HospitalInspections.org

Based on observation and review of the hospital patient rights it was determined the state agency number for patients to file a grievance was not provided. This affected all patients served by the hospital.

Findings include:

A tour of the hospital Emergency Department on 8/03/10 at 9:45 AM with Employee Identifier (EI) # 3, Emergency Room Registered Nurse Manager, revealed the patient rights posted did not include the state agency complaint hotline number.

A review of the written patient rights was requested and reviewed on 8/03/10 at 11:10 AM. The patient rights did not list the state agency complaint hotline number.

Based on review of medical records, hospital policy and interview it was determined the facility failed to ensure the patients received care in a safe environment. The hospital staff failed to recognize a suicidal patient who had repeated visits to the facility and failed to keep the patient safe. This had the potential to affect all patients served by the hospital and affected Patient Identifier (PI) # 6.

Findings include:

Hospital Policy: Inpatient Suicidal Precautions
Date Revised: 8/09
Policy: If a patient begins to develop signs of suicidal ideation after hospital admission, suicide precatuions may be initiated by the Registered Nurse.
1. A staff member or sitter should be assigned to provide 1:1 constant observation
2. The physician/Licensed Independent Practitioner (LIP) should be contacted immediately for an order for 1:1 observation and psychiatric consult.
Securing the Environment:
Sitter should be aware of the following items which can be used to harm one-self... Items include but are not limited to: Mirrors, room, bathroom, overbed table.

Hospital Policy: Patient Rights and Responsibilities
Your Rights:
The right to receive care in a safe setting.


1. Patient Identifier (PI) # 6 was admitted to the hospital 7/15/09 with diagnoses of Adjustment Disorder, Substance abuse, Alcohol abuse, history of Pancreatic Cancer and Cancer of the Jaw.

PI # 6 presented to the Emergency Room 7/15/09 at 1950.
The Physician's Clinical report documented the patient's chief complaint, "Weakness, Suicidal Thoughts and Depression. (Has had worsening depression...is pouring alcoholic beverages down his PEG (percutaneous gastrostomy) tube... The patient has had similar symptoms several times previously."

The patient was discharged from the hospital on 7/23/09 at 1325.

PI # 6 returned to the Emergency Room 7/24/09 at 1452 and was admitted to the hospital with diagnoses of Suicidal Ideation and Ethanol Intoxification. The patient became depressed after discharge 7/23/09 and poured two fifths of vodka through his G-tube. A psychiatric consult was ordered. He was discharged on 7/29/09, five days after his admission.

PI # 6 returned to the Emergency Room 7/30/09 with a self inflicted injury to his right hand. The Physician's Clinical report documented his chief complaint, "Injury to right hand. Fell, states hand went through glass window."

Progress and Procedures 2227: Patient now admits to putting hand through window out of frustration according to the physician's documentation. The physician discussed the case with the Psychiatrist and the patient was admitted to a regular room.

A psychiatric consult was completed 7/31/09 at 12:30. The psychiatrist documented, "Pt (patient) needs in-pt Psychiatry transfer when bed available and medically cleared."

A psychiatric progress note dated 8/3/09 documented, "Waiting for psych (psychiatric) bed. Keep previous recommendation." He was discharged 8/4/09.

There was no suicide risk assessment score in the triage area of the nurse's report from the Emergency Room for the 7/30/09 visit.

PI # 6 returned to the Emergency Room 8/4/09 by ambulance at 1850.
The Physician's Clinical report documented his chief complaint, "Decreased Mental Status...( pt reportedly ingested 12 beers via G-tube today)... the patient was found unresponsive. The patient has had similar symptoms previously."

There was no suicide risk assessment score in the triage area of the nurse's
report at 1800 for 8/4/09.

The patient was discharged from the Emergency Room at 0210. Condition at departure: improved and stable. The patient was discharged home. The patient left the Emergency Department in a wheelchair and via taxi with fare provided.

PI # 6 returned to the Emergency Room 8/5/09 at 8:53.

The Clinical Report- Nurses documented on the Triage initial assessment at 8/5/09 at 08:45, the chief complaint, "Depression and Suicidal Thoughts."

There was no suicide risk assessment score in the triage area of the nurse's report 8/5/09. The patient was admitted to a psychiatric bed 8/5/09 and was discharged 8/13/09.

PI # 6 returned to the hospital for admission 8/18/09 at 1815 with a diagnosis of AMS (altered mental status), ETOH ( Ethyl Alcohol) and Depression. The patient was admitted to a regular medical surgical floor.

The physician orders from the emergency department documented, "Consult Psychiatric services for evaluation."

The mental health screen of the admission assessment that was completed 8/18/09 at 1815, was marked no identified problems and that, "Pt denies."

The Patient Assessment/ Care Record documented at 0530 ( 8/19/09), "Pt (patient) called out 'I need a nurse in here right away' ... pt found lying in floor with mirror broken beneath him approximately 1 inch round laceration to left forearm bleeding profusely." The patient was transferred to the Emergency Department.

The progress note written by the physician at 7:00 AM documented, "Pt admitted 8/18/09 reported self inflicted left forearm wound. Pt is right handed." The patient required surgical repair to his arm was transferred from surgery to intensive care and then to the psychiatric floor.

The patient was hospitalized the following times:
1. 7/15/09- 7/23/09
2. 7/24/09- 7/29/09
3. 7/30/09- 8/4/09
4. 8/4/09 Emergency room visit
5. 8/5/09- 8/13/09 and
6. 8/18/09-9/3/09.

After repeated Emergency room visits and suicidal ideations the hospital failed to recognize this patients mental status and keep him in a safe environment to prevent him from harming himself.

An interview was conducted with Employee Identifier #7, Registered Nurse Manager, 8/5/10 at 1:03 PM regarding the patient injuring himself with the broken mirror from his room. She stated that the floor nurses followed the Emergency Department physician orders and they did not order suicidal precautions or 1:1 observation.

Based on a review of medical records, interview with administrative staff and hospital policy the hospital failed to have a signed order for seclusion and a face to face assessment by a physician or Licensed Independent Practitioner (LIP). This had the potential to affect all patients served by this hospital and affected Patient Identifier (PI) # 7.

Findings Include:

Hospital Policy: Restraint and/or Seclusion
Purpose: To provide guidelines on the appropriate and safe use of restraints and/or seclusion, which are to be used only as a last resort, in situations with adequate clinical justification when less restrictive alternative measures are insufficient.

Definition- Seclusion is defined as involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior. Seclusion is utilized on the Psychiatric unit only. The patient is continually monitored in person.

Responsibilities: Registered Nurse- Obtain physician order when restraints and/or seclusion is needed.

Procedure: Violent/Self Destructive Management Restraint and/or seclusion.
5. Immediately notify primary physician or LIP of restraint and/or seclusion initiation; Face to Face evaluation should occur within one hour. If attending/admitting physician is unable to perform face to face evaluation within one hour, the House Supervisor should be contacted to perform the face to face evaluation. Revised 1/2010 and received by the surveyor 8/5/10 at 1:20 PM.

1. Patient Identifier (PI) # 7 was admitted to the hospital 7/17/09 with a diagnosis of psychosis not otherwise specified.

A Restraint/Seclusion Order- Behavioral Management was present in the medical record dated 7/20/09 at 0550. The order was for seclusion for 4 hours. The order was not signed by the physician and failed to have a time for the order to expire documented in the appropriate space. There was no documented face to face assessment by the physician or a LIP within an hour documented in the medical record.

The observation/special precaution tool and flow sheet time ended at 0545 with a note on the form, "seclusion." The back of this form documented at 0600 for 7/20/09, "Pt. (patient) in seclusion room for striking at staff x 2 times. Will continue q15 (every 15 minutes) and follow POC (plan of care)."

The psychiatric nurse note dated 7/20/09 documented, "0700 seclusion/release Pt released from seclusion; contract for safety, pt debriefed on her previous behavior."

The physician's flow sheet for 7/20/09 at 1020 documented an order, "Ativan 1 mg (milligram) IM (intramuscular) x (time) 1 dose now." At 1025 the order was, "1:1 observation..." The 1030 order was for,"Increase Risperdal M tab to 1 mg PO (by mouth) daily."

A late entry note was in the medical record with no date, the time was 0600 and below this was 0550 with (late entry) seclusion, documentation, "Pt. in day area became aggressive with staff. Attempted to hit staff x 2 as she walked by. Seclusion room initiated. Notified...who said he would notify Dr... Will continue to monitor. Pt in seclusion room yelling and hitting the door. Will continue to monitor."

In response to written questions submitted 8/4/10 to the Corporate Risk Manager, Employee Identifier (EI) # 5, regarding the one hour face to face not being completed 7/20/09 on PI # 7. EI # 4, the Psychiatric Unit Nurse Manager, responded on 8/5/10 at 12:35 PM, that the process had been changed for the one hour face to face assessment due to the physician not being available from the emergency room at times.

Based on record review and hospital policy review, the hospital failed to assure that Suicide Assessments were completed for 4 of 9 patients. This had the potential to affect all suicidal patients served.

Findings include:

Hospital Policy: Assessment and Reassessment of Emergency Department Patients
Date revised: July 2009
Purpose: To determine the severity of illness or injury for all patients who present to the Emergency Department for treatment.

Psych Patients: A suicide risk assessment should be completed on all patients presenting to the Emergency Department with a complaint of needing a psych evaluation, suicidal thoughts, overdose, or any other complaints that requires the patient to see a psychiatric intake nurse. A suicide risk assessment should be completed on all patients with psychiatric complaints whether they are suicidal or not. A suicide risk assessment should be done initially as part of the triage process. If the patient's risk level/score indicates that they are high risk, the patient should then be placed on 1:1 monitoring... and a suicide assessment/reassessment should be completed each shift. If the patient's risk level/score indicates that they are moderate risk, the patient should then be placed on every fifteen (15) minute observation...and a suicide assessment/reassessment should be completed on a daily basis. Documentation of the suicide risk assessment score should be done in the triage area of the nurse's clinical report in T-System. Suicide Risk Assessment should be completed again upon receiving orders for discharge. The patient should have a score of 15 or less on the suicide assessment to be eligible for discharge.

Medical Record Findings:

1. Patient Identifier (PI) # 5 was admitted to the hospital on 8/03/09 with diagnoses to include Major Depression, Personal history of injury, Epilepsy and Paraplegia.

A review of the medical record on 8/03/10 revealed a Suicide Assessment documented the admit score was 13, indicating low risk. There was no date or time documented when this assessment was conducted or an observation level documented.

2. Patient Identifier # 2 was admitted to the hospital on 7/07/09 with diagnoses to include Major Depressive affective disorder recurrent episode, severe, Suicidal ideation, Loss of weight, Bipolar disorder, Abnormal involuntary movement, Borderline personality disorder and Family history of psychiatric condition.

A review of the medical record on 8/03/10 revealed a Suicide Assessment documented the admit score was 30, indicating high risk. There was no documentation of the observation level or of a reassessment every shift as indicated for patients who score 26 or above.

PI # 2 was re-admitted to the hospital on 7/08/09 with diagnoses to include Major depressive affective disorder recurrent episode, severe, Bipolar disorder, Borderline personality disorder and Abnormal involuntary movement.

A review of the medical record on 8/03/10 revealed a Suicide Assessment documented no admit score. The discharge score, dated 7/15/09, documented a 7, indicating low risk. However, there was no signature of the staff person who performed this assessment.


18259


3. PI # 7 was admitted to the hospital emergency room 6/23/09 with a diagnosis of Psychosis at 2249.

The Physician's Clinical report documented her chief complaint, "Depressed and suicidal thoughts."

The Clinical Report- Nurses documented on the Triage initial assessment the chief complaint, "Depression, suicidal thoughts and hallucinations." There was no suicide risk assessment score in the triage area of the nurse's
report. The physical assessment documented by the nurse 6/23/09 at 00:06, "She voices +SI (positive suicidal ideation) with a plan to OD (overdose).

The disposition/discharge documented 6/23/09 at 1430, "Condition at departure: improved...Reviewed referral to a psychiatrist and Alcoholics Anonymous (drug rehab)..." There was no mention of the patient's earlier suicidal ideation and no suicide risk assessment score documented.

PI # 7 returned to the Emergency Department 7/4/09 at 23:01.
The Physician's Clinical report documented her chief complaint, "Depressed... The patient has had delusions... the patient has had similar symptoms previously."

The Clinical Report- Nurses documented on the Triage initial assessment at 7/4/09 2330, the chief complaint, "Anxiety and Bizarre Behavior and Confused, Agitated, Aggressive Behavior and Violent Behavior."
The history documented by the nurse,"Arrived by EMS (Emergency Medical Service)."

At 12:00 PM the psychiatric nurse documented, "... No beds available at any resource. Patient resting in bed, calm and cooperative at this time."

At 1403 the patient was discharged home and accompanied by a parent.
There was no mention of a suicide risk assessment being completed even with the patient's history and the physician documentation, "Similar symptoms previously."

PI # 7 returned to the Emergency Department 7/17/09 at 11:17.
The Clinical Report- Nurses documented on the Triage initial assessment at 7/17/09 at 11:26, the chief complaint, "Hallucinations.(suicidal risk assessment:19)."
The patient was readmitted to the psychiatric floor at 15:32. There was no reassessment of the suicidal risk assessment documented in the emergency room or if the patient was on every 15 minute observation as the moderate score of 19 would indicate.

4. PI # 6 returned to the Emergency Room 7/30/09 with a self inflicted injury to right hand.

The Physician's Clinical report documented his chief complaint, " Injury to right hand. Fell, states hand went through glass window."
Progress and Procedures 22:27: Patient now admits to putting hand through window out of frustration according to the physician's documentation. The physician discussed the case with the Psychiatrist and the patient was admitted to a regular room.

A psychiatric consult was completed 7/31/09 at 12:30. The psychiatrist documented, " Pt (patient) needs in-pt Psychiatry transfer when bed available and medically cleared."
A psychiatric progress note dated 8/3/09 documented, " Waiting for psych (psychiatric) bed. Keep previous recommendation."
He was discharged 8/4/09.

There was no suicide risk assessment score in the triage area of the nurse's
report from the Emergency Room for 7/30/09.

PI # 6 returned to the Emergency Room 8/4/09 by ambulance at 18:50.
The Physician's Clinical report documented his chief complaint, " Decreased Mental Status...( pt reportedly ingested 12 beers via G-tube today)... the patient was found unresponsive. The patient has had similar symptoms previously."

There was no suicide risk assessment score in the triage area of the nurse's
report at 1800 on 8/4/09.

PI # 6 returned to the Emergency Room 8/5/09 at 8:53.
The Clinical Report- Nurses documented on the Triage initial assessment at 8/5/09 at 08:45, the chief complaint, "Depression and Suicidal Thoughts."

The patient was admitted to a psychiatric bed and discharged 8/13/09. There was no suicide risk assessment score in the triage area of the nurse's report.