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Based on record review, staff interview, staff written report review, staffing grid review, review of pictures, policy and procedure review, and document review, the governing body of the facility failed to ensure that the services performed by a contract Mental Health Technician (MHT) were provided in a safe and effective manner to prevent the neglect and self harm of Patient #1.

Findings include:

Cross Refer to A144 for the governing body's failure to ensure that the services performed by a contract MHT were provided in a safe and effective manner to prevent the neglect and self harm of Patient #1.

Based on record review, staff interview, staff written report review, staffing grid review, review of pictures, policy and procedure review, and document review, the adolescent psychiatric facility failed to ensure Patient #1 received care in a safe setting and Registered Nurse (RN) #1 failed to supply the supervision necessary to prevent Patient #1 or others access to a known safety hazard.

Findings include:


On 4/04/2018 the State Office Complaint Department received a complaint which stated:
"Date of Alleged Event: 03/28/2018 On Monday, April 02, 2018, the Department of Safety and Investigative Servcies was advised that, at approximately 2:15 p.m., (Patient #1) was noted to be actively cutting her left forearm while in her bed under the cover. Patient (#1) was on one to one observation due to her history of self injurious behavior and high elopement risk. At the time of this incident, MHT (#1) was assigned Patient (#1's) observation. ...painters were working in a time-out room on the female unit on the morning of 4/2/2018. They left on break at 10:45 and asked the unit nurse to lock the door. Later, the nurse advised that she had attempted to lock the door; however, the lock was not functioning properly. The room was left unsecured with the painter's supplies still inside. At some point, Patient (#1) entered the room and confiscated two putty knives. She hid them in her pants and later transferred them to her pillowcase. Around 2:15 p.m. MHT (#1) noticed that Patient (#1) was actively cutting herself. Patient (#1) handed over the putty knives. The nurse was alerted and immediately assessed Patient (#1). She was noted to have a "small cut" to her lower left forearm. Patient (#1) refused to allow the nurse to clean the area or dress it. She did allow the nurse to apply Bacitracin ointment to the open wound. Patient (#1) said that she got the putty knives out of the time-out room "after lunch". She said that her one-on-one staff, MHT (#1), was at the nurse's station when she got the knives. She hid them in her pants and then took them to her room and put them in her pillowcase. She said she walked up and down the hallway "for a couple of minutes," before going back to her room. Patient (#1) said she went back to her room, MHT (#1) came to her door and sat in a chair in the doorway. Patient (#1) said she was lying in bed under the cover and MHT (#1) saw her cutting herself and went to get the nurse."

On 4/10/2018 at 9:50 a.m. an unannounced visit was made to the Adolescent Psychiatric facility. A meeting was held with the Service Outcome Director. The reason for the visit was explained and the paper work required for the survey was asked for. The first floor of the psychiatric building is the female unit. MHT #1 was on Administrative leave and unavailable to interview. The Service Outcome Director stated that Patient #1 was on one on one observation when the incident happened. While on one on one observation a MHT must be no further than arm's length from the patient at all times.

A copy of the 4/3/2018 Work Request for the broken lock to Seclusion Room 1107 on the Female Unit Southside was reviewed. The status showed that the lock was fixed that same day as the request was made (4/3/2018). Seclusion Room 1107 was noted to be directly across from the nurse's station.

On 4/10/2018 at 10:20 a.m. the Service Outcome Director stated that patient accountability is done every 30 minutes on the building and bed checks are done at night.

Interview with Employee #1 on 4/10/2018 at 10:25 a.m. revealed that they had done in-services for staff and maintenance from 4/2 to 4/6/2018, and that Patient #1 is now on two on one observation. She stated that MHT #1 had been placed on Administrative leave because of the incident.

On 4/10/18 at 11:09 a.m. an interview was held with the Maintenance Director. He stated they got the repair request to fix the lock on Room 1107 on 4/3/2018 and had it fixed the same day. He stated that Maintenance received an in-service on 4/4/2018. Observation revealed the patient's room was greater than 12 feet from the nurse's station and the lock on Seclusion Room 1107 was fixed and in working order.

On 4/10/2018 at 11:10 a.m. an interview was held with the unit's RN Charge Nurse. She stated that she received a text message that the police were on the unit because a patient had knives. "I went into the time out unit to talk to her (Patient #1) and gave her paper towels to wipe her face. She was trying to run off the unit. I asked the patient what happened. She said that she got putty knives and scratched herself. We talked about better coping skills. She stated she was angry because the B shift nurse came and talked about her arms, about feeling angry and said that will pass, but there are scars. Said to use different coping skills." The Charge Nurse stated that she sent out text messages to upper management and the Risk Manager

On 4/16/2018 at 12:20 p.m. the facility was re-entered. An interview was held with Employee #2 regarding the reason for the visit. He stated that this is a Child Adolescent Psychiatric building. He also stated that the Service Outcome Director was on her way. At 1:15 p.m. an interview with the Service Outcome Director revealed that their building is an Adolescent Psychiatric building and is in no way associated with the state hospital's Medical Surgical hospital unless a patient gets sick and has to be transferred there. She submitted a copy of their license.

Record review for Patient #1 revealed she is a 16 year old female (DOB 4/26/2001) admitted to the Child Adolescent Psychiatric Building on 3/28/2018 with DMDD and Conduit Disorder. Has a history of self harm by cutting.

On 4/16/2018 at 1:15 p.m. the incident was discussed with MD #1. She confirmed that the patient is a cutter, the incident did happen, the MHT was terminated, the door was fixed, and in-services were given to all staff members and maintenance.

The MSH Investigative Findings done by the IPS Nurse Administrator, dated April 9, 2018, were reviewed. The findings included:
Maintenance Employee #1 - Misconduct - Substantiated - Administrative Leave
Maintenance Employee #2 - Misconduct - Substantiated - Administrative Leave
Neglect by RN #1 - Substantiated - Administrative Leave
Neglect by MHT #1 - Substantiated - Administrative Leave/Terminated
The findings stated that the " ...painters asked RN (#1) to lock the time out room door after they left on break; however they left the unit without ensuring that their tools were secured. RN (#1)determined the lock on the time out door was not functioning properly. She was aware the painters had left their supplies assuming she was locking them up. She failed to remove the supplies to a safe location, failed to post an employee at the door to ensure no patient could gain access to the equipment, and failed to communicate to staff members that the painters left their equipment in a room on the South Side Unit that was not securable. RN (#1) failed to supply the supervision necessary to prevent Patient (#1) (or others) access to a known safety hazard. Neglect by RN (#1) was substantiated ...".

Review of the facility's Shift A Staffing Grid for 4/2/2018 revealed that Patient #1 was 1:1 with MHT #1 at the time of the incident.

Review of the 4/2/2018 written statement by Maintenance Employee #1 from the maintenance paint shop revealed, "Before leaving for lunch we asked the nurse if she could lock the door or did we need to take our stuff with us. She said she could lock it and came over to do so before we left. So afterwards we left for lunch."

Review of the 4/2/2018 written statement by RN #1 regarding the 4/2/2018 incident revealed that she was not aware that the painters had left their tools in the unlocked seclusion room when they went on break.

Review of a 4/3/2018 1:05 p.m. Social Service Note revealed that the patient told the Social Worker that the reason she stole the scrapper was so that she wouldn't have to leave Whitfield. She is hoping she will go to the other building when she turns 17. "Patient appears to believe that if she acts out, she will be transferred to female receiving. Patient wants to be closer to a patient or patients on female receiving that were previously on Oak Circle."

Review of the facility's Patient Observation Policy revealed the definition of one to one observation is "the constant observation of a patient by a staff member for the purpose of continuously monitoring the patient's behavior and/or medical condition ... Patient (on one to one) will not be left unattended for any reason, and the observer must be able to see the actions of the patient assigned ... the staff member will remain just outside the patient's arm length while the patient is awake ..."

Other items Reviewed:
Picture of Injury
Picture of tools used to inflict injury
Non-Medical Equipment Repair Policy
Hazard Surveillance Program/EOC Tours Policy
Patient Accountability Policy
Maintenance Inservice

On 4/16/2018 at 2:00 p.m. an Exit Conference was held with the Service Outcome Director and Employee #1. The findings were discussed. Nothing else was submitted for review.

Based on record review, staff interview, staff written report review, staffing grid review, review of pictures, policy and procedure review, and document review, the psychiatric facility failed to ensure the Registered Nurse (RN) supervised the care of Patient #1 to prevent neglect and self harm and failed to supply the supervision necessary to prevent Patient #1 or others access to a known safety hazard

Findings Include:

Cross Refer to A144 for the facility's failure to ensure the RN supervised the care of Patient #1 to prevent neglect and self harm and to prevent Patient #1 or others access to a known safety hazard.

Based on record review, staff interview, staff written report review, staffing grid review, review of pictures, policy and procedure review, and document review, the psychiatric facility failed to ensure they had an effective system in place to prevent the neglect and harm of Patient #1.


Findings Include:

Cross Refer to A144 for the facility's failure to ensure they had an effective system in place to prevent the neglect and harm of Patient #1.