HospitalInspections.org

Based on review of records, policies and procedures, tour and observation of units, nurse staffing records, interviews, and personnel files it was determined that the facility failed to ensure a safe environment for the patient which subsequently resulted patient's self harm.

A qualified surveyor made an unannounced on-site visit to this facility to investigate the complaint on 6/20/2016 through 6/23/2016.

Facility policy #006 entitled "Patient's Rights and Responsibilities" , last revised 12/9/14, revealed that the patient has the right to expect reasonable safety ensured by the hospital practices and environment.

Facility policy #F-025 entitled "Managing the Patient With Potential For Violence" , last revised 1/23/15, addressed the following:

1. Signals that may indicate the patient is losing control or may be potentially dangerous.
2. Facial expression; may be tense, hostile looking, looking around as though trapped or frightened.
3. Paranoid; may be suspicious and guarded in conversation and take issue with any comments made.
4. Agitation; appears to feel easily criticized, restless, irritable, trapped, frightened.
5. Alcohol/drug intoxication; may be demanding of drugs, especially if having a withdrawal.
6. Psychotic hallucinations/delusions; a potentially violent situation due to feeling frightened, confused or cornered.
7. Hostility or suspiciousness.
8. Posture; body movement, appearance, manner, affect, voice, directional pacing.
9. Threats to self or others.
10. Possession of any kind of weapon.
11. Refusal to respond to requests.

Facility policy #F-045 entitled, "Guideline for Mental Health Patients" (including Suicidal, Substance Abuse, and Violence), last revised 8/5/15, revealed that staff will implement the following precautions on inpatient units while caring for mental health patients:

· Patients' rooms and property will be searched to prevent harm to patients.
·Meals will be served on non-glass plates with plastic utensils.
·Unnecessary equipment will be removed from the patient's room.
· Bottles of alcohol or other toxic substances will be removed from the patient's room.

Review of a blank safety check sheet entitled, "Inpatient Checklist for Reducing Risk of Suicide and Deliberate Self-harm or Staff Harm" revealed that environmental safety checks would include movable equipment.

A phone interview was conducted with RN #1 on 6/21/2016 at 3:45 p.m. RN #1 stated that patient rounding involves ensuring that the patient is safe and attending to patient needs. Rounding is done every other hour for nursing and every other hour for technicians. Nurses and technicians alternate. Rounding is the same on the day shift and the night shift. RN #1 stated that assessing for safety included making sure the room is clear of anything the patient could use for self-harm themselves with. RN #1 stated that patient assessments are done twice a shift. RN #1 stated that as part of a full assessment, patients are asked if they are having any thoughts of harming themselves or a plan to harm themselves. RN #1 stated that Patient #1 had denied any thoughts of self-harm. RN #1 further stated that that upon hearing Patient #1's sitter scream, staff ran to the patient's room. RN #1 stated that a co-worker went to the window and tried to grab the patient but was unsuccessful.

A phone interview with RN #2 was conducted on 6/21/2016 at 3:47 p.m. RN #2 stated that patient rounding is done every other hour alternating between nurses and technicians. RN #2 stated that patients are assessed by the nurse for suicidal and/or homicidal ideations twice a shift and as needed. When asked about environmental checks for 1013 (involuntary psychiatric hold) patients, RN #2 stated that staff observe the room and ensure that there is nothing dangerous and potentially harmful to the patient, caregivers or visitors. Concerning the events pertaining to this complaint, RN #2 stated that he/she ran to the patient's room after hearing a loud bang. Upon arriving at the patient's room, RN #2 saw the sitter and a combative patient. RN #2 stated that the patient was standing on the air conditioner holding the blood pressure machine (a machine used to measure blood pressure). When asked by RN #2 to step down, the patient put one foot into the window launched himself/herself off the window. RN #2 caught the patient's ankles and held on for a couple of seconds. RN #2 was unable to maintain the hold on the patient and the patient fell.

Interview with Sitter #5 was conducted on 6/22/16 at 10:47 a.m. in a conference room at the facility. Sitter #5 stated that initially, the patient was sleeping. After waking up the patient appeared agitated, was moving around, tossing and turning. The patient repeatedly took his/her glasses off and would stand up and sit back down. The patient grabbed an empty cup as though there were something in the cup. Sitter #5 stated that he/she asked if the patient needed anything, but the patient would not respond and just stared. Sitter #5 stated that the patient then jumped up forcefully and snatched the blood pressure machine. Sitter #5 stated that he/she ran out of the room and yelled for help three times. A male nurse approached. When Sitter #5 and the male nurse stepped back into the room, the patient was standing in front of the window. Sitter #5 further explained that the patient hit the window twice with the blood pressure machine. Sitter #5 described how part of the blood pressure machine was stuck in part of the window, and the rest of the glass in the window was broken. Sitter #5 stated that he/she and the nurse asked the patient not to jump, to come down, saying to the patient, "you don't have to do this". Sitter #5 stated that the male nurse reached for the patient and was uncertain if the nurse grabbed the patient's legs or missed. Sitter #5 stated that he/she "blinked" and when his/her eyes opened, the patient had jumped.

A follow-up interview was conducted with RN #1 on 6/23/2016 at 6:35 p.m. in a conference room at the facility. RN #1 stated that he/she recalled that the patient was mostly calm prior to the event. The patient was asleep at the beginning of RN #1's shift.
RN #1 stated that he/she asked the patient how the patient was feeling and whether the patient had thoughts about suicide. RN #1 stated that the patient responded that he/she had regrets about what he/she had done (attempt to commit suicide). RN #1 stated that he/she had documented the suicide ideation assessment in the patient's medical record and selected 'appropriate to situation, cooperative' . RN #1 stated that the patient said he/she was ready to go home. The RN stated that the patient was calm and respectful and that the patient's sitter had told him/her that the patient was restless, tossing and turning.

Nursing documentation in the medical record for Patient #1 revealed that on 5/9/16 at 11:57 p.m., Patient #1 was resting in bed with no complaint of chest pain or shortness of breath. Vital signs were stable. The patient's behavior was documented as appropriate to the situation.

Review of the unit staffing plan for 5/1/16 through 5/14/16 revealed that the unit was adequately staffed for the patient census.

The following observations were made during a tour of unit six (6) central on 6/20/16 at 1:34 p.m.:

·One central nurses' station with three corridors (entrances leading to patient bedrooms).
·The window in room 621 measures 65x39.5 inches as measured by the facility's engineer.
·The lower part of the window measures 46 inches wide. This lower window is sealed closed by four steel screws and adhesive corking. The Facility Services Manager explained that because of concerns regarding the heating and air conditioning system and infection control concerns, a decision was made long ago to seal the lower portion of all hospital windows.

Equipment check documentation dated 6/1/15 to 5/30/16 indicated that inspections of all doors, windows, and hardware were completed by facility engineer's department personnel.

Documentation detailing the interventions that had been made by facility engineers was given to the surveyor.

Review of personnel training for employees (#1, 2, 3, 4, 5, 6, 7, 8 and 9) revealed that all had current training in managing the patient with potential for violence.