HospitalInspections.org

The Condition of Participation: Patient Rights was out of compliance.

Findings included:

The Hospital failed to ensure care was maintained in a safe environment for 2 Patients (#1 and #9) out of a total sample of 10 patients. Patient #1 was able to use a syringe to self-administer an unknown substance unobserved while ordered for 1:1 constant observation for safety and was found to be intoxicated and sedated. While in the Emergency Department (ED) on constant observation, Patient #9 was able to obtain a tourniquet (a device used to apply pressure to stop the flow of blood), wrap the tourniquet around his/her neck and tighten the tourniquet around his/her neck, causing his/her face to turn gray.

Cross Reference:
482.13(c)(2)- Care in a Safe Setting (A0144)

The Hospital failed to ensure care was maintained in a safe environment for 2 Patients (#1 and #9) out of a total sample of 10 patients. Patient #1 was able to use a syringe to self-administer an unknown substance unobserved while ordered for 1:1 constant observation for safety and was found to be intoxicated and sedated. While in the Emergency Department (ED) on constant observation, Patient #9 was able to obtain a tourniquet (a device used to apply pressure to stop the flow of blood), wrap the tourniquet around his/her neck and tighten the tourniquet around his/her neck, causing his/her face to turn gray.

Findings include:

1. Review of the Hospital policy titled "Constant Observation", dated August 2023, indicated the following:
-Purpose: to maintain the safety of a patient at risk for self-harm (intentional or unintentional) or harm to others with the least possible limits on a patient's freedom.
-One to One: Remains at a distance that provides unimpeded view (including toileting) and keeps patient and observer safe per nursing assessment. The patient is demonstrating such severe impairment in judgement, a high level of impulsivity, or that the patient has demonstrated the intent to harm self or others such that the patient requires close observation with interventions to maintain safety.
-Direct 1:2+ Observation (one staff to 2-3 patients): The observer maintains unimpeded view of the patient. The patient demonstrates severe impairment of judgement and some impulsivity or behavioral dis-control. The patient cannot be verbally redirected.
-The assignment of personnel to constant observation should consider the clinical condition of the patient and the training and experience of the observer.
-Patient wears a hospital gown instead of street clothes.
-Observer immediately notifies Registered Nurse (RN)n of any changes to a patient's behavior.
-The observer tells the RN assigned to the Patient immediately when the patient is unwilling or unable to make visible his/her face or hands.

Patient #1 presented to the Hospital's Emergency Department on 2/6/24 with a chief complaint of cellulitis (an infection of the skin) to the right upper extremity and alcohol and addiction disorders.

Review of Patient #1's medical record indicated the Patient was admitted to the medical surgical unit on 2/6/24 for IV daptomycin (an antibiotic medication) treatment; an addiction specialist physician also consulted on his/her care for multiple drug tapers including medications such as phenobarbital (antiseizure medication), alprazolam (benzodiazepine medication used to manage alcohol withdrawal), clonazepam (benzodiazepine medication used to manage alcohol withdrawal), gabapentin (anticonvulsant and nerve medication), and methadone (an opioid agonist medication used to treat opiate withdrawal). On 2/9/24 Patient #1 had a Peripherally Inserted Central Catheter (PICC) IV device inserted for management and administration of his/her antibiotic medication. On 2/21/24 around 3:00 A.M., Patient #1 was found face down in his/her bathroom by RN #1. A flush syringe was next to Patient #1 on the floor with an unknown substance in it. The Patient was awakened and returned to bed. The Physician was notified, and Hospital security was called. A room search was conducted by Hospital staff and two bags filled with pulls and another syringe with an unknown substance were discovered behind Patient #1's television. The Physician order a psychiatric evaluation for Patient #1 and ordered the Patient to be on 1:1 observation at 3:25 A.M. on 2/21/24. At 5:22 A.M. on 2/21/24 the observer was talking to Patient #1 through a closed bathroom door in his/her room out of line of sight for an unknown amount of time. Patient #1 was found unconscious on his/her toilet with another syringe in his/her hand. Two RNs and a security staff member returned Patient #1 to his/her bed, and the nursing staff changed the patient out of his/her jeans and changed him/her into a hospital gown. Patient #1 was assessed by a psychiatric resident at that time to lack capacity at that time due to the sedating effects of injection of an unknown substance by the Patient into his/her PICC device.

Further review of Patient #1's medical record failed to indicate any documentation from the 1:1 patient observer on duty at the time of the incident on 2/21/24 at 5:22 A.M. with Patient #1.

During an interview on 7/15/24 at 12:45 P.M., RN #1 said on 2/21/24 Patient #1 had been acting suspiciously and was drug-seeking. She said in the early morning on 2/21/24 she found Patient #1 face down by his/her toilet. Patient #1 had brought his/her IV pole into the bathroom with him/her. She said other staff had mentioned Patient #1 sitting on the floor prior to this and wandering the medical surgical unit, possibly looking for syringes. She said after she found Patient #1 on the floor, she called security and security did a search of the Patient's room. She said after the staff discovered Patient #1's stash of pills in his/her room, he/she began to threaten the Hospital staff and make allegations he/she was touched inappropriately. RN #1 said later in the shift on 2/21/24, the staff member performing the 1:1 constant observation for Patient #1 let the Patient shut the bathroom door and was not able to keep sight of the Patient in the bathroom but staff performing 1:1 should always keep sight on their patients. RN #1 was unable to recall the name of the constant observer, but said she was a Hospital Patient Care Assistant (PCA). She did not know how Patient #1 obtained the syringe while on 1:1 observation or where it came from. She said constant observers document on their own flowsheets while providing constant observation to patients.

During an interview on 7/15/24 at 1:05 P.M., RN #2 said she admitted Patient #1 to the medical surgical unit on 2/6/24. She said she performed a basic inventory for Patient #1 but did not require a complete body search. Patient #1 did come in with one bag, but it was not searched as he/she was admitted for a medical reason.

Patient #1 was able to obtain a syringe and self-administer an unknown substance unobserved while ordered for 1:1 constant observation for safety and was found to be actively intoxicated and sedated.


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2. Patient #9 presented to the ED on 6/12/24 with a chief complaint of suicidal ideation (SI).

Review of Patient #9's medical record indicated Patient #9 reported increasing anxiety and suicidal thoughts, was having frequent thoughts that it would be better if he/she died and did not answer when asked if he/she had a plan. Patient #9's medical record further indicated a previous ED visit in May 2024 with suicidal ideation. Continuous observation 1:2+ was ordered for Patient #9 on 6/12/24 at 12:01 P.M. On 6/12/24 at 2:18 P.M., Patient #9 was found with an intravenous (IV) tourniquet around his/her neck by staff walking by the bed and was pulling it tightly around the neck, and the tourniquet was removed by staff that were present. Patient #9 was reassessed and slight erythema (redness) of the anterior (the front) neck was present, and a computed tomography (CT) scan of the head and neck was ordered, and Patient #9 was upgraded to a 1:1 sitter.

Review of ED Nursing Progress Note dated 6/12/24 at 2:07 P.M. indicated a RN walked out of another Patient's room and found Patient #9 with a tourniquet around his/her neck. A Medical Doctor (MD) found Patient #9 attempting to harm him/herself with tourniquet. MD was redirecting Patient #9 prior to RN arrival. A tourniquet was taken from the Patient and the Patient was searched. Nothing else was found. Patient #9 is on level 3 continuous observation (CO). Sitter stated unaware of CO. Roles clarified and sitter aware. All potential hazards moved away from Patient #9 and the Patient's stretcher. Primary RN and MD aware as well as charge RN.

During an interview on 7/16/24 at 1:02 P.M., RN #3 said she had assumed care of Patient #9 around 12:30 P.M. on 6/12/24 and that the Patient seemed restless, so RN #3 verbally checked in with the Patient. RN #3 said during report from the previous RN, she was made aware that Patient #9 was ordered for constant observation and that the constant observer assigned to Patient #9 was an ED tech because the ED was short on constant observers at that time. RN #3 could not remember if she had checked in with the tech assigned to observe Patient #9 at the start of her shift, but that her understanding was the tech was watching Patient #9, and at least one other patient and that the hallway bed Patient #9 was assigned to was diagonally across from the other room the tech was assigned to observe, making it difficult to observe both patients clearly. RN# 3 said that for the event in which Patient #9 was able to obtain a tourniquet from a nearby IV cart, tie it around his/her neck and tighten it was first observed by a physician walking by and not the constant observer assigned to Patient #9. RN #3 said the physician came around the corner near Patient #9 and saw the Patient with the tourniquet wrapped around his/her neck and Patient #9 was leaning into it and his/her face had changed color and was gray. RN #3 said the other nurse assigned to the area also observed the event shortly after the physician discovered the Patient and that the nurse removed the tourniquet and Patient #9 was subsequently moved into an ED room designed to keep suicidal patients safe and changed to a 1:1 observer. RN #3 said the physician first observed the incident, followed shortly by another nurse and was unable to say why Patient #9 was able to obtain the tourniquet from a nearby cart, wrap it around his/her neck, tighten it and strangle him/herself while on constant observation status and why the constant observer did not see this.

During an interview on 7/12/24 at 2:30 P.M., the Senior Manager of safety and risk acknowledged the self-harm event in which Patient #9 was able to obtain a tourniquet, wrap it around his/her neck, lean into it, thereby experiencing a change of color in his/her face to gray, occurred while on constant observation and said her understanding is that the tech assigned to Patient #9 was responsible for observing 2 patients and due to the location of the patients, the tech was sitting sideways to try to watch both patients at the same time and did not observe Patient #9's self-harm event. She said the tech was counseled regarding alerting nursing staff if the observer is unable to have a clear, unimpeded view of patients at all times, but was unable to say if any other corrective actions were implemented.

Patient #9 was able to obtain a tourniquet, wrap it around his/her neck and strangle him/herself while on constant observation for suicidal ideation. The Hospital was unable to provide documentation of any corrective actions implemented to prevent a like occurrence.