until after the incident occurred. S3 further revealed she had not been informed, prior to sitting with the patient, that she was supposed to sign a form describing (one to one observation), as per the hospital's policy.

Interview with S4, LPN on 5/29/12 at approximately 12:10 p.m. revealed she provided one to one observation for patient #7 on 5/20/12 during the evening shift. S4 stated she began sitting with the patient on 5/20//12 at approximately 6:30 p.m.or 7:00 p.m. while the patient was in the emergency department, and she continued to provide one to one observation when the patient was transferred to the 3rd floor. S4 stated she was not made aware that she was supposed to sign a form prior to sitting with patients who were PEC'd and on one to one observation. S4 further revealed she did not know the hospital's policy regarding Observation Guidelines prior to the incident concerning patient #7 and she revealed she was not aware that staff was suppose to remain within arm's length of a patient when providing one to one observation. S4 confirmed she was not within arms length of the patient when she provided care to the patient on the 3rd floor.

During a telephone interview with S6, RN on 5/29/12 at approximately 1:20 p.m. she revealed that she was the Charge Nurse on the night shift for 5/20/12. S6,RN stated she worked from 11:00 p.m. to 7:00 a.m. but she had not received report prior to Patient #7's incident. S6, RN revealed that whenever a staff member is assigned to sit with a patient who is on one to one observation, then the staff member is required to sign a form regarding observation procedures/guidelines prior to sitting with the patient. S6 confirmed she did not give S3 the form to sign pertaining to one to one observation.

Attempts were made to interview the evening shift Charge Nurse, S9, RN but the attempts were unsuccessful.

Interview with S2, CNO on 5/29/12 at 11:00 a.m. revealed employees review the policies and procedures when they are hired. S2 further stated that if an employee has never provided care for a patient on one to one observation, then staff would review the policy with the staff member prior to the staff member sitting with the patient. S2, CNO stated that an employee sitting with a patient on one to one observation is required to sign a form prior to sitting with the patient. S2 stated that when a patient is placed on one to one observation, the staff member assigned to the patient is expected to remain at arm's length of the patient at all times.

Further review of the medical record for Patient #7 revealed there were no forms noted in the record for staff members (S3LPN, S4LPN) assigned to provide one to one observation for the patient on 05/20/12.