HospitalInspections.org

The Condition of Patient Rights has not been met.

Based on clinical record review, interviews and policy review for 1 of 3 patients with suicidal and/or self-harm tendencies (Patient #21) the facility failed to ensure that staff provided a safe environment when the patient was able to harm self on 5 occasions while on constant observations by swallowing Lithium, banging head on a wall, swallowing a paperclip, swallowing a screw, and using hospital socks as a ligature to strangle self. In addition, the facility failed to ensure that safety interventions were identified or implemented and/or that safety policies were clear and appropriate for the population served.

Please see A144

Based on clinical record review, interviews and policy review for 1 of 3 patients with suicidal and/or self-harm tendencies (Patient #21) the facility failed to ensure that staff provided a safe environment when the patient was able to harm self on 5 occasions while on constant observations by swallowing Lithium, banging head on a wall, swallowing a paperclip, swallowing a screw and using hospital socks as a ligature to strangle self. In addition, the facility failed to ensure that safety interventions were identified or implemented and/or that safety policies were clear and appropriate for the population served. The findings include:



a. Patient #21 presented to the Emergency Department (ED) on 1/2/19 at 6:26 PM with a suicide attempt by sitting in the street waiting to be hit by a car. The patient had a history in part of Post-Traumatic Stress Disorder (PTSD), bipolar disorder, anxiety, asthma, gastric bypass, opiate dependence and stroke. Review of the clinical record indicated that Patient #21 was placed on constant observation at the time of admission to the ED. An RN note dated 1/2/19 at 7:21 PM indicated that she was informed by MD #22 that Patient #21 reported taking a "handful" of Lithium at the time of triage and attempted to take 4 additional but was stopped by the physician. The patient indicated that he/she took a handful prior to admission.

The clinical record indicated that Patient #21's belongings were secured at 6:44 PM. Interview with the triage nurse on 1/29/19 at 11:00 AM identified that the patient came to the ED and was in the line to check in, left the line and then was brought back to the ED by security. The patient was seen in triage, placed in the triage area and constant observation was initiated. Interview with Emergency Department Technician (EDT) #1 who performed constant observation indicated that she had the patient belongings, catalogued, and secured all the items. The clinical record indicated that the patient had multiple pill bottles. The EDT indicated that she did not recall what was in the pill bottles and did not document that at that time.

The ED record indicated that Patient #21's Lithium level was 0.7 mmol/L (normal 0.6 mmol/L) at 8:55 PM and on 1/3/19 at 3:58 AM (7 hours later) the Lithium level was 1.8 mmol/L. The hospital failed to adequately supervise the patient to prevent the consumption of Lithium.

Patient #21 was admitted from the ED to the Stepdown unit for monitoring. Review of the discharge summary dated 1/4/19 indicated that Patient #21's Lithium levels were monitored and normalized without need for intervention. A psychiatric consult evaluation completed on 1/3/19 at approximately 7:30 AM by Psychiatrist #21 indicated that the patient was considered a very poor provocative historian who reports having more than 50 inpatient psychiatric admissions for PTSD, personality disorder and mood disorder. Psychiatrist #21 indicated the patient had consistent themes of grandiose provocative attention getting behaviors that could place him/her at high risk for acting out and self-injurious behaviors. The consult recommended in part, follow Lithium level for downward trend, nicotine patch and maintain diligent 1:1 arm's length observation given the risk history at this time.


b. On 1/4/18 Patient #21 was admitted to the in-patient psychiatric unit on a Physician's Emergency Certificate (PEC) with a physician order to provide constant 1 to 1 observation. An admission treatment plan dated 1/4/19 identified an active problem of safety risk/suicide related to overdose on Lithium with interventions to assess suicidality and behaviors, and perform mouth checks. A nurse's note dated 1/4/19 at 7:23 PM indicted that Patient #21 was loud, yelling on the unit, attempting to hurt self, and received Ativan 2 milligrams. An additional nurse's note dated 1/4/19 at 11:01 PM indicated that the patient was argumentative with the evening staff and the patient reported hitting his/her head.

Interview with RN #21 on 1/25/19 at 12:00 PM identified that she could not recall what self-injurious behaviors Patient #21 exhibited and that she did not document Patient #21's behaviors in her note.

An APRN note dated 1/4/19 at 9:05 PM indicted that the APRN was called by the RN at 8:30 PM to assess Patient #21 after he/she intentionally bumped his/her head on the wall repeatedly. Patient #21 was noted to be alert and oriented, following commands and neuro checks were completed per protocol.

Review of the treatment plan failed to address Patient #21's self-harm behavior of bumping head.

On 1/5/19 a physician note indicated that Patient #21 needed a medical evaluation secondary to a bumped head and lower extremity swelling and to rule out a Deep Vein Thrombosis (DVT).


c. On 1/5/19 at approximately 1:00 PM, Patient #21 was seen in the ED for a medical evaluation which identified no DVT or head injury. An ED psychiatric evaluation dated 1/5/19 at 1:08 PM indicated that Patient #21 had grandiose attention seeking behaviors which placed him/her at high risk for acting out and for self-injurious behaviors and was placed on a 1:1 for safety. The note also indicated that the patient had multiple suicide attempts in the past including using hospital socks as ligatures at another hospital.

A nurse's note dated 1/5/19 at 4:11 PM indicated that Patient #21 informed the ED RN that he/she had swallowed a paperclip a "few hours ago" but was unable to specify a time or where the paperclip was obtained.

A physician note dated 1/5/19 at 7:35 PM indicated that he/she was informed by the nurse that Patient #21 stated he/she swallowed a paper clip on the way to the ED (via ambulance). X-rays were completed that indicated the presence of a paper clip in the left lower abdominal quadrant.

A surgical consult was obtained and indicated no intervention was required, the patient could pass the paperclip.

Interviews with staff identified that they were unable to determine where the paperclip was obtained and/or when the patient swallowed it.

Patient #1 returned to the psychiatric unit on 1/5/19 at 9:05PM.

Review of the treatment plan identified that the patient swallowed a paperclip and reiterated interventions to assess suicidality and behaviors and perform mouth checks.

The treatment plan failed to identify Patient #21's history of using hospital socks as a ligature.


d. On 1/10/19 at 9:08 PM, an APRN note indicated that a rapid response was called because Patient #21 wrapped socks around his/her neck. A nurse's (RN #21) note dated 1/10/19 at 9:30 PM indicated that Constant Observer (CO) #21 yelled for help and indicated that Patient #21 had attempted to choke self by tying hospital issued socks around his/her neck. The note indicated that on arrival to the room the patient was alert and oriented, color normal, no cyanosis noted, patient was talking and did not appear in distress.

Interview with CO #21 on 1/24/19 at 11:40 AM indicated that on 1/10/19 she had been relieved for dinner break and upon return Patient #21 was in bed, covered with blankets and facing the window. CO #21 indicated that the patient was quiet for approximately three (3) hours and then she could hear the patient saying "help me", "help me". CO #21 stated she went around the bed, removed the blankets and saw the socks around Patient #1's neck. CO #21 placed her hands under the socks and the socks released immediately.

Interview with the Unit Manager on 1/24/19 at 9:40 AM identified that her expectation was that a constant observer is within arm's length of the patient, and hands, face, and neck are visible.

Review of the suicide precaution policy indicated that for constant observation, maintain visual contact with the patient. The policy failed to outline specific expectations of the constant observer.

Following this incident, Patient #21 was evaluated in the ED. An ED MD note dated 1/10/19 at 9:47 PM indicated that Patient #21's neck was noted to have superficial erythema without any other issues. The MD/RN indicated that the patient explained with a great deal of enthusiasm about his/her suicidal ideation and gleefully explained the decision to strangle self and how he/she tied the socks together. Review of the ED record indicated that Patient #21 was placed on 1:1 immediately on arrival and throughout stay. During the ED stay on 1/10/19, CO #22 provided 1:1/constant observation for Patient #21. Patient #21 was discharged back to the psychiatric unit on 1/11/19 at 1:15 AM.

The treatment plan updated to include Patient #21's behavior of attempting to strangle self with hospital socks.


e. A nurse's note dated 1/11/19 indicated that upon return from the ED Patient #21 was posturing with the intent to assault and hurt staff. Alternatives to restraints were unsuccessful and Patient #21 was placed in four point restraints on 1/11/19 at 1:45 AM. While in restraints, Patient #21 informed staff that he/she had swallowed a bolt. An MD note dated 1/11/19 at 2:07 AM indicated that Patient #21 claimed he/she swallowed a bolt that was taken from a stretcher while in the ED earlier.

On 1/11/19 at 2:41 AM Patient #21 was sent to the ED for evaluation. An X-ray identified a paper clip was in the patient's right pelvic area and a screw was in the patient's stomach. Patient #21 required an endoscopy to remove the screw (previously identified as a bolt) and was treated with a laxative-type preparation to ensure the paperclip was evacuated.

Interview with CO #22 on 1/24/19 at 10:40AM identified that he/she was with Patient #21 in the ED on 1/10/19 into 1/11/19 and indicated that Patient #1's hands were in view "most of the time". CO #22 indicated that the patient did try to lower the side rail of the stretcher but CO #22 stopped him/her from doing so. CO #22 identified that she did not see Patient #22 remove a screw.


Review of facility documentation indicated that on 1/11/19 staff reeducation was completed stressing that staff cannot participate in diversional activities while conducting constant observation, must maintain proper lighting, and includes moving chair to have constant view of the patients face, neck and hands. Education further directed staff to check the bed for any items and have the patient remove socks when getting into bed.