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Based on observation, interview and document review, the hospital failed to provide adequate supervision of a patient with a history of ingesting items for 1 of 3 patients (P1) reviewed.

See A144.

An IJ was identified on 1/4/22, at 2:15 p.m., related to patients receiving care in a safe setting. The IJ was removed 1/5/21, at 4:20 p.m. after verification of implementation of an acceptable removal plan, but the hospital remained out of compliance at the Condition of Patient Rights. See A144.

Based on observation, interview, and document review, the hospital failed to provide adequate supervision to provide care in a safe setting for 1 of 3 patients (P1) when P1 broke glass and used glass shards to repeatedly cut herself, ingested parts of staff's plastic isolation gown, and ingested parts of her pillow all while under 1:1 supervision.

The IJ began on 12/25/21, at approximately 3:56 p.m. when P1 kicked out a glass panel in the intensive care area (ICA) and used glass shards to cut her left forearm, requiring transport to a tertiary hospital where she received sutures. During this time, P1 was on 1:1 observation. On 12/26/21, at approximately 12:50 p.m. while she continued on 1:1 observation, P1 kicked out a glass window in the ICA and took pieces of glass shards back to her room where she cut herself on the arm and neck. On 1/1/22, P1 was able to tear pieces of a staff's plastic isolation gown and ingest them while on 1:1 observation. P1 was sent to a tertiary hospital for medical treatment and discharged on 1/3/22. P1 arrived back to the facility on 1/3/22, approximately 6:40 p.m. On 1/4/22, during the night shift, P1 ingested parts of her pillow while on 1:1 observation. The president of medical affairs and the administrator were notified of the IJ finding on 1/4/22, at 2:15 p.m. The IJ was removed on 1/5/21, at 4:20 p.m. after verification of an acceptable removal plan.

Findings include:

P1's treatment plan dated 12/17/21, indicated P1 had a diagnosis of borderline personality disorder. P1's care treatment plan dated 12/28/21, indicated P1 also had a diagnosis of antisocial personality disorder, and had a history of self-injurious behaviors and harming staff.

P1's intervention protocol dated 12/23/21, indicated:
The ICA would always have two staff assigned to the area and the level of observation was a 1:1 with eyes on P1 at all times.
P1 would be searched a minimum of 3 times a shift.
The ICA would be searched a minimum of 3 times a shift.

On 12/25/21, a progress note indicated at approximately 3:56 p.m. P1 kicked out a glass panel on the television room door and cut her left inner forearm multiple times. P1 also cut the inside of her left ankle from breaking the glass panel. P1 was transported to a tertiary hospital where she received several sutures to her left forearm and returned to the facility. P1 was on 1:1 observation with two staff in the ICA when she kicked out the glass panel.

On 12/26/21, a progress note indicated at approximately 12:50 p.m. P1 walked to the entry door to the television room and kicked a glass window twice to break it into several pieces. P1 picked up a piece of glass and took it to her room where she cut her left inner elbow area and along her neck.

P1's Physician's Orders dated 1/1/22, indicated P1:
Was in the ICA because of her history of foreign body ingestion.
She could only have items from an approved list of items.
Was on 2:1 staffing, with distant 1:1 observation with at least one set of eyes on P1 at all times.
The ICA would be searched at least once a shift.
P1's hands and neck were to be visible at all times.
If redirection did not stop P1's behavior, staff were to promptly intervene with least restrictive but necessary means to keep P1's hands and neck visible at all times; staff were allowed to delay physical intervention until additional staff arrived if P1 might escalated her behaviors.

On 1/1/22, a progress note indicated at approximately 4:15 p.m. P1 walked toward staff and pulled a piece of the staff's plastic isolation gown tie off and swallowed it; P1 drank some water and then vomited up the plastic. P1 took the plastic tie and flushed it down the toilet. P1 walked around and then pulled out a piece of the gown's left arm and swallowed it. P1 drank water and vomited up the plastic onto the floor. P1 picked up and re-ingested the plastic, drank more water and began choking. P1 was transported by emergency medical services (EMS) to a tertiary hospital.

Review of videotape from 1/1/22, from 3:30 p.m. until 5:30 p.m. revealed human services technician (HST)-B was in the hallway occasionally standing in P1's doorway looking into the room. A few times P1 came out of room, and registered nurse (RN)-B (who was in the room) came out with P1 into the hallway. At approximately 4:15 p.m. HST-B went into P1's room. RN-A was interviewed at this time and stated this was at the approximate time P1 ingested part of RN-E's isolation gown.

On 1/2/22, a progress note indicated P1 was hospitalized and had an esophagogastroduodenoscopy (EGD, a procedure where a patient is sedated and a tube inserted into the stomach to remove foreign bodies).

On 1/4/22, a progress note indicated P1 was having difficulty sleeping and at one point in the night, was observed by staff grabbing an object from behind the toilet and ingesting. P1 vomited the object and re-ingested. The note indicated staff attempted abdominal thrusts when it appeared P1 was choking; staff was able to retrieve part of the object before P1 could swallow more. The note indicated P1 showed the staff her ripped pillow with stuffing missing, indicating the stuffing was ingested. The note further indicated there were periods of time when P1 had her pillow covered up with her blanket.

On 1/5/22, at 2:18 p.m. licensed practical nurse (LPN)-A was interviewed and stated she was passing out medications on 1/1/21, when she heard call for assistance in the ICA. LPN-A stated when she arrived, she found P1 sitting on the toilet and coughed up some blue plastic, P1 grabbed it and re-ingested it. LPN-A stated she observed P1 then pull out another piece of plastic from the skin fold under her belly area and swallowed that too.

On 1/5/22, at 2:39 p.m. RN-E was interviewed and stated she was in P1's room wearing a plastic isolation gown when P1 grabbed a piece of the gown's ties in the back and swallowed the tie. RN-E stated she removed her gloves so P1 could not grab those and P1 grabbed her left forearm and pulled on the gown as RN-E withdrew her arm and the plastic gown "snapped." RN-E stated P1 then swallowed the piece of the gown, but vomited it out onto the floor. RN-E stated she did not have gloves on so did not reach for the plastic and P1 was able to grab it and re-ingest. RN-E stated this time P1 started choking and RN-E tried to do the Heimlich maneuver and P1 vomited the piece out which she swallowed again; EMS was called and P1 was transported to the emergency department.

On 1/5/22, at approximately 2:45 p.m. RN-L was interviewed and stated she was in P1's room on 1/3/22, doing a 1:1 observation and P1 was not sleeping well. RN-L stated she was visualizing P1's hands and neck but she had a weighted blanket covering her pillow. RN-L stated P1 was having diarrhea during the night and at one point, she observed P1 coughing and vomited up some substance, which she grabbed and then re-ingested. RN-L stated P1 showed RN-L the pillow and said that was what she had swallowed. RN-L stated P1 did not show signs of distress so they did not send P1 to the hospital. RN-L stated no changes were made to P1's plan of care and 1:1 observation continued.

The facility policy Therapeutic Observation dated 11/2/21, directed staff could immediately increase levels of observation for protection if there was imminent danger to staff or patients. Levels of observation in the policy included distant 1:1 observation, close 1:1 observation, and continuous observation but lacked indication of 2:1 observation.

The immediately jeopardy that began on 12/25/21, IJ was removed on 1/5/22, at 2:40 p.m. when the hospital successfully implemented a removal plan which included: increasing P1's level of observation to 2:1 and her staffing ratio to 4:1 replacing panels of breakable glass with less breakable glass in the ICA, and educating staff on these changes. This was verified on 1/5/22, with staff interviews verifying the education and P1's increased level of staffing, observation of P1's staffing and observation ratio, and observation of the ICA.