HospitalInspections.org

Based on the scope and severity of the deficiency related to Patient Rights, the facility failed to substantially comply with this condition.

The findings include:

Based on observation, interview and document review, it was determined the facility staff failed to ensure the safety of a patient on suicide precautions by allowing the patient to elope from the facility and attempt suicide (Patient #6). Additionally, the facility failed to ensure the safety of two (2) unmonitored patients, both of which were on sexual aggression precautions, by allowing them to commit a sex act while alone together in a patient room (Patient #7 and Patient #8). See tag A-0142

An Immediate Jeopardy (IJ) was identified on 10/26/2023 at 5:03 p.m. related to tag A-0142.

The immediate interventions implemented by the facility included fence repairs, signage alerting staff that the area is off limits for any patient activities until further notice; the Director of Plan Operations (DPO)/maintenance designee created a rounding document to assess the perimeter of all fencing with patient outdoor/courtyard areas; staff working on or providing care to patients on the acute psychiatric unit received training/retraining on "Suicide Assessment and Management Policy" and "Use of the Inpatient Psychiatric Unit Outdoor Space."

The surveyors confirmed the corrective actions were complete or implemented by observing two (2) holes under the fence filled with concrete, reviewed attestations for training, reviewed the completed rounding tools, and spoke with staff about corrective actions. The immediate jeopardy was removed on 11/1/2024 at 5:41 p.m. See tag A-0142

Based on observation, interview and document review, it was determined the facility failed to ensure the safety of a patient on suicide precautions by allowing the patient to elope from the facility and attempt suicide (Patient #6). Additionally, the facility failed to ensure the safety of two (2) unmonitored patients, both of which were on sexual aggression precautions, by allowing them to commit a sex act while alone together in a patient room (Patient #7 and Patient #8).

Findings:

Patient #6 (P6) elopement

A surveyor review of the "Standardized Intake Assessment - Direct Admissions" for P6 conducted by SM21 on 10/20/2023 at 1:05 p.m. contained the documentation "Past Suicidal Behavior: 1st attempt Date: last 9/23; 2nd attempt date: does not recall... Rationale/Considerations for Suicide Risk Determination: 'Pt has been consistently reporting SI [suicidal ideation] and desire to self harm. [P6] reports to have plan w/intent but declined to discuss. [P6 ] is currently experiencing high level of anxiety and emotional pain. [P6] does not feel [P6] will get better." SM25 was notified at 1:00 p.m.. on 10/20/2023. Actions to be Taken to Manage Risk Upon Admission - [left blank]. No "Other Interventions" checked. "Elopement Risk Factors: 'History of Elopements'."

A surveyor review of the "Nursing Supervisor Report" for Unit 7B on 10/21/2023 revealed the following documentation "Evening Shift: ... [P6] dug hole under fence in outside area and eloped to the river, staff lost sight and Code Yellow called. [Local] PD [police department] and Rescue responded, Pt found standing in river up to [P6's] shoulders and returned to shore and hospital with staff and PD support, returned to unit and placed in paper scrubs for safety and then proceeded to jump over nurse's station and break items for SIB [self-injurious behavior], secluded until able to maintain safety."

During an interview on 10/26/2023 at 1:53 p.m., Staff Member (SM13) confirmed that SM13 was present with "about four or five" patients in the outdoor fenced courtyard area of the Unit 7B to include P6 in the afternoon of 10/21/2023. SM13 stated that SM13 had the patients outside for ordered recreational therapy and was responsible in calling a "Code Yellow" following P6's elopement. SM13 stated that SM13 had lost sight of the patient while outside in the courtyard, as other patients were obstructing SM13's view. SM13 speculated that several of the patients had collaborated to "distract" SM13 prior to the patient's escape. SM13 became aware of the patient's escape by sudden cheers from several patients and briefly saw the patient running outside the fence before losing sight of the patient altogether. SM13 immediately escorted all the patients back inside the Unit 7B to notify the operator via radio of a "Code Yellow."

SM13 stated that once the patients were safely inside, SM13 immediately exited the unit through the back exit door to search for P6. SM13 stated that other staff responding to the Code Yellow alert had already located the patient in the river adjacent to the campus. SM13 stated that "911" was called, and the Nursing Supervisor (SM4) of Unit 7B had called to notify the CEO and the Administrator on Call.

During an interview on 10/26/2023 at 2:19 p.m., SM15 stated that during P6's elopement on 10/21/2023, SM15 was working inside of Unit 7B with "a few" patients, while the other patients were outside. SM15 became aware of the elopement upon SM13 calling a Code Yellow at 2:17 p.m. SM15 advised that the nurse assigned for Unit 7B at the time of the event, SM4, was temporarily away from the unit assisting with a medication pass on another unit.

During an interview on 10/30/2023 at 11:36 a.m., P6 stated that P6 dug a hole under the fence and then crawled under it. P6 was in the river for about five (5) minutes before staff arrived and remained in the river for a total of twenty (20) minutes. P6 was aware of the river's location and had been told by staff during past admissions at the facility that "you could get killed in the river if you jumped in." P6 stated that P6 has not been suicidal since that 10/21/2023, stating "there's no point in trying and failing again." P6 stated that it took P6 and P7 about thirty (30) minutes to dig under the fence ... First, they were "digging to get worms," and then the other patients helped to block them because the other patients thought that P6 was "just going to run." P6 stated that SM13 was attempting to watch all the patients in the courtyard, but the patients put chairs in front of where SM13 was sitting. P6 stated that SM13 was aware that the patients were digging a hole for worms. P6 ran to the river once before and climbed over the fence, but was now aware that P6 could go around the fence at the river instead of climbing it. P6 admitted to getting some "scratches and splinters" from going to the river. P6 admitted to dunking P6's head under the water to drown, but P6 heard SM26 crying, and "since [P6] wasn't dying, there was no point." P6 confirmed having rocks in pockets. P6 was angry that P6 was moved from Unit 9 to Unit 7B. P6 did not recall being assessed after coming out of the river. P6 has been at this facility for sixteen (16 months) and expressed concerns about turning eighteen on Saturday and being transferred to an adult facility. P6 confirmed that P6 had a suicide plan on intake on 10/20/2023, but didn't want to tell the facility staff what it was.

During an interview on 10/30/2023 at 3:21 p.m., SM23 stated that SM23 was the first to respond to the "Code Yellow" related to P6's elopement on 10/21/2023. SM23 stated that a Code Yellow will provide a description of the patient's clothes and location. When SM23 arrived at Unit 7B, SM23 was told they were looking for P6 and SM23 instinctively went to the river. SM23 stated that SM23 did not see P6 running to the river, SM23 just chose to run to the river first and no one else observed P6 run to the river. When SM23 got near the river, SM23 unlocked the fence, as the unit keys unlock the gate lock, then went down to the water. SM23 stated that P6 was in the water, fully wet, and treading water and P6 stated "I have nowhere to go" ... Other staff arrived ... P6 was in the water about ten (10) minutes ... P6 came out of the water voluntarily ... P6 told SM23 that P6 had rocks in pockets, but SM23 did not see any rocks ... P6 spoke with the Sheriff, then P6 was taken back to the Unit 7B. SM23 asked for the Unit 7B courtyard to be "closed."

During an interview on 10/30/2023 at 3:50 p.m., SM15 stated that SM15 was doing Q [every] 15 minute observations on all patients on Unit 7B on 10/21/2023. SM15 would look out the window to the fenced courtyard to make observations of those patients during their recreational session. SM15 could not recall if any of the patients that day on Unit 7B were on every five (5) minute observations. SM15 stated the nurse, SM4, left to assist on another unit. SM15 stated that usually there must be a nurse on the unit. SM15 stated that there were two or three patients inside with SM15 and the rest were out in the fenced courtyard. SM15 stated that the patients had been "digging for worms and roly-polies" earlier in the day. SM15 confirmed that SM15 could see P6 when SM15 looked out to observe for fifteen-minute observations.

During an interview on 10/31/2023 at 10:40 a.m., SM25 stated that Q15 minute observations are the standard across the board when someone comes to the acute psychiatric unit. The level of observation might increase to a 1:1 if, for example, it's an adult who tries to harm themselves. But Q5 minutes is logistically difficult, and this facility never has the staffing for a 1:1 ... the facility would not take a patient who needs 1:1. SM25 stated that P6 had "multiple admissions to acute care across the years." If patients can't be at the level of observations needed on the RTC, then they would be admitted to Unit 7B. SM25 stated that it was not specifically relayed to SM25 that P6 had a suicide plan, but a patient has to have a suicidal plan to be admitted to Unit 7B ... the criteria is the patient needs to be homicidal or psychotic, manic/psychotic, unable to maintain themselves, homicidal or suicidal, ... not just fleeting suicidal thoughts. A patient with a suicidal plan would be placed on the higher level of observation which at this facility would be to place them on Unit 7B. SM25 was not working that weekend to assess P6 after the elopement. SM25 did not know if P6 was assessed but assumed that P6 was.

Incident with Patient 7 (P7) and Patient 8 (P8)

On 10/31/2023 at 3:16 p.m., the surveyors reviewed the video camera footage of Unit 7B which showed P8 entering a room, then P7 entering the same room at 2:29 p.m. The patients exited the room together about seven (7) minutes later when SM24 discovered P7 and P8 in the room together. SM29 and SM31 were observed behind the nurses station, in view of P8's room during this time period.

A review of a "Nursing Progress Note" for P7 from 10/26/2023 at 10:00 p.m. contained the documentation "It was reported this evening by a peer that this patient and a peer engaged in inappropriate sexual contact earlier in week when this pt. was found in... peer's room."

A review of the medical record for P7 contained evidence that P8 had a physician order for:
"... Level of Observation ... Every 15 min Checks ..." start date 10/11/2023, and
" ... Precaution: Sexual Aggression Risk ... 10/26/2023 ..."

A review of the medical record for P8 contained evidence that P8 had a physician order for:
"... Level of Observation ... Every 15 min Checks ..." start date 10/11/2023, and
" ... Precaution: Sexual Aggression Risk ... 10/26/2023 ..."

During an interview on 10/31/2023 at 2:46 p.m., SM2 provided the surveyors with a verbal account of SM2's investigation of the incident related to P7 and P8 that occurred on 10/24/2023. SM2 stated: On 10/24/2023, during rounds the staff found P7 in P8's room, fully clothed. Both P7 and P8 stated that "nothing happened" and both patients were brought out of the room and reeducated about appropriate boundaries. P8 had been given permission to go into the room, but P7 had not. As per the SM2, patients on this unit are not allowed to be in each other's rooms. SM2 stated that P7 and P8 are both currently on Sexual Victimization Precautions (SVP). SM2 stated that some patients on the inpatient Psychiatric Acute Unit 7B have "blocked beds" - meaning no roommate, while some patients have a roommate. SM2 stated that the incident was considered a "boundary violation."

During an interview on 11/1/2023 at 2:35 p.m., SM24 (Milieu Manager) stated that 10/24/2023 was a busy day and recalls the patients on Unit 7B doing arts and crafts. There were no cups on the unit, so SM24 went off of the unit to get some cups, since there were two (2) nurses and a behavioral technician still on the unit. When SM24 returned, SM24 did rounds, noticed P8's door was slightly open, saw movement behind the door, and noticed P8 was in bed "in the blankets." SM24 saw P7 in the corner of the room, so SM24 separated the patients, and notified the nursing supervisor. SM24 stated that both patient's stated "nothing happened." SM24 stated that later P8 told another peer that something that had happened in the room, and the peer notified the nursing supervisor. SM24 recalled that SM28 and SM31 were on the unit when the patients were in the room together. SM24 stated that staffing was short for a few weeks as some contracts needed to be "reworked." SM24 stated that Unit 7B is usually a 4:1 patient to staff ratio with at least one (1) Behavioral Technician (BT) and one (1) RN. SM24 stated that staff are usually aware and identify issues before they become issues. SM24 denied having access to the facility's event reporting system.

During an interview on 11/1/2023 at 3:47 p.m., SM31 (RN) recalled that SM24 "caught" P7 in P8's room while doing rounds during change of shift. SM31 had just arrived on the unit and was receiving report and 'getting settled.' SM31 was notified by SM24 about the boundary violation. SM24 stated that SM29 was doing rounds and observations. SM31 stated that staffing can be "iffy" and has not yet been interviewed by anyone about the incident.

A review of the facility's policy titled "Levels of Observation" states in part:

"Purpose: 1. All patients will be routinely observed in compliance with physician orders and prescribed protocols.
Policy: 2. The physician will order one of three levels of observation at time of admission and as the patient's condition warrants a change:
Q [every] 15 [fifteen] minute (may include a precaution level if indicated)
Q 5 [five] min [minute] (requires separate order for suicide precautions (SOS))
One-to-one (requires a precaution level)
3. The RN may increase the level of observation if the patient's condition changes. The physician will be notified as soon as possible of the change in condition.
4. The RN may not decrease the level of observation, i.e. change from 1:1 to Q 15 minute observations. A decrease in the level of observation or change in precaution level requires a physician/LIP [licensed independent practitioner] order...
8. The Charge RN on the night shift will verify all precautions are marked as ordered on the Patient Observation Rounds Sheets as part of the chart check process.
9. Every 15 [fifteen] Minute (Routine) Observations
Minimum level of observation for all patients. Staff will observe patient and document on the Patient Observation Record every 15 minutes...
Staff will be vigilant for potential risk factors identified for specific patients (levels of precautions)."

Based on interview and document review, it was determined the facility failed to complete a post elopement assessment and complete the patient observation rounds documentation per facility policy for one (1) patient who eloped during a suicide attempt.

The findings include:

The surveyor conducted a review of the medical record for P6. During the medical record review, the surveyor could not find documentation that P6 was assessed by a nurse or assessed by a physician within twenty-four (24) hours after an elopement and suicide attempt.

During an interview with SM3 on 11/1/2023, SM3 confirmed that there was no nursing or physician assessment of P6 after the elopement incident on 10/21/2023.

The surveyor conducted a review of the Patient Observation Rounds for P6 from 10/20/2023 and 10/21/2023. During the record review, the surveyor discovered that there were no "Precautions" checked for those days. On 10/22/2023 'Suicide, Self-Injury, Sexual Aggression, and Sexual Victimization' precautions were all checked, but 'Elopement' was not. There was no RN Review signatures for 11:00 a.m. through 3:00 p.m. on the rounding sheets from 10/21/2023 and 10/22/2023.

A review of the facility's policy titled "Patient/Resident Elopement" states in part:

"...d. A routine nursing assessment will be completed on this individual.
e. Notify attending physician to complete a physical assessment within twenty-four (24) hours. Consult with attending physician for EOS order.
f. The patient should be evaluated for the need of safety precautions ..."

A review of the facility's policy titled "Levels of Observation" states in part:

"...5. Staff will complete the patient observation record as rounds are made, using the coding system described on the record. This concurrent documentation will be required.
Staff conducting Patient Observation rounds must carry the patient observation rounds sheets and clipboard.
Staff will observe the patient and note his or her behavior and location concurrently so rounds sheets do not contain late, missing or early entries.
Staff will initial appropriate documentation in the designated areas and sign the sheet where indicated.
The RN will review the Patient Observation Rounds Sheet at least twice each shift at the times designated on the form. This will be indicated by the signature, date and time in the indicated area on the form.
7. When Patient Observation Rounds Sheets are prepared for a new day, the staff will review the eMAR and previous sheet for notation of precautions and ensure all precautions are noted on the form. A corresponding precaution sticker will be applied to indicate the high-risk precaution order.
8. The Charge RN on the night shift will verify all precautions are marked as ordered on the Patient Observation Rounds Sheets as part of the chart check process. "