HospitalInspections.org

Based on clinical record reviews, policy and procedure reviews, hospital quality activity review, staff interviews, observations, and reviews of video camera tapes, it was determined:

A0395:

a. For one patient (Patient #2), the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for a behavioral health patient identified to be at risk for elopment.

b. For nine patients (Patients #3, 4, 5, 6, 7, 8, 9, 10, and 11), the hospital failed to ensure the observation checks conducted every 15 minutes on the behavioral health unit was adequate to ensure the patients' health, safety, and well-being.

c. For three patients (Patients #5, 6, and 10), the hospital failed to ensure that the observation checks on the behavioral health unit were conducted every 15 minutes.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of qualtiy health care in a safe environment.

Based on record review, policy and procedure review, hospital quality review records, staff interview and observations, it was determined:

1. For one patient (Patient #2), the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for a behavioral health patient identified to be at risk for elopement.

2. For nine patients (Patients #:3, 4, 5, 6, 7, 8, 9, 10, and 11), the hospital failed to ensure the every fifteen minute observation checks on the mental health unit was adequate to ensure the patients' health, safety, and well-being.

3. For three patients, (Patients #5, 6, and 10), the hospital failed to ensure that the observation checks were made on every patient every fifteen minutes.

Findings include:

In accordance with regulatory reporting, the hospital self-reported to the appropriate Department agency, an incident that occurred on their Palo Verde Mental Health Unit involving Patient #2. The report included: "At 1600 hrs patient was attending Coping Skills Group out on the patio located off the day room on the West Unit with other patients and BHT (name). BHT (name) reported the patient was disruptive to the group and she asked patient to return to the unit. Patient went back on the unit and the group continued. Shortly after RN (name) went to the patio and informed BHT (name) that staff were unable to locate (Patient #2) after checking the unit. BHT (name) nor any of the other patients participating in the group saw the patient climb the wall." Documentation in the report revealed the patient was found coming down the elevator from the top floor of the parking garage and was returned to the unit. The report included their actions taken to prevent a similar incident from occurring in the future and included: "Patient was placed on a 1:1 level of observation. The patio located off the dayroom in the West Unit will no longer be utilized for patient activities until made secure."

The hospital's policy and procedure on the subject of Behavioral Health One-to-One Monitoring, Procedure # 16.04.08 included: Visual checks every 15 minutes by an assigned staff member will be initiated on all new admissions and maintained for the patient's length of stay. If, based on clinical assessment a patient requires a higher level of observation, the RN may implement 1:1 observation and notify the physician within 1 hour of starting the intervention. 1:1 observation will be initiated when a patient is at risk for harming themselves or others or when the patient's behavior becomes disruptive to managing the milieu."

The hospital's policy and procedure on the subject of Suicidal Patient Protocol for Palo Verde Hospital, Procedure # 16.04.14, included: "The suicidal patient protocol is expected to assess the seriousness of the patient's threats. The protocol will be used to identify nursing responses appropriate to the level of threat identified and the prevention of self-inflicted harm...Apply appropriate actions necessary to secure the patients' retention in the hospital. The patient remains on the locked unit at all times until the risk of suicide or suicidal behavior has decreased...Master Treatment Plan will indicate level of observation and safety issues...document the patient's behavior, nursing interventions, and evaluation of interventions on the daily progress note...."

1. Documentation in Patient #2's clinical record revealed he was admitted to the hospital's mental health unit, Palo Verde, from the Emergency Department on 3/24/2011 at approximately 10:30 a.m. with diagnoses that included psychosis and behavior changes.

The Registered Nurse's first admission note (timed 12:19 p.m. and filed 12:42 p.m.) included: "...Pt arrived from annex at approximately 10:30...admitted under a T-36 petition as dto/dts (danger to self/danger to others)...Pt has been irrational, agitated, and very delusional with religious preoccupation...Pt has poor insight. Pt was cooperative with initial intake process, however, he has since been redirected for going into other patients rooms and taking there(sic) things. Pt was redirected with out incident. Pt has also been asking to go outside And was trying door, he is considered an awol (absent without leave) risk...." The psychiatrist's progress note dated 3/24/2011 at 12:43 p.m. included: "Met with pt and found him very psychotic and disorganized in his thought process and content...Unable to gather any meaningful hx (history) from him at this time...I will continue the evaluation tomorrow...." At 4:22 p.m. the RN filed an addendum to the original admission note. The RN's addendum included: "Pt began to escalate this afternoon pounding on his wall demanding to see his 'children adam and eve'. Pt was threatening to this Rn if I did not leave the room or immediately bring his children here. Pt was redirected by male BHT (Behavioral Health Technician) who took pt outside to deescalate. Pt is very delusional grandiose in nature with religious preoccupation. Pt attempted to scale the west unit patio wall, however was unsuccessful...Dr. (name) was notified...." There was no other documentation that provided more details of the unsuccessful attempt such as which wall of the patio the patient attempted to scale and specifically how the patient made the attempt. There was no documentation that the hospital followed up to determine if there were any areas on or around the wall and/or gate that may lead to a successful attempt by this patient or any other patient. There was no documentation in the patient's Care Plan that the patient was identified to be at risk for AWOL at that time nor documentation of the incident after he successfully went over the wall.

A Psychiatric Progress Note dated 3/25/2011 at 12:17 p.m. included: "Patient is very disorganized, very psychotic...he is intrusive, needing constant redirection from staff...Behavior: cooperative, restless and hyperactive...Judgment: severely impaired...." The Psychiatric Progress Note dated 3/26/2011 at 12:46 p.m. included: "Continued DTS/DTO-safety issues...Anticipate acute regression without continued inpatient care...No less restrictive environment is available to ensure the patient's safety and the patient is on petition for DTS/DTO...He is still severely psychotic and delusional...He wants the petition to be dropped so that he can go home. He continues to have poor insight...He is refusing to stay in the hospital on voluntary basis and is refusing to acknowledge he has a mental illness or need for treatment and needs to be continued on petition...."

The physician admission orders included "Suicide Precautions." Documentation in the record revealed the patient's observation status at the time of admission was every fifteen minutes and documented on forms titled West Day, West Evening, and West Night Q (every) 15 Min Rounds. Documentation on the forms revealed the patient was observed in the patio as follows: 3/25/2011 at 9:45 a.m., 10 a.m., 4:30 p.m. and 9:45 p.m.; and 3/26/2011 at 12:30 p.m. Pre-printed documentation on the bottom of the forms included "PROGRAM PRECAUTIONS: AWOL-awol risk; SR risk...." There was no documentation on the forms that Patient #2 was an AWOL risk until 3/26/2011 after the successful elopement.

Documentation in a BHT progress note dated 3/26/2011 at 5:24 p.m. included: "Pt ate all meals on the unit, did not attend morning group, but did go out on the patio several times today...In the late afternoon this writer was facilitating a coping skills group which Pt. came out to several times and disrupted conversations. When this writer redirected Pt, Pt left the group and headed back into the building. That was the last time this writer saw Pt before he eloped from the unit. Pt was brought back by security about 20 minutes after his elopement. Hygiene and appearance is fair...."

A Security Services internal report of the incident included the following: "On 03/26/2011, I...was dispatched to the northeast parking garage in reference to a suspicious individual with no shoes and a hospital band on. Shortly after my arrival at the northeast parking garage I was advised that the individual I am looking for is a petitioned patient from Palo Verde Hospital west unit. S/O (Security Officer) (name) and I made contact with the individual bottom level of the elevator southeast corner of the garage...I escorted the patient...back to the west unit with no problems. Once on the west unit, BHT (name) advised me that she was giving a group lesson in the court yard right outside the day room. The petitioned patient...was not part of the group lesson. BHT (name) stated she not see the patient jump the northeast corner wall of the court yard do (sic) to the fact that her back was turned towards the petitioned patient. Staff also advised me that they had the door leading out to the court yard from the day room propt (sic) open. Several pictures were taken of the wall the patient used to jump up to pull himself up and get over the wall using the ledge...."

A review of the BH (behavioral health) Adult Daily Assessments revealed an RN assessment completed at 9 a.m. The RN documented in the Safety section of the assessment that the patient was on "Suicide" precautions. Interventions were "Dayroom observation; ID band on." Visual checks were "Q15 min." The RN documented at 2:51 p.m., "Unchanged Assessment." There was no documentation that the RN assessed the patient after the elopement incident. The next RN assessment was documented at 9 p.m. on the next shift.

The surveyor requested hospital administration to provide documentation of their actions after the incident to prevent a similar event happening in the future, and the surveyor was advised that staff were told the only patio to be utilized for patient access was the centrally located courtyard. The surveyor was told no modifications were made to the West Unit patio nor were there any policies that addressed patient use of outside areas.

An interview was conducted on 10/25/2011 at 12 p.m. with the Director of Nursing of Palo Verde. Her documented investigation of the incident as well as the Security Services Incident Report were reviewed during the interview. The surveyor asked the Director to explain the reference in the Security Services report that the BHT reported the door had been propped open from the inpatient hallway to the outside patio which was not mentioned in the clinical record nor in her report. The Director stated staff propped the doors open so patients would be free to come and go. She acknowledged Patient #2 would not have been outside if the door had not been propped open. She stated during interviews that there were no policies or procedures that addressed the Program Precautions referred to in the Q15 min Rounds forms including AWOL risk, suicide risk, etc. The Director also acknowledged during the interview that there was no documentation that the patient was assessed by the RN when he was returned to the unit after eloping nor was there documentation in the patient's care plan that addressed his AWOL risk.

Observations were made of the centrally located courtyard of the Palo Verde Mental Health Unit on 10/25/2011. The surveyor was accompanied by the Director of Palo Verde, the Director of Nursing, and the hospital's Director of Clinical Practice. One of the doors from the in-patient unit hallway was propped open with an unsecured chair, and another unsecured chair was observed outside of one of the other unit hallways. There was a group activity being conducted by a staff member in the courtyard at the time of the observation. The Director of Nursing and the Director of Palo Verde acknowledged the door was propped open, and that there were two unsecured chairs in the courtyard which could be moved and used in an attempt to go over the walls.

Patient #2 was identified at the time of admission to the psychiatric unit on 3/24/2011 to be at risk for elopement. After being identified to be at risk for elopement, the patient's unsuccessful attempt to go over a wall in the patio was observed shortly after his admission. There was no documentation in the clinical record that addressed specific interventions to be used for this high risk patient. According to documentation on the Q15 min observation forms, the patient was allowed access to the outside patio on numerous occasions. On 3/26/2011 at approximately 4 p.m., the exit door leading from the hallway of the inpatient unit to the patio was propped open, and the patient left the unit unobserved while there was a group being conducted outside and was able to go over an unknown location on one of the walls to the outside. The patient was located by Security Services in the parking garage elevator after a "suspicious individual" in that location was reported to them. The hospital did not have policies or procedures that addressed patients identified to be at risk for elopement including access to outside areas located at Palo Verde. Observations of the main courtyard on 10/25/2011 revealed two unsecured chairs in the courtyard, one of which was used to prop open a door from the inpatient unit hallway. Patients were observed in the courtyard during that observation.

2. The following patients were on the north hall of the East Unit of the Palo Verde Mental Health Unit on 9/27/2011 and 9/28/2011.

-Patient #3 (Room 436) was admitted on 9/26/2011 with diagnoses including major depressive disorder. The patient was admitted with suicidal ideation and unable to contract for safety.

-Patient #4 (Room 436) was admitted on 9/22/2011 with diagnoses including depressive disorder. The patient was admitted with suicidal ideation.

-Patient #5 (Room 437) was admitted on 9/27/2011 with diagnoses including alcohol dependence, anxiety disorder, and rule out post traumatic stress disorder.

-Patient #6 (Room 437) was admitted on 9/26/2011 with diagnoses including Bipolar disorder and depression. The patient was admitted with suicidal ideation and unable to contract for safety.

-Patient #7 (Room 438) was admitted on 9/25/2011 with diagnoses including severe recurrent major depressive disorder. The patient was admitted with suicidal ideation.

-Patient #8 (Room 438) was admitted on 9/23/2011 with diagnoses including alcohol disorder and Bipolar disorder with depressed episode and psychotic features. The patient was admitted with suicidal ideation.

-Patient #9 (Room 439) was admitted on 9/21/2011 with diagnoses including mood disorder with suicidal ideation.

-Patient #10 (Room 439) was admitted on 9/23/2011 with diagnoses including severe recurrent major depressive disorder. The patient was admitted with suicidal ideation.

-Patient #11 (Room 442) was admitted on 9/23/2011 with diagnoses including schizoaffective disorder and danger to self (suicidal ideation).

A review of the Security video tapes for 9/27/2011 of the North Hall of the East Unit revealed the following:
-Room 436 (Patients #3 and 4): Staff observation from the doorway from 22:08:50 to 22:08:53 (3 seconds).
-Room 437 (Patients #5 and 6): Staff observation from the doorway from 22:09:07 to 22:09:09 (2 seconds).
-Room 439 (Patients #9, and 10): Staff observation from the doorway from 22:09:25 to 22:09:28 (3 seconds).
-Room 438 (Patients #7, and 8): Staff observation from the doorway from 22:09:48 to22:09:49 (1 second).
-Room 442 (Patient #11): Staff observation from the doorway from 22:09:54 to 22:09:55 (1 second).

The next observation rounds observed on the tapes were as follows:
-Room 437: Staff observation from the doorway from 10:41:23 to 10:41:26 (3 seconds).
-Room 439: Staff observation from the doorway from 10:41:41 to 10:41:44 (3 seconds).
-Room 442: Staff observation from the doorway from 10:42:00 to 10:42:01 (1 second).
-Room 438: Staff observation from the doorway from 10:42:06 to 10:42:07 (1 second).
-Room 436: Staff observation from the doorway from 10:42:19 to 10:42:21 (2 seconds).

The 15 minute rounds observations for the remaining of the night shift on 9/27/2011 were consistent with the above. Staff observations of the patient's were made from the doorways for a period of 1 to 3 seconds.

The security video tapes of the north hall on the east unit on 9/28/2011 were consistent for the amount of time the staff observed the patients in their rooms during the night shift. For example, staff were observed on the tapes making rounds on the unit as follows:

-Room 437: Staff observation from the doorway from 03:24:48 to 03:24:50 (2 seconds).
-Room 439: Staff observation from the doorway from 03:25:01 to 03:25:04 (3 seconds).
-Room 442: Staff observation from the doorway from 03:25:15 to 03:25:16 (1 second).
-Room 438: Staff observation from the doorway from 03:25:20 to 03:25:23 (3 seconds).
-Room 436: Staff observation from the doorway from 03:25:36 to 03:25:38 (2 seconds).

(Nine patients observed in a period of approximately 11 seconds.)

The Director of Nursing of Palo Verde Mental Health unit stated during interviews on 10/26/2011 that the hospital's current policy did not define the components of every fifteen minute visual checks including at night when patients are in their rooms sleeping.

3. A review of security camera video tapes of the North Hall of the East Unit on 9/27/2011 revealed a Behavioral Health Technician making observation rounds on the unit at 4:56 p.m. and not again until 5:25 p.m. Documentation on the East Evening Q15 Min. Rounds form dated 9/27/2011 revealed Patient #6 was in his bedroom at 5:15 p.m. even though no observation rounds were made at that time.

The above was reviewed on 11/7/2011 with the Director of Nursing and the Nursing Manager of Palo Verde, and they acknowledged the discrepancy in the video tapes and the documentation.

-According to the security camera video tapes on that date, observation rounds were made at 6:04 p.m. on the unit and not again until 6:41 p.m., a period of 37 minutes, however documentation on the rounds form revealed Patient #6 was observed in his room at 6:15 p.m. and 6:30 p.m.

-Observation rounds were made per the video tapes at 6:58 p.m. and not again until 7:29 p.m., a period of 31 minutes, however documentation on the rounds form revealed Patient #'s 5, 6, and 10 were observed in their rooms at 7:15 p.m.

Based on record reviews and staff interviews, it was determined for one patient (Patient #1) that the hospital failed to ensure there were polices developed and implemented governing surgical services that included outpatient surgery post-operative care planning and coordination, and provisions for follow-up care. The patient had outpatient surgery and was not provided with complete verbal and written patient discharge instructions prior to being discharged to home.

Documentation in the surgeon's Operative Report dated 1/25/2011 revealed a laparoscopic cholecystectomy with intraoperative cholangiogram was performed on the patient under general anesthesia on that date. Documentation in the anesthesiologist's intraoperative record revealed the patient was taken to the operating room at 8:28 a.m. The anesthesiologist administered 4 mg of Zofran (a medication used to prevent nausea and vomiting) during the procedure at 9:34 a.m. The procedure ended at 9:37 a.m., and the patient was taken to the post anesthesia recovery unit (PACU) at 9:42 a.m.

The patient received medication ordered by the anesthesiologist for high blood pressure while in the PACU which was effective. His recovery was otherwise uneventful. There was no documentation in the clinical record that he experienced any nausea and/or vomiting after the procedure. The patient was taken from the PACU to the hospital's Special Procedures Unit at approximately 10:55 a.m. where his continued recovery was monitored. There was no documentation that the patient experienced any complications while there. A Discharge Summary form with Discharge Instructions included: "Call your doctor if you are having:...persistent nausea or vomiting...You will need to call your doctor's office to make a follow up appointment for ***...In case of any unusual reactions or problems, contact your doctor immediately. Doctor's name Dr. (name)...." There was no additional documentation that clarified when the patient should have a follow up appointment nor was there a contact telephone number for the physician provided. Although the form was signed by the patient, there was no documentation that the discharge instructions were reviewed with the patient and/or the patient's responsible party by the RN nor was there documentation that the patient was discharged in the company of a person who would be driving him home and staying with him overnight the first night as directed in the Discharge Instructions.

An interview was conducted on 10/24/2011 with the RN who discharged the patient from the Special Procedures Unit on 1/25/2011. The RN reviewed the documentation and reported that patients are frequently provided with specific instructions directly from the physician which are not part of the written discharge instructions in the medical record. The RN also reported the patients already have the physician contact information and that is why she does not provide it in the discharge instructions. The RN acknowledged there was no documentation that she reviewed the discharge instructions with the patient and the responsible family member to ensure they understood the instructions and acknowledged there was no documentation of how the patient left and with whom he left.