HospitalInspections.org

Based on record review, video surveillance, and staff interview, it has been determined that the hospital failed to provide nursing services which ensures all observation safety protocols were followed and implemented, and that patient care plans were reviewed and revised as required for 1 of 1 patient who engages in intentional swallowing of foreign objects, (Patient ID #1).

Findings are as follows:

1. The hospital failed to ensure staff who were assigned to a patient for constant observation, ensured the safety of the patient, and adhered to the "Categories of Observation" policy (Refer to A-0398).

2. The hospital failed to follow their policy "Interdisciplinary Treatment Plans", regarding the failure to update Patient ID #1's plan of care upon return from the medical hospital on 10/13/2023, following an episode of intentional swallowing of a foreign object.

Based on record review and staff interviews, it has been determined that the hospital failed to ensure nursing staff develop and keep current the nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs for 1 of 1 patient care plan reviewed regarding the intentional swallowing of foreign objects (Patient ID #1).

Findings are as follows:

The Hospital's policy titled, "Interdisciplinary Treatment Plans" effective 3/9/2021 states in part,

"I. Purpose:
The purpose of this Interdisciplinary Treatment Plans policy is to establish an interdisciplinary team care planning process to ensure that patient care and treatment is planned appropriately for the patient's needs and severity of condition, impairment, illness or disability.

...III. Policy:
It is the policy of Butler Hospital to ensure that an interdisciplinary care plan is developed for each patient and that each discipline involved in the care of the patient must participate in patient assessment and propose a joint approach toward achieving the goals and interventions set for the patient.

V. Procedure:
1) Treatment planning and patient care are performed by a clinical team which is headed by a physician and includes members of the nursing staff, social service clinicians, occupational therapists, psychologists, dietitians, and various medical and other consultants".

Record review for Patient ID #1 revealed s/he presented to the hospital in June of 2022. Diagnoses include, but are not limited to developmental delay, borderline personality disorder, pseudotumor cerebral s/p shunt, psychogenic non -epileptic seizure and epilepsy. The patient has a history of swallowing foreign objects. S/he also has had multiple admissions to this hospital.

Record review revealed that Patient ID #1 had swallowed a battery on 8/28/2023 and was sent to Rhode Island Hospital. The patient returned to Butler hospital on 9/1/2023.

On 10/3/2023 a physician progress note revealed that Patient ID #1 reported to staff that s/he again had swallowed a battery. The patient was again sent to the Rhode Island Hospital where it was confirmed that s/he had swallowed a battery. Patient ID #1 returned to Butler Hospital, however, after failing to pass the battery naturally s/he was sent back to Rhode Island Hospital on 10/11/2023 for removal of the battery and was discharged back to Butler Hospital on 10/13/2023.

On 11/27/2023, the State Health Department received an incident report identifying that Patient ID #1, who was on constant observation had again swallowed a battery. A federal incident investigation was initiated.

Review of Patient ID #1's current care plan dated 10/13/2023, when the patient was previously seen at Rhode Island Hospital for swallowing a battery, failed to reveal a care plan relative to the patient's known history of intentional swallowing of foreign objects.

During an interview with the Risk Manager regarding the current care plan and the lack of identifying the patient's intentional swallowing behaviors, she was unable to produce evidence that the plan of care had been updated after the patients last incident of swallowing a foreign object.

Based on record review and staff interviews, it has been determined that the hospital failed to ensure nursing personnel follow hospital policies relative to ensuring the safety for 1 of 1 patient with intentional swallowing of foreign objects who was on constant observation and swallowed a battery resulting in an unintended medical procedure. (Patient ID #1)

Findings are as follows:

The hospital's policy titled, "Categories of Observation" effective 8/10/2021 states in part,

"...1) Constant Observation shall be ordered for any patient who needs to have a staff member with him/her at all times ...

a. An assigned staff member must be with the patient at all times, including in the bathroom.

b. The staff member must be able to visually observe the patient at all times and be able to quickly intercede should it become necessary ..."

Record review revealed that Patient ID #1, who presented to the hospital in June of 2022. Diagnoses include, but are not limited to developmental delay, borderline personality disorder, pseudotumor cerebral s/p shunt, psychogenic non-epileptic seizure and epilepsy. Patient ID #1 also has a history of intentional swallowing of foreign objects.

Record review revealed that the patient had swallowed a battery on 8/28/2023 and was sent to Rhode Island Hospital, then returned to the Butler hospital on 9/1/2023.

On 10/3/2023 a physician progress note states that patient reported to staff that s/he had swallowed a AAA battery from the TV remote control around 6:30 AM, during which time she was on constant observation. The patient was sent to the Rhode Island Hospital, and it was confirmed that s/he swallowed a battery. The patient was sent back to Butler Hospital, however after failing to pass the battery naturally, s/he was sent back to Rhode Island Hospital on 10/11/2023 for the removal of the battery.

Record review completed on 11/29/2023 revealed Patient ID #1, had intentionally swallowed a battery from a TV remote control. It was identified that this is the third time in approximately 3 months that the patient had obtained and swallowed a battery while under the supervision of the Butler Hospital staff.

During a surveyor interview on 11/29/2023 at 2:40 PM with the unit Nurse Director, she informed the surveyor that the patient had just been transferred to her unit and that all staff were made aware that the TV remote controls are to only be used by the staff and not given to patients. Additionally, she stated that the Mental Health Workers are assigned to cover the constant observation for one hour at a time, on a rotating basis for any patient on constant observation.

The Nurse Director provided a copy of the schedule for the incident date of 11/27/2023. This schedule identified Staff C, a Mental Health Worker as having Patient ID #1 as her constant observation assignment. The 11/27/2023 second shift schedule, revealed the following constant observation coverage for Patient ID #1:

-Staff C was assigned the 1-1 coverage from 3:30-4:30 PM, 5:30-6:30 PM and 7:30-8:30 PM.
-Staff F was assigned the 1-1 from 4:30-5:30 PM and from 8:30-9:30 PM.
-Staff E was assigned the 1-1 from 6:30 -7:30, however she had to leave, and Staff D was assigned from 6:30-7:30 per the unit director.

A review of the surveillance video with the Risk Manager on 11/30/2023 revealed the patient and the constant observer on the unit.
-Staff D, a Mental Health Worker was observed with the patient between 6:30 - 7:30 PM. Staff D is seen taking the TV remote from behind the nurse's station, holding it in his hand and walking with the patient to the Sensory room around 7:10 PM where they remained.
-At approximately 7:30 PM Staff C is observed going into the Sensory Room where the patient and Staff D were watching TV.
-Staff D is observed leaving the Sensory Room without the TV remote control.
-8:05 PM, Staff C is observed exiting the Sensory Room with the patient who has the TV Remote Control, and they go into the kitchen for a short time.
-Upon leaving the kitchen the patient is seen handing the TV remote control to Staff C.
-7:45 PM, Staff F is observed with the patient check board to document the 5-minute checks.
Staff F is observed standing in front of the Sensory Room looking into the room to complete the check for Patient ID # 1.

During an interview with Staff D, a per diem Mental Health Worker, on 11/30/2023 via phone, he stated that when he came to work on 11/27/2023, he was on R-3 unit, until approximately 4:30 PM, then moved to the L-2 unit to replace a worker who had gone home. He states he assigned to cover the constant observation for Patient ID # 1 from 6:30-7:30 PM. He stated that the patient wanted to go into the sensory room to watch TV, so when the room was available, he went to the nurses station and took the TV remote control and went to the Sensory room with the patient. He stated the TV remote had tape on it covering the area to the battery compartment. He stated once the patient chose a channel, he placed the remote control on the arm of the chair that he was sitting in. At 7:30 when Staff C arrived to take over the constant observation coverage, he reported to her and left the TV remote on the arm of the chair.

During an interview with Staff C on 11/30/2023 at 1:10 PM, via phone in the presence of the Risk Manager and Unit Director, she informed the surveyor that she presented to work at 3:00 and was assigned to constant observe Patient ID #1. She stated she covered the constant observation as scheduled from 3:30-4:30 and again from 5:30-6:30. Upon her return from dinner to the patient at 7:30 PM she noted the patient and Staff D were in the sensory room watching TV. She stated that the patient had the TV Remote which was "taped up". She stated they remained in the Sensory Room for approximately another half hour and then went to the kitchen. The patient asked to go to her room, she stated she returned the TV remote to the nurse's desk. Staff C stated the patient then told her s/he had swallowed the battery from the remote. She stated that she did not give the TV remote to the patient and did not see him/her remove the battery or swallow the battery.

During an interview with Staff F, a Mental Health Worker, on 11/30/2023 at approximately 11:35 AM, she stated that she was assigned to complete the 5-minute checks between 7:30-8:30 PM. She stated that while doing the 5-minute checks, she saw Patient ID #1 with the TV remote in her hand while in the Sensory Room with Staff C. She acknowledged that she knew that only staff was to have the TV remote, however she didn't say anything because Staff C was with the patient.

During surveyor interview with the Risk Manager and the Unit Director on 11/30/2023 at approximately 3:10 PM after viewing the video and completing staff interviews, both were unable to explain how Patient ID #1 who was on constant observation was able to obtain and swallow the TV remote battery without staff knowledge. The Unit Director informed the surveyor that per policy, staff assigned to constant observation need to be able to observe the patient visually at all times and quickly intercede if necessary. She stated that the staff have all been educated about patients not having the TV remote controls.