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5501 OLD YORK ROAD

PHILADELPHIA, PA 19141

PATIENT RIGHTS

Tag No.: A0115

Based on the systemic nature of standard-level deficiencies related to Patient Rights, it was determined the facility failed to substantially comply with this condition to ensure professional standards of operation were followed for the provision of safe care for the patients receiving patient care services at Albert Einstein Medical Center with behavioral health disorders.

Findings:

Review of facility policy "Patient Rights and Responsibilities" dated August 21, 2012, revealed "AEMC (Albert Einstein Medical Center) is committed to delivering quality medical care to our patients, and making their stay as pleasant as possible without regard to race, color, creed, sex, age, marital status, national origin, disability, sexual orientation, gender identity or veteran status. The 'Patient Rights and Responsibilities'... endorsed by the administration and staff of this hospital, applies to all patients. ...As it is our goal to provide medical care that is effective and considerate within our capacity, mission, and philosophy, applicable law and regulation, these rights set forth herein are submitted as a statement of our policy, in recognition that observance of these rights is an integral part of the healing process and an affirmation of the patient's dignity as a human being."

These following standards were cited and show a systemic nature of non-compliance:

482.13(c)(2) Tag-0144: Patient Rights-Care in a Safe Setting.
The information reviewed during the survey and observational tour of the inpatient behavioral health units provided evidence that the facility failed to ensure care was provided in a safe setting by failing to provide patient care in accordance with facility policy and physician orders to prevent elopement for inpatients with an involuntary commitment (302) status.

482.23(b)(3) Tag 0395: RN (Registered Nurse) Supervision of Nursing Care.
The information reviewed during the survey and observational tour of the inpatient behavioral health units provided evidence that the facility failed to ensure patients with physician orders requiring "Close Observation/ (1:1 Eyesight)" received that level of care for two of two medical records reviewed (MR2 and MR3).

482.41(d)(2) Tag-0724: Physical Environment-Facilities, Supplies, Equipment Maintained.
The information reviewed during the survey and observational tour of the inpatient behavioral health units provided evidence that the facility failed to ensure the provision of a safe setting for the delivery of care and services for patients on behavioral health units by failing to mitigate ligature risks in accordance with the facility Risk Assessment.

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on review of facility policy, documents, medical record review (MR), observation, and interview with staff (EMP), it was determined the facility failed to appropriately monitor behavioral health patients with involuntary commitment (302 status) to prevent elopement for four of four medical records reviewed (MR1, MR2, MR3 and MR5).

Findings include:

A review of facility policy "Rounds" dated March 3, 2020, revealed "I. Purpose A. To provide guidelines for insuring a safe and therapeutic environment by accounting for all people in our care, evaluating therapeutic and physical environment and observing safety measures. II. A. Rounds will be completed on all individuals by the assigned nursing staff every 15 minutes. Rounds sheets are completed by the staff of the outgoing shift to the oncoming shift making sure to include all changes that occurred... III. 4. The staff person conducting rounds will walk the entire Unit with the Rounds Sheet to document that they viewed each person in our care a minimum of every 15 minutes and ensure that all bedroom doors are wide open... 6. All individuals are monitored according to their observation status in addition to the rounds... IV Procedure: C. A close observation order can only be discontinued by a physician..."

1) A review on April 22, 2021, of MR1 admitted with involuntary commitment (302) status on May 9, 2020, to Tower 7, a locked behavioral health unit, revealed MR1 was under a physician's order for "Level I/Unit Confined. Constant Order." Further review of a nurses note dated May 10, 2020, at 10:18 PM authored by EMP18 revealed "Noted to take a chair to the end of the hallway by the back exit as if he was returning it to the activity room. Later it was noted that a ceiling tile had been pulled back and there was fiber dust on the floor. He was noted to have dust on his sweatshirt..." A physician's progress note dated May 12, 2021, at 6:14 PM authored by EMP41 revealed "...ROC (resident on call) was called at (6:15 PM) to be informed that the patient has eloped. He was last seen on the unit at (5:20 PM) and was no longer there during the next set of 15-minute rounds at (5:30 PM)... Security footage showed that the patient climbed through the ceiling tiles and escaped the unit. There are currently no updates on his whereabouts."
An interview conducted on April 22, 2021, at 1:20 PM with EMP5 confirmed there is a video monitor at the nurses station of the elevator lobby but staff were not observing MR1's activity at the time of their elopement. EMP5 stated "The patient eloped through the ceiling around dinner time and staff were focused on handing out trays." EMP5 further stated "There is a camera in the elevator lobby. We were able to view the video after the event. There is a monitor in the nursing station, but staff also need to care for patients."
2) A review on April 22, 2021, of MR2 admitted with involuntary commitment (302) status on December 11, 2019, to Tower 7, a locked behavioral health unit, revealed a physician's order was placed December 19, 2019, at 11:19 AM for "Close Observation/Arms Reach, Constant Order, Elopement Risk, Continue 1:1, male staff only." A review of MR2's "Safety Observation Records" dated January 6, 2021, through January 9, 2021, revealed staff was not providing "Close Observation/Arms Reach" as ordered and instead was providing routine every 15 minutes checks. There was no documentation in the medical record of a written order to discontinue the "Close Observation/Arms Reach" level of observation. A nurses note dated January 8, 2020, at 2:19 PM authored by EMP42 revealed MR2 "had been provocative toward other peers and sexually inappropriate toward female peer this morning... (MR2) became more intrusive and arguing with peer, pacing and responding to internal stimuli loudly... (MR2) walked to the exit door and attempted to leave.... (MR2) became physically aggressive... (MR2) was escorted to quiet room, 4 point restraints applied at (1:20 PM) for aggression." A nurses note dated January 9, 2020, at 12:52 PM authored by EMP42 revealed "Around (11:06 AM), when a social worker opened the door, (MR2) followed her and eloped. Staff ran out immediately and tried to catch (MR2). But (MR2) had already taken the elevator and left."
An interview conducted on April 22, 2021, at 2:02 PM with EMP5 confirmed MR2 had a written order in place for "Close Observation/Arms Reach, Constant Order, Elopement Risk, Continue 1:1, male staff only" due to bizarre and aggressive behavior at the time of their elopement. EMP5 further confirmed MR2 was not receiving the level of observation ordered by the physician at the time of their elopement.
3) A review of MR3, admitted with involuntary commitment (302) status on September 14, 2020, to Levy 9, a locked behavioral health unit, revealed a physician's order was placed September 14, 2020, at 7:06 PM for "Close Observation/Eyesight While Awake, Constant Order, Aggressive Behavior." A review of the "Safety Observation Records" dated November 13, 2020, through November 16, 2020, revealed staff was not providing "Close Observation/Arms Reach" as ordered and instead was providing routine every 15 minutes checks. There was no documentation in the medical record of a subsequent written order to discontinue the "Close Observation/Eyesight" level of observation. Further review of the Safety Observation Records dated November 16, 2020, revealed documentation of every 15 minutes checks from 12:00 AM through 11:45 PM inclusive of the period of time the patient was not on the unit. A nurses note dated November 16, 2020, at 2:49 PM authored by EMP22 revealed MR3 "eloped off unit and once discovered was brought back to unit because the patient was still physically in the hospital."
An interview conducted on April 22, 2021, at 2:30 PM with EMP5 confirmed MR3 had a physician's order in place for "Close Observation/Eyesight While Awake, Constant Order, Aggressive Behavior" at the time they eloped from the unit and was not receiving the level of observation ordered by the physician at the time of their elopement. EMP5 further confirmed MR3 was able to follow a mail clerk off the unit and that staff were unaware that MR3 had eloped from the unit on November 16, 2020. EMP5 stated "The mail clerk didn't think anything of it. The patient had their own clothes on and had their belongings with them. (MR3) was found roaming around the hospital in another building. One of our psychiatrists (recognized MR3) and called the unit to verify they had not been discharged."
4) A review of MR5, revealed they were admitted on November 5, 2020, to Tower 4, an unlocked medical unit with a diagnosis of a possible brain mass. A review of a physician progress note dated November 6, 2020, at 4:03 PM authored by EMP43 revealed MR5 "...is admitted here with suicidal ideation. ...(When MR5) was called to inform about this (brain mass) ...the patient developed suicidal ideation and jumped on train tracks ...and subsequently was brought to the hospital." Further review revealed a physician's order was placed November 5, 2020, at 11:38 PM for "One to One Observation (1:1), constant order, Suicide Risk." A review of the "Safety Observation Records" dated November 6, 2020, through November 9, 2020, revealed documentation of every 15 minute checks was not completed on November 6, 2020, at 12:15 PM, 12:30 PM, 12:45 PM, and 11:30 PM; on November 8, 2020, at 3:30 AM; and on November 9, 2020, at 11:45 AM, 1:15 PM, 1:30 PM, and 6:15 PM. A review of the Columbia-Suicide Severity Rating Scale Screen (C-SSRS) dated November 9, 2020, at 4:17 AM by EMP24 revealed MR5 was at high risk. A review of a physician progress note dated November 9, 2020, at 4:04 PM, authored by EMP25 revealed MR5 "...is on a 302 commitment. May not be allowed to leave AMA (against medical advice). Transfer to psychiatry when she is medically cleared. She is obviously at high risk continues to be extremely labile and impulsive. One to one at all times." A physician progress note dated November 9, 2020, at 11:24 PM authored by EMP44 revealed "Received page from RN [XXXX] name redacted, at (11:24 PM) stating that the patient had eloped and could not be located. He stated that 1:1 observer was at bedside however the patient suddenly ran out of her room. 1:1 reportedly... ran down the hall in pursuit of the patient. However, the patient had already entered the elevator."

An interview conducted on April 22, 2021, at 3:06 PM with EMP5 confirmed MR5's "Safety Observation Records" contained gaps in documentation on November 6, November 8, and November 9, 2021. EMP5 further confirmed MR5 was able to run past the observer and elope into an elevator. EMP5 also confirmed MR5 had a physician's order for One to One Observation (1:1), constant order, Suicide Risk in place.

RN SUPERVISION OF NURSING CARE

Tag No.: A0395

Based on facility policy, medical record (MR) and interview with staff (EMP), it was determined the facility failed to ensure patients receiving treatment for behavioral health disorders with involuntary commitment received an acceptable standard of nursing care by the Registered Nurse (RN) and/or with oversight of RN Nursing Supervision to ensure patients with physician orders requiring "Close Observation/ (1:1 Eyesight)" received that level of care for two of two medical records reviewed (MR2 and MR3).

Findings include:
A review of facility policy "Rounds" dated March 3, 2020 revealed "...II. A...6. All individuals are monitored according to their observation status in addition to the rounds... IV Procedure: C. A close observation order can only be discontinued by a physician..."

1) A review on April 22, 2021, of MR2 admitted with involuntary commitment (302) status on December 11, 2019, to Tower 7, a locked behavioral health unit, revealed a physician's order was placed December 19, 2019, at 11:19 AM for "Close Observation/Arms Reach, Constant Order, Elopement Risk, Continue 1:1, male staff only." A review of MR2's "Safety Observation Records" dated January 6, 2021, through January 9, 2021, revealed staff was not providing "Close Observation/Arms Reach" as ordered and instead was providing routine every 15 minutes checks. There was no documentation in the medical record of a written order to discontinue the "Close Observation/Arms Reach" level of observation. A nurses note dated January 9, 2020, at 12:52 PM authored by EMP42 revealed "Around (11:06 AM), when a social worker opened the door, (MR2) followed her and eloped. Staff ran out immediately and tried to catch (MR2). But (MR2) had already taken the elevator and left."
An interview conducted on April 22, 2021, at 2:02 PM with EMP5 confirmed MR2 had a written order in place for "Close Observation/Arms Reach, Constant Order, Elopement Risk, Continue 1:1, male staff only" due to bizarre and aggressive behavior at the time of their elopement. EMP5 further confirmed MR2 was not receiving the level of observation ordered by the physician at the time of elopement.

2) A review of MR3, admitted with involuntary commitment (302) status on September 14, 2020, to Levy 9, a locked behavioral health unit, revealed a physician's order was placed September 14, 2020, at 7:06 PM for "Close Observation/Eyesight While Awake, Constant Order, Aggressive Behavior." A review of the "Safety Observation Records" dated November 13, 2020, through November 16, 2020, revealed staff was not providing "Close Observation/Arms Reach" as ordered and instead was providing routine every 15 minutes checks. There was no documentation in the medical record of a subsequent written order to discontinue the "Close Observation/Eyesight" level of observation. Further review of the Safety Observation Records dated November 16, 2020, revealed documentation of every 15 minutes checks from 12:00 AM through 11:45 PM inclusive of the period of time the patient was not on the unit. A nurses note dated November 16, 2020, at 2:49 PM authored by EMP22 revealed MR3 "eloped off unit and once discovered was brought back to unit because the patient was still physically in the hospital."
An interview conducted on April 23, 2021, at 4:00 PM with EMP2 confirmed MR3 had a written order in place for "Close Observation/Eyesight While Awake, Constant Order, Aggressive Behavior" at the time of their elopement. EMP5 further confirmed MR3 was not receiving the level of observation ordered by the physician at the time of elopement and that the Behavioral Health Associate (BHA) had documented every 15 minute rounds on MR3's Safety Observation Record dated November 16, 2020, during the period of time MR3 was off the unit after eloping.

FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE

Tag No.: A0724

Based on review of facility documents, observation, and interview with staff (EMP), it was determined the facility failed to ensure the provision of a safe setting for the delivery of care and services for in-patients on behavioral health units on Tower 7 and Levy 9 by failing to mitigate ligature risks in accordance with the facility's Risk Assessment.

Findings include:

A review of facility documents "Mental Health Environment of Care Checklist General Criteria Risk Assessment" completed on Levy 9 February 19, 2020, and on Tower 7 February 25, 2020, revealed the facility had reviewed the following: "...6. Electrical Outlets. ...As of August 2008 there are GFCI-Tamper Resistant outlets that should be used. (Facility Comment Levy 9: Outlets in rooms and hallway not connected to GFCI. Risk was considered very low by assessment team: no adverse history, high risk patients on 1:1 observation. Outlets in patient rooms have been upgraded to tamper-proof. Facilities intends to replace hallway outlets with tamper proof type in 2020.) 7. HVAC vents. ...Vents should blush with the wall and secured with tamperproof anchors ...Partially Met. Vents should not be able to be removed and used as a weapon or for self-harm. 9. Vinyl Baseboard. ...Vinyl baseboard is used in many buildings. It should be secured to the wall. Look for sections that may be loose or have gaps making it easy to remove. If removed it could be used as a weapon. 12. Other items on the wall. 12.b. Are dispensers for alcohol based hand cleaners not accessible to patients? Alcohol based gels and foams may be consumed by patients and therefore should not be accessible to them. 13. Other Projections. Are items projecting from the wall, even if otherwise considered a safety item, designed so they cannot be used for harm of self or to harm others? ...21. Window coverings. 21.a. Are the window covering designed so they cannot be used for hanging? 21.b. Is the hardware supporting the window covering designed and installed such that it cannot serve as an anchor point for hanging and secured with tamper resistant fasteners? ...There should be no cords or ropes attached and curtains should not be used. Hardware should be flush with the wall so that it can't be used to secure a noose.. 23.d. Are doors on closets or wardrobe cabinets removed or designed to eliminate anchor points? ... 35. Trash bags. Are trash cans in areas accessible to the patients free of plastic bags that can present a suffocation hazard? Mental Health Environment or Care Checklist for Sleeping Rooms: 40. Mounted Fixtures. Are all mounted fixtures designed to prevent attachment of devices that could be used to inflict self-harm? ...no attachment points ... or anything fixed to the walls or ceilings. 41. Mirrors. Are patient room mirrors shatter-resistant? ...Mirrors should be stainless steel, not glass. 42. Beds. Have electric and manually adjustable beds been eliminated unless indicated by clinical need? ...Platform beds are the safest for an acute psychiatric environment. ...If hospital beds (electrical or mechanical) are used in locked units, they should be in a sleeping room that is close to the nursing station, patients should be watched when the beds are occupied ... and the room should be locked when not occupied..."

An observational tour conducted on April 22, 2021, at 10:51 AM to 1:26 PM of the locked inpatient behavioral health units Tower 7 and Levy 9 revealed the following:
1. An observation conducted on April 22, 2021, at 11:04 AM with EMP5 on Tower 7 in-patient room 7003 revealed the locking mechanism on window frames was of weight-bearing construction and projected out from window frame greater than one inch. Further observation revealed an electric outlet on the wall of the patient room by the head of the bed with thin pointed objects protruding from each receptacle. A five inch breach in the cove base molding where it had torn away from the wall was also noted in the corner of the room that could be used by the patient to inflict self-harm and/or to someone.
An interview conducted on April 22, 2021, at 11:07 AM with EMP5 confirmed the locking mechanism on window frames in patient room 7003 was of weight-bearing construction and projected out from window frame greater than one inch. EMP5 further confirmed the electric outlet had thin pointed objects protruding from each receptacle. EMP5 stated "it looks like something is broken off in there." EMP5 further confirmed the presence of a five inch breach in the cove base molding where it had torn away from the wall in the corner of the room and could be used by the patient to inflict self-harm and/or to someone.
2. An observation on April 22, 2021, at 11:10 AM with EMP5 at the entrance to in-patient room 7012-Tower 7 revealed the nurse call light above the door was missing two of the four plastic light covers. Further observation revealed several of the nurse call light covers over the door way entrance to patient rooms 7004, 7008 and 7010 were missing all or several of the plastic covers for the nursing call lights. In addition, the plastic covers were not flush with the wall to prevent a ligature risk.
An interview conducted on April 22, 2021, at 11:26 AM with EMP5 confirmed the nurse call light covers over the door way entrance to patient rooms 7012, 7004, 7008 and 7010 was missing all or several of the plastic covers. EMP5 stated "The Nurse Call lights are deactivated on this unit. We do not need them because we do rounds every 15 minutes. Patients can come to the nurses' station or ask staff who are posted in the hall. Sometimes they scream out. That is how we address their needs."
3. An observation on April 22, 2021, at 11:28 AM with EMP5 inside in-patient room 7012 revealed uncapped medical gases outlets (oxygen and vacuum) protruding from the wall presenting a ligature risk.
An interview conducted on April 22, 2021, at 11:28 AM with EMP5 confirmed the presence of uncapped medical gases outlets (oxygen and vacuum) protruding from the wall presenting a ligature risk inside in-patient room 7012. EMP5 stated "I believe all the oxygen and medical gases are inactivated but I'll have to check with facilities."
4. An observation on April 22, 2021, at 11:32 AM with EMP2 revealed a radiator unit along the back wall of the Tower 7 in-patient unit within the corridor outside of in-patient room 7012, a section of the radiator cover was not secured and could be used by a patient to inflict harm to self and/or someone.
An interview conducted on April 22, 2021, at 11:32 AM with EMP2 confirmed a section of the radiator cover was not secured along the back wall of the inpatient unit within the corridor outside of in-patient room 7012 which could be used by a patient to inflict harm to self and/or someone.
5. An observation on April 22, 2021, at 11:36 AM with EMP6 on Tower 7 revealed several patients were dressed in hospital gowns. Further observation revealed the attached strings on the hospital gowns strings tied at the neck and back. The strings on the gowns presented a ligature risk.
An interview conducted on April 22, 2021, at 11:36 AM with EMP6 confirmed several patients on Tower 7 were dressed in hospital gowns with strings that tied at the neck and back and the strings on the gowns did present a ligature risk.
6. An observation on April 22, 2021, at 12:08 PM with EMP5 of the in-patient psychiatric unit Levy 9 in-patient room 9203 revealed a small hand-held radio on the bedside table. Further observation revealed the battery compartment of the radio could be easily opened and contained two AA batteries that could potentially allow the patient to inflict self-harm.
An interview conducted on April 22, 2021, at 12:08 PM with EMP5 confirmed the facility provided hand-held radios containing easily accessible compartments with removable batteries to patients and the patients were able to use them without supervision. EMP5 stated "We give them to the patients so they can play music." Further interview confirmed the hand-held radio in room 9203 was given to the patient to use without supervision.
7. An observation on April 22, 2021, at 12:10 PM with EMP5 and EMP7 of the in-patient psychiatric unit Levy 9 in-patient room 9203 and 9207 revealed the curtains covering the windows were not the ligature resistant type that break away and presented a ligature risk.
An interview conducted on April 22, 2021, at 12:41 with EMP5 and EMP7 confirmed the curtains covering the windows in patient room 9203 and 9207 were not the ligature resistant type that break away and presented a ligature risk.
An interview conducted on April 23, 2021, at 4:05 PM with EMP2 confirmed the facility last conducted Behavioral Health Safety Risk Assessment on the inpatient behavioral health units Tower 7 and Levy 9 in February 2020.

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