HospitalInspections.org

The Condition of Participation for Patient Rights has not been met.

Based on a review of clinical records, facility documentation, facility policies, and staff interviews, for three (3) of ten (10) patients who were admitted to the Transitional Living Program (P#1, #10, and #11), the hospital failed to ensure a safe environment when one patient (#1) utilized an unauthorized electrical cord to commit suicide and staff failed to secure personal phone charger cords for two patients (#10 and #11) in accordance with hospital policy and that weekly environmental safety rounds were conducted in accordance with hospital policy.

Please see A144

Based on a review of clinical records, facility documentation, facility policies, and staff interviews, for three (3) of ten (10) patients who were admitted to the Transitional Living Program (P#1, #10, and #11), the hospital failed to ensure a safe environment when one patient (#1) utilized an unauthorized electrical cord to commit suicide and staff failed to secure personal phone charger cords for two patients (#10 and #11) in accordance with hospital policy and that weekly environmental safety rounds were conducted in accordance with hospital policy. The findings include:

1. Patient (P) #1's diagnoses included anxiety and depression. Review of the P#1's discharge summary dated 4/26/2020 from Hospital #2 identified that P#1 had several suicide attempts between January 2020 to when s/he was admitted to Hospital #2 on 4/13/2020 after expressing suicidal ideation. The discharge summary identified that the patient was deemed stable, ready for discharge from the acute psychiatric hospital, and was seeking placement in a transitional living program (TPL). P#1 was transferred from Hospital #2 and admitted to Hospital #1 on 4/26/2020.

Review of P#1's admission assessment dated 4/26/2020 at 4:15 PM identified, in part, that a Columbia Suicide Severity Rating Scale (CSSRS) was conducted and P#1 was assessed to be low risk for suicide. The record identified that a body search and a search of the patient's personal belongings was conducted with no contraband or sharps discovered. The inventory identified that the patient's valuables, including a cell phone and personal credit cards were collected and secured for the patient.

P#1 remained on Hospital #1's observation unit overnight, with safety checks maintained. On 4/27/2020 at 11:37 AM, Medical Doctor (MD) #1 evaluated P#1 and identified that the patient had a serious history of suicide attempts and was coming from an outside inpatient unit. MD #1's evaluation identified that P#1 was not expressing or exhibiting any acute mood or depressive symptoms or suicidal thinking. The evaluation identified that P#1 was tolerating Lithium (mood stabilizer), which was most recently added at Hospital #2 for suicidal ideation. Subsequent to the evaluation P#1 was deemed stable for transfer to the Transitional Living Program (TLP).

P#1 was transferred to TLP House #1 on 4/27/2020 at 1:20 PM. Upon admission to the TLP a Columbia Suicide Severity Rating Scale (CSSRS) was conducted on 4/27/2020 at 1:25 PM and identified that P#1 remained a low suicide risk.

Review of the P#1's treatment plan indicated that the patient's problems were related to anxiety, pain, sleep disturbance, mood disorder, and trauma. Interventions included group programs, tailored for the patient's ability to cope, including Dialectical Behavior Therapy (DBT), medication therapy, psychotherapy and standard patient safety checks per TLP policy which included safety checks at specified times of 7:00 AM, 9:00 AM, 12:30 PM, 3:45 PM, 6:45 PM and 9:45 PM, 11:00 PM and every two hours throughout the night.

Review of the patient's record for the period 4/27/2020 through 5/11/20, identified P#1 participated in group therapy and patient safety checks were conducted according to facility policy. The medical record described P#1 as stable with no mood symptoms.

According to the clinical record, a family meeting was held on 5/11/20. Review of the patient's record for the period of 5/11/2020 to 5/12/2020 identified that the patient verbalized that the family meeting was emotional, and s/he felt it went very well. The record identified for the remainder of the day P#1 participated in group programs and complied with patient safety checks as per his/her usual routine.

Review of P#1's record dated 5/12/2020 at 1:00 PM identified that the patient came to Social Worker (SW) #1, also a resident counselor, for skills coaching, for increased anxiety and suicidal ideation. P#1 reported having thoughts about "not wanting to be here, and if I die then I will stop this cycle of anxiety". The record identified that subsequent to engaging in skills coaching with the staff, the patient reported feeling better and his/her anxiety was lower. P#1 reported feeling safe on the unit and indicated s/he would come to staff if he/she had anymore suicidal ideation. A CSSRS screen was then conducted by SW#1 on 5/12/20 at 1:30 PM and the patient scored low risk with no intention or thoughts of suicide. Psychiatrist #2 (MD #2) was notified of the patient's statement, interventions and outcome of the interventions. The record dated 5/12/20 at 2:50 PM identified that Psychiatrist #2 reached out (via phone) to the patient's family therapist. P#1 resumed participation in group DBT therapy with Licensed Clinical Social Worker (LCSW) #2 at 3:00 PM.

Review of shift reports from SW #1 and Resident Counselor (RC) #5 for the remainder of the day, identified that the P#1 participated in groups and was compliant with all rules and guidelines with no further incidents to report.

Interview with Psychiatrist #2 on 6/5/20 at 1:15 PM identified that she was informed of the patient's statement and that the patient denied any SI. Psychiatrist #2 stated that she stayed in communication with staff and was aware that the patient was using coping techniques successfully to manage his/her anxiety. P#1 attended group therapy with the Psychologist and had no SI. Psychiatrist #2 stated that she felt the patient was safe with no suicidal ideations. Psychiatrist #2 stated that she did not feel that a face to face assessment was indicated that day, based on what was reported to her and P#1's current behavior, as she was seeing the patient the next day.

Review of the P#1's record dated 5/13/2020 identified that the patient did come to the staff for skills coaching in the morning after reporting that s/he woke up feeling anxious. SW#1 facilitated skills coaching with P#1. Subsequently P#1 attended community meetings, reported feeling physically good, and emotionally encouraged. P#1 spent leisure time using the telephone, going to the gym, and doing meditation.

Review of a progress note identified that Psychiatrist #2 met with P#1 for a psychotherapy session on 5/13/2020 at 7:32 PM. Review of Psychiatrist #2's notes identified that P#1 had been struggling with increased anxiety, felt lost because s/he believed his/her current anxiety invalidated his/her previous progress. Psychiatrist #2 facilitated therapeutic techniques to help P#1 see that struggles with negative emotions are a normal part of therapy. P#1 denied current suicidal ideation during the session and verbalized that although s/he felt anxious P#1 felt safe.

On 5/14/2020, P#1 was seen and evaluated by Psychiatrist #2. Psychiatrist #2 documented that P#1 was struggling with feelings of self-worth and identified that P#1 stated s/he felt that s/he was not excelling. Psychiatrist #2 identified that P#1was now at the state of distress that preceded his/her previous suicide attempts. Psychiatrist #2 identified that she would continue to challenge the patient's negative thoughts. Additionally, she adjusted P#1's medication regimen with an increase in Zyprexa (antipsychotic) from 2.5 milligrams (mg), at hour of sleep (HS), to 5 mg. at HS, and Venlafaxine (antidepressant) from 75 mg. to 150 mg. daily. The evaluation identified that P#1 expressed feeling anxious, had no delusions, and denied suicidal intentions or plans. No changes were made to the patient's level of monitoring or level of care at that time.

Review of the patient's record dated 5/15/20 identified that when P#1 expressed feeling anxious s/he sought out staff for coping skills coaching. P#1 was seen by Psychiatrist #2 on 5/15/20 at 5:32 PM at which time s/he denied suicidal ideation.

Review of shift report documentation dated 5/16/20 to 5/17/20 at 4:00 PM identified that P#1's patient safety checks were maintained, the patient participated in group programs, expressed goals for the day, and P#1" felt fine" and was stable.

Review of facility documentation (Faab) for 5/17/20 indicated the patient remained in the milieu (inside and on the grounds outside of his/her residence (House #1). The record identified that the patient did not sign out his/her cell phone on 5/17/20.

Review of the safety check documents identified that the patient's last check in was 5/17/20 at 3:30 PM.

Interview and review of the medical record with Resident Counselor (RC) #3 on 5/21/20 identified that on 5/17/2020, P#1 was socializing in the milieu at the 3:30 PM check. RC #3 identified that at approximately 5:40 PM he went to P#1's room to remind the patient of dinner. RC #3 stated that he knocked on the patient's door and there was no response, so he opened the door and called out to P#1. When P#1 did not respond he entered the patient's room and found P#1 hanging from the bathroom door with a cord around his/her neck. RC #3 immediately called for help, as he checked P#1 and found no pulse. RC#3 directed to call 911, Security Officer (SO) #1 arrived within seconds and attempted to lift P#1 off the door while directing RC #3 to get scissors. At the same time, nursing staff arrived, and they lifted P#1 off the door onto the floor. Cardiopulmonary Resuscitation began immediately. AED was applied, continuous oxygen was administered to the patient along with chest compressions which continued until rhythm checks were advised (at no point did the patient have a shockable rhythm). EMS arrived and took over the code. P#1 was pronounced deceased at 6:21 PM by EMS.

Review of the clinical record during the period of 5/13/20 through 5/17/20 and interview with Psychiatrist #2 on 5/21/20 at 12:15 PM identified that based on P#1's presentation, denial of suicidal ideation or intentions, and medication adjustments, Psychiatrist #2 stated P#1 was safe to stay in the environment of the TLP, and that no changes in safety monitoring was indicated. Psychiatrist #2 identified that subsequent to the family meeting, she acknowledged P#1's increased anxiety and met with P#1 more frequently.

Interview and review of the facility's investigation documentation dated 5/18/20 with Chief Quality Officer (CQO) #1 identified P#1's level of care and treatment plan provided the patient with privileges to leave the TLP house and enter other, authorized buildings, supervised by staff, for therapy groups and exercise. CQO #1 indicated P#1's personal belongings were searched upon admission and it was clear that P#1 did not have any cords in his/her personal belongings. The facility was unable to determine where the electrical household type cord came from as it was not part of the facility's usual equipment.

CQO #1 further stated that after the incident on 5/17/20, a search of TLP, House #1, was conducted and there was no evidence that electrical cords were accessible to patients. However, on 5/26/20 at approximately 10:00 AM, during documentation review with the Director of Safety and Security, CQO #1 and Risk Management, it was identified that the facility had not conducted weekly environmental safety audits in TLP House #1, where Patient #1 received treatment, since 12/2019. The facility was unable to identify why this had not been completed. Interviews further identified that if an extension cord was observed during rounds, the cord would have been removed as this type of cord is expected to be secured in the Residential Counselor's office as are charging cords and any power cords. It was also identified, during interview, that TLP House #1's annual safety audit for 2019 had no date to identify when it had been completed. The facility could offer no evidence as to when it had been completed.

The facility failed to conduct weekly environmental safety checks in TLP House #1, where Patient #1 received treatment, from approximately 12/2019 to 5/17/20 to ensure a safe environment.

Review of the TLP Environmental Safety Rounds policy identified that unit environmental rounds are walking rounds in the house conducted by the Senior Residential Counselor (or their designee) on a weekly basis.


2. Review of facility documentation dated 5/22/20 identified that a search of all resident TLP buildings and non-residential buildings accessed by TLP patients were searched on 5/22/20. Review of the search records identified that two phone charging cords were found in Patient #10 and P#11's rooms in TLP House #2.

a. P#10 was admitted to TLP, House #2 on 5/8/20 with a diagnosis of depression and admitted for substance abuse rehabilitation. Upon admission, the patient's belongings were checked, and his/her possessions included a cell phone. No chargers or cords were identified among P#10's belongings. The record identified that the patient's cell phone had been secured with the staff.

b. P#11 was admitted to TLP, House #2 on 5/14/20 with an admission diagnosis of depression and admitted for substance abuse rehabilitation. Upon admission, the patient's personal belongings had been checked and his/her possessions included a cell phone and charger. The record identified that the patient's cell phone and charger were secured with staff.

During an interview on 5/29/20 at 11:00 AM with Senior Residential Counselor (RC #4) of TLP, House #2, RC#4 was unable to identify how and why charging cords were found in Patient #10 and P#11's rooms, as all phones and devices (including charging cords) were collected on the patients' admission and secured in the staff office for safekeeping.

Review of facility documentation indicated that weekly environmental safety checks had been completed however the facility was unable to explain how the residents were able to obtain phone charging cords.


3. Review of the facility investigation of the incident on 5/17/2020, identified that after the P#1's body was removed from the room on the evening of 5/17/20, staff proceeded to pack P#1's personal belongings. The facility investigation identified that while packing P#1's belongings a spray bottle of cleaning disinfectant was found by staff in the patient's bureau.

Interview with the Director of Quality Improvement (QI) on 6/16/20 identified that she was the staff person who discovered the spray bottle in the patient's bureau behind his/her clothing. The spray bottle was identified as one of the facility's cleaning solutions. The Director of QI identified that through an investigation, she discovered that on 5/14/20 the Environmental Service (EVS) staff person for Building #1 reported that a cleaning solution bottle was missing from her supply caddy, and she reported this to the RC and EVS supervisor.

Interview with EVS staff #1 on 6/16/20 at 2PM stated that she noted a bottle of cleaner was missing from her caddy, she retraced her steps and when unable to locate she notified RC #10.

Interview with RC #10 on 6/16/20 at 2:30PM stated that s/he had no recollection of being informed that a bottle of cleaning solution was missing from her caddy.

The Director of QI identified that on 5/20/20 through 5/26/20, Residential Counselors were re-educated on a timely response and interventions to potential hazards brought to their attention by staff or patients. In addition, the EVS staff was reeducated on reporting and acting on missing items. The Director of QI identified that action steps taken by the resident counselor to mitigate such risks shall be documented in the incident reporting system. Additionally, future weekly safety rounds will include a query of the staff regarding the occurrence of incidents or reported concerns and the steps that were taken to mitigate the risk.

The facility lacked investigation that follow up on the missing cleaning solution had been completed upon identification that the solution was missing.

Review of the Hospital Patient Right's and Safety policies identified that the hospital would maintain a security management program to ensure overall safety of the environment.

The Hospital Policies further identified that the residential counselor staff will assist in the provision of a safe, therapeutic environment and safe handling, storage and distribution of all personal items that can cause harm. The policy identified that upon admission to the Transitional Living Program, all patient belongings are searched by staff.




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4. Based on clinical record review, interview and review of facility policy for one patient (Patient #1) in the Transitional Living Program (TLP) the facility failed to ensure that the treatment team was informed when the patient did not comply with the programs rules. The finding includes:

Review of Patient #1's (P#1) clinical record dated 4/27/20 identified that the patient was informed that the treatment team had approved the use of his/her own communication device (cell phone) as long as the patient abided by specific rules. Review of an acknowledgment form dated 4/27/20 identified that the P#1 was informed and agreed to the terms of the use of his/her phone including that the devices would be stored and charged in the residential counselor office, must be signed in and out at specific times, of the patients weekly schedule, and all devices would be used within one of the common areas of the building.

Review of the patient's record for the period of 4/27/20 to 5/16/20 identified that the patient utilized his/her cell phone, and was compliant with the signing in and out of the device and the rules and regulations of the TLP program

Interview with Residential Counselor (RC) #2 on 6/6/20 at 1:30 PM identified that the practice and policy for use of the cell phone, by a patient, directs that the patient must use the phone in a common area including the living room, lounge, or business area. RC #2 identified that on one occasion he observed P#1 in his/her room with the cell phone and the patient was redirected to comply with the regulations and to use the phone. P#1 immediately moved to the common area as instructed without incident. RC #2 was unable to recall the specific date that this had occurred. RC #2 stated that on one other occasion, again unable to recall the specific date, he observed the patient talking on his/her cell phone in his/her room. RC #2 stated that when he redirected the patient, s/he immediately complied and returned to the living room. RC #2 stated that he did not inform the treatment team of these incidents because it had not been a chronic issue.

RC #2 identified that on the night on 5/16/20 during the time period of 6:00 PM to 6:40 PM, when the patient signed out and used his/her cell phone he observed the patient in the common area during the initial use of the phone and although it is not a constant observation he did not observe the patient in his/her room with the phone on that day. RC #2 identified that patient returned the phone to him at 6:40 PM he checked the history for any Internet usage of that phone and there was nothing to report.

Interview with Psychiatrist #2 on 6/5/20 at 1:15 PM identified that she, along with the treatment team, approved the use of the patient's cell phone in accordance with the TLP and Building #1's protocols. The protocols specified the cell phone use rules, including that the patient was to use the phone at designated times that did not interfere with his/ her treatment plan and with the appropriate level of supervision. This included signing the phone in and out, using it in a common area, and the staff would review the browser history upon return of the phone. Psychiatrist #2 stated that she was not aware that the patient had used his/her phone in any other area outside of the identified common areas. She indicated that she would have expected that the treatment team be made aware when a patient breaks the rules. Psychiatrist #2 indicated that although the patient may have lost phone privileges, it would not have altered the patient's treatment plan.

Review of the facility's policy regarding cell phone usage identified that the access to personal cell phones is permitted with the approval of the treatment team and the patients cannot remove their device from the house.

The Condition of Participation for Physical Environment has not been met based on observations, review of hospital documentation, and interviews with staff. Several points of ligature hazards, breakable light lens in bedrooms and bath rooms, and tempered glass corridor windows, without security film, were identified throughout the Main House (acute unit of the hospital).

Please see A701

Based on observations in three (3) of seven (7) occupied residence buildings (Main, Main #2, Main #3), facility documentation review, and interviews, the facility failed to ensure patients resided in a safe, ligature free environment. The findings include:


Observations made on 05/20/20 and 05/26/20 at 9:00 AM, and times throughout the survey, the surveyor, while accompanied by the Director of Safety and Security, the Director of Quality Improvement and Risk Management, and the Chief Quality Officer observed the following:
a. The Main House 3 (Adolescent unit) and the Main House 2 (Adult unit) had patient sleeping rooms that contained shower rooms / bathrooms that had overhead lighting fixtures with glass lens that appeared breakable and posed a potential injury hazard. The lens were not designed or maintained to psychiatric institutional standards or Behavioral Health Design Guide Edition 9.0 November, 2019; i.e. light lens and internal portions of these lamp units shall be properly safeguarded from patients-permanent measures are required to be applied. Subsequent to this observation and staff interview of the Director of Safety and Security, the Director of Quality Improvement and Risk Management, and the Chief Quality Officer the facility ordered and was in the process of having all the light lenses and fixtures replaced.

b. The Main House 3 (Adolescent unit) had windows to common areas, the nurse station, and group rooms containing tempered glass that breaks into small shards when broken and pose a potential injury hazard, and elopement hazard. The tempered glass was not designed or maintained to psychiatric institutional standards or the Behavioral Health Design Guide Edition 9.0 November, 2019; i.e. no protective glazing or security film. Subsequent to this observation and staff interview of the Director of Safety and Security, the Director of Quality Improvement and Risk Management, and the Chief Quality Officer the facility has ordered security film for all the tempered windows in the main house.

c. The Main house shower rooms contained grab bars in the shower areas and bathrooms designed to psychiatric institutional standards and/or the Behavioral Health Design Guide Edition 9.0 November, 2019; however they were not maintained i.e. there were gaps along the inside which were not tight to the wall, leaving a space that could be used as a ligature point. Subsequent to this observation and staff interview of the Director of Safety and Security, the Director of Quality Improvement and Risk Management, and the Chief Quality Officer the facility has ordered pick proof institutional caulk to seal these gaps. Information was also received that the bathrooms are locked unless the patient has been assessed as to having no suicidal ideations.