HospitalInspections.org

Based on staff/physician interviews and review of facility documents, including quality activity reports, the Superintendent of the hospital failed to provide assistance and guidance to effectively operate the hospital and to ensure that all patient requirements were met. In addition, the Superintendent and executive staff failed to establish clear expectations for patient safety, failed to ensure adequate resources were allocated for reducing risks to patients, failed to ensure adequate resources were allocated for measuring, improving, and sustaining the hospital's performance and failed to make patient safety a priority for investigation and improvement, specifically in the case of sample patient #1's suicide attempt and emergent hospitalization. The failures created a negative outcome for sample patient #1 and created the potential for other negative patient outcomes.

The findings were:

Reference findings in Tags A 0309, A 0313, A 0314, A 0315 and A 0316 under the Condition of Quality Assurance/Performance Improvement (QAPI).

Based upon staff interviews, the facility failed to ensure emergency responders were able to respond in a timely manner without unnecessary delays. Specifically, the hospital failed to ensure the responding fire department and ambulance service vehicles were escorted the closest appropriate entrance to expedite emergency care to a patient (sample patient #1) who had hanged him/herself.

The findings were:

An interview with staff member #6 on 9/28/10 at approximately 8:18 a.m. revealed that on 9/20/10 when responding to the emergency involving sample patient #1, s/he noted the ambulance service vehicle was driving to the wrong building. S/he stated s/he honked his/her horn and flashed his/her lights to get the ambulance driver's attention and had them follow him/her to the correct building. S/he stated that when they arrived at the correct building it was noted the fire department vehicle was present in the "sally port" (a secure entryway that consisted of a series of gates) and that the ambulance would be unable to get around the fire vehicle. When staff member #6 tried to have fire personnel move the vehicle, s/he stated they ignored him/her, and rather stayed waiting at the front door of the building.

An interview with staff member #1 on 9/28/10 at approximately 3:00 p.m. revealed that on 9/20/10 when responding to the emergency involving sample patient #1, s/he responded to the patient's room while other hospital Department of Public Safety officers were waiting to direct ambulance and fire personnel to the appropriate entrances. S/he stated that in the effort to gain entry to sample patient #1's room, the officer that would have directed the fire department and ambulance service vehicles to the appropriate entrances was asked to come into the building with an object to force open the patient's door. This resulted in the fire department parking their vehicle in the "sally port" rather than continuing to drive up to the entrance adjacent to the unit where the patient was located.

In conclusion, the facility failed to ensure personnel that were assigned to escort emergency response vehicles to the closest appropriate entrance were present, thus delaying emergency response personnel's entrance to care for a patient (sample patient #1) needing emergency care.

Based on staff interview, review of facility documents, review of medical records and review of facility meeting minutes, the hospital failed to use the data collected regarding patient self harm attempts to monitor the effectiveness and safety of service and quality of care. The failure contributed to negative patient outcomes.

The findings were:

1. Reference Tag A0115 for findings related to failure to provide a safe setting for patient care delivery, specifically failure to provide staff with the tools and knowledge to rescue a patient from a locked room when the lock had been jammed.

2. Facility documents/Medical Record review-
A review of facility quality documents revealed that in the previous six months, nine patient self harm incidents had been reported. Five of these incidents included the use of bed sheets as a ligature, one resulting in an emergent transport and subsequent death of a patient. The other self harm incidents included the use of a plastic fork to puncture a blood vessel in the arm, a patient using a restraint to attempt to choke him/herself and two patients using clothing in attempts to hang themselves.

Bedsheets
Sample patient #6 was a 16-year-old admitted to the hospital on 4/21/10 with a diagnosis of conduct disorder. A medical record entry on 4/24/10 at 10:00 p.m. stated, "while doing routine accountability patient was found lying on floor face down with sheet tied around his neck, tied to the door knob. As soon as the door opened the pressure released and patient was able to breathe again". A facility document that documented the incident did not contain any further discussion or investigation. Facility "Critical Incident Committee" minutes were reviewed and revealed no documentation of discussion or conclusions in regards to this incident. When asked by the surveyors, the Director of Quality Support Services stated the case was discussed in the committee but it was "not and action item, so not included in the minutes".

Sample patient #7 was a 36-year-old admitted to the hospital on 4/28/10 with a diagnosis of mixed personality disorder. A medical record entry on 5/10/10 at 9:32 a.m. stated, "patient stated s/he was going through a lot. Reached under his/her upper clothing and removed the end of a blanket s/he had torn off from around his/her waist". A facility document reflecting the report of the incident reflected the patient had "reached under his/her upper clothing and removed two blanket ends. S/he had torn each about 5 1/2 feet long and had wrapped them around his/her waist". Facility "Critical Incident Committee" meeting minutes dated 5/14/10 stated, "the patient pointed out a folding arm at the top of his/her bedroom door and said that s/he thought about hanging him/herself from it. However, the bedroom doors in HSFI (the hospital building the patient was in) probably should not have folding arms. Or, do they?" continued information gathered from the committee concluded that there were not folding arms in the patient rooms, but that there were folding arms on the doors to the bathroom and the quiet living area. The minutes concluded, "Patients can NOT lock themselves into the bathrooms". No discussion was documented on how the patient had obtained/constructed the intended ligature.

Sample patient #2 was a 49-year-old admitted to the hospital on 6/23/10 with a diagnosis of bipolar disorder. A medical record entry dated 6/25/10 at 6:35 a.m. stated, "patient was found in the side room while doing checks attempting to tie his/her bed sheet around his/her neck" A review of the facility's "Critical Incident Committee" meeting minutes revealed no documentation of discussion in relation to this incident. A facility document reflecting comments in regard to the incident, dated 9/30/10, revealed the facility had contacted a prior facility the patient had been and the patient was known to use a sheet as a cape. The comment continued to highlight that the patient had stated s/he had wanted to "kill him/herself". No further documentation of quality assessment was provided by the facility.

Sample patient #4 was a 32-year-old admitted to the hospital on 8/9/10 with a diagnosis of borderline personality disorder. A medical record entry dated 8/15/10 at 9:40 p.m. stated, "as staff was going down to patient's room at 9:17 p.m. to place on precautions heard banging on his/her closed room door. Hospital police opened door and patient fell to the floor with flat sheet tied around his/her neck. Color cyanotic. No loss of consciousness noted." A review of the facility's "Critical Incident Committee" meeting minutes revealed no documentation of discussion in relation to this incident. A facility document reflecting comments in regard to the incident, dated 9/30/10, revealed the patient had been x-rayed to check for any fractures and revealed none. The patient continued to make suicidal statements and was monitored 1:1. No further documentation of quality assessment was provided by the facility.

Sample patient #1 was a 46-year-old admitted to the hospital most recently on 10/6/08 but had been originally admitted to the hospital in 1990 with a diagnosis of antisocial personality disorder. A medical record entry dated 9/20/10 at 1:30 a.m. stated, "I was paged at 1:10 a.m. with a code 0 page that a patient had hanged him/herself. When I arrived patient was on floor outside of his/her room getting CPR with chest compressions and rescue breathing with bag valve mask. S/he had hanged him/herself with a strip of bed sheet on the door hardware. S/he had no spontaneous respirations and no pulse. Neck was red anteriorly from bed sheet abrasion. CPR continued for approximately ten minutes until ambulance service arrived with no spontaneous pulse or respirations. Per hospital Department of Public Safety officers , patient left a note on the wall,...Patient received epinephrine and atropine...After approximately 3 doses of medications, patient had sinus tachycardia on the monitor...and the patient was placed on the ambulance gurney for transport to the ER..." The patient was pronounced dead on 9/25/10 at another local hospital. A facility document reflecting the report of the incident reflected the patient had "jammed the door lock of his/her bedroom. Therefore the staff member was unable to unlock the door...Other staff responded, unfastened the hinges on the door, but were still unable to open the door with wrenches. They kicked the door and hit the latch with an O2 cylinder. Upon gaining access it was noted the patient had strips of bed sheets tied around his neck which were attached to the door hinge hardware." A review of the facility's "Critical Incident Committee" meeting minutes revealed no documentation of discussion in relation to this incident at the meeting four days after the incident reported on 9/20/10. A facility document reflecting comments in regard to the incident, dated 9/30/10, revealed no further documentation of quality assessment.

3. Staff interviews -
An interview with the Director of Quality Support Services on 9/27/2010 at approximately 2:00 p.m. revealed the facility had discovered sample patient #1 had torn up sheets given to him/her to use as a ligature. S/he stated that patients are given two sheets each on laundry day each week. When asked by the surveyors if sheets were accounted for prior to more sheets given to patients or inspected for damage, s/he stated they were not. S/he stated the facility was still investigating the hanging death of sample patient #1, but interviewing the staff involved had not been completed. S/he stated s/he had suggested tighter management of sheets, but had met resistance from other decision makers in the hospital.

An interview, on 9/29/2010 at approximately 10:30 a.m., with the Director of Quality Support Services in the presence of the Director of the Mental Health Institutes Division, s/he stated there were plans to look back at previous cases involving patient deaths and the reviews and corrective actions that were decided upon. S/he planned to follow-up to ensure the corrections were made and evaluate their effectiveness. However, this review had not taken place, nor were there plans to review other incidents not involving deaths.

In conclusion, the facility failed to fully evaluate cases of patient self harming behaviors and determine a pattern of patients using bed sheets provided as a means to harm themselves, and in the case of sample patient #1 a means to kill him/herself. The facility failed to implement corrective actions suggested by the quality program in response to the death of sample patient #1, leaving patients at risk for negative outcomes.

Based on staff interview, review of facility documents, review of medical records and review of facility meeting minutes, the hospital failed to analyze the causes of adverse patient events in a complete manner, specifically in the case of patient self harm attempts. The failure contributed to negative patient outcomes.

The findings were:

Reference Tag A0275 for findings related to quality assurance involvement in the review of patient self harm attempts.

Reference Tag A0144 for findings related to quality assurance involvement in the review of staff accountability rounds and adherence to facility policy.

Reference Tag A0144 for findings related to quality assurance involvement in the review of routine unannounced patient room searches and adherence to facility policy.

Based on staff interviews and review of facility documents, the hospital failed to implement preventative actions and mechanisms that included feedback and learning/education throughout the hospital, specifically in regards to staff education compliance.

The findings were:

An interview with the Director of Staff Education was conducted on 9/30/2010 at approximately 4:00 p.m.. S/he stated that upon review of education records and attendance records, it was determined that 81 direct care staff in the high security forensic institution had not received the building education that was offered to all staff upon the opening of the building. S/he stated staff that began working between June 2009 and January 2010 did not receive the building orientation.

Reference tag A0115 for findings related to staff knowledge of policy regarding patient accountability checks and non-adherence to hospital policy that was updated October, 2009.

Based on review of facility documents and staff interviews and the number and nature of the deficiencies cited, it was determined this requirement was not met. The Governing Body and the Superintendent of the hospital failed to provide assistance and guidance to effectively operate the hospital and to ensure all patient requirements were met.

Reference findings in the following Tags: A 0043 Condition of Governing Body, A0057 Chief Executive Officer, A0093 Emergency Services, A0115 Condition of Patient Rights, A0144 Patient Rights: Care in a Safe Setting, A0275 QAPI Quality of Care, A0287 QAPI Improvement Activities, A0385 Condition of Nursing Services, A0386 Organization of Nursing Services, A0392 Staffing and Delivery of Care, A0700 Condition of Physical Environment, A0701 Maintenance of Physical Plant, A0724 Facilities, Supplies, Equipment Maintenance.

Based on staff interview and review of facility quality documentation, the Superintendent and executive staff failed to make patient safety a priority for investigation and improvement, specifically in the case of sample patient #1's suicide attempt and emergent hospitalization. The Superintendent and executive staff also failed to utilize past patient self harm attempts to implement improvements to prevent future patient self harm attempts. The Superintendent and executive staff also failed to ensure random patient unit searches for contraband were conducted per facility policy. These failures contributed to negative patient outcomes.

The findings were:

Reference Tag A0275 for findings related to the use of data collected regarding patient self harm attempts and the failure to analyze the data to implement changes to improve patient safety.

Reference Tag A0115 for findings related to the hospital's failure to ensure random unit searches were conducted per hospital policy, to ensure contraband was not present in patients' rooms that could contribute to danger to patients and/or staff.

An interview with the Director of Quality Support Services on 9/27/10 at approximately 3:00 p.m. revealed discussion between the Superintendent and other executive staff and the Director of Quality Support Services involving monitoring of patient uses of bed sheets and accounting for the number and condition of sheets given to patients was had. S/he stated it was determined accounting for sheets and their integrity was not consistent with the therapeutic program that had been developed.

Based on review of facility quality documents and staff interview, the Superintendent and executive staff failed to establish clear expectations for patient safety. Specifically, the executive staff failed to ensure patient accountability checks and routine unit searches were performed according to hospital policy. Also, quality recommendations for increased patient safety were disregarded resulting in an increased risk of negative patient outcome. The findings were:

Reference Tag A0115 for findings related to the hospital's failure to ensure random unit searches were conducted per hospital policy to ensure contraband was not present in patients' rooms that could contribute to danger to patients and/or staff.

Reference Tag A0313 for findings regarding ignored recommendations for increased patient accountability for bed sheets with staff oversight.

Based on review of facility quality documents and staff interviews the Superintendent and executive staff failed to ensure adequate resources were allocated for reducing risks to patients. The findings were:

Reference Tag A0288 for findings regarding failure to ensure all staff received education regarding the high security forensic institution building's security systems.

Based on review of facility documents/materials and staff interviews, the director of the nursing service failed to provide adequate types and numbers of nursing personnel and staff necessary to provide nursing care for the night shift (III) for unit C-1 of the forensic psychiatry complex. In addition, the director of nursing failed to ensure that there was adequate nursing supervisory support available to the forensic psychiatry complex and specifically C-1 on the night shift (III) of 9/19-20/10. The failure may have been contributory to the negative patient outcome for sample patient #1 and created the potential for other negative patient outcomes.

The findings were:

1. Lack of Nursing Supervision Coverage

A report was requested on the number of shifts the nursing supervisor providing coverage for the forensic psychiatry complex on the night shift (III) on 9/19-20/10 was pulled away from supervisory coverage to work as a charge nurse on one of the forensic units during the months of June, July, August and September, 2010. Review on 9/28/10 of the report created on 9/28/10 revealed the following findings:

June: 6 shifts pulled off supervisory duties to serve as charge nurse
July: 6 shifts pulled off supervisory duties to serve as charge nurse
Aug: 16 shifts pulled off supervisory duties to serve as charge nurse
September through 28th: 9 shifts pulled off supervisory duties to serve as charge nurse.

Per interview with the nursing supervisor on 9/28/10, the standard supervisory staffing for the facility was supposed to be three for the facility. On the night shift (III) of 9/19-20/10, s/he was the only supervisor. When s/he got the emergency call about sample patient #1's hanging, s/he was in another building on the campus and was attempting to orient another nurse to the nursing supervisory role that night as well. S/he stated s/he left to drive over to the forensic psychiatry complex to respond to the emergency call. S/he saw an ambulance on the campus driving in the wrong direction, so s/he flagged the ambulance down and led them to the forensics complex. There was another delay when the entrance to the forensics complex was found to be blocked by a fire truck that had also responded to the emergency. The fire truck driver had apparently stopped at the entrance ("sallyport") building/gate for the forensic complex and determined that the truck might get stuck if it went through the next door in the "sallyport." The "sallyport" provided entrance to the circle drive that went around the perimeter of the fenced-in complex and provided more direct access to various wings of the complex. The fire truck blocked that "sallyport" and the firemen had entered the complex through the front entrance. The ambulance crew and the nursing supervisor also went through the front entrance and directly to unit C-1, which was the first unit from the front entrance. S/he stated s/he arrived at the scene of the emergency with the ambulance crew. Per review of the trip sheet for the ambulance crew, they arrived at the patient room approximately 15 minutes after the patient had been found hanged in his/her room.

2. Inadequate Nursing Staff to Complete Assignments

Reference Tag A 0144 for findings, including staff interviews and observations from a unit surveillance camera of staff conducting rounds and supervising the unit on C-1 on the night shift (III) of 9/19-20/10.

Based upon staff interviews and facility tour the hospital failed to ensure the condition of the overall hospital environment, specifically patient room door locks, were developed and maintained in such a manner that the safety and well being of patients was assured.

The findings were:

Reference Tag A0115 for findings related to failure to provide staff with the tools and knowledge to rescue a patient from a locked room when the door lock had been jammed.

An interview with staff member #4 was conducted on 9/28/2010 at approximately 7:10 a.m. S/he stated s/he has had issues in getting his/her key to open the door between the day hall and the patient hallway prior to 9/20/10 and had notified management or maintenance three times. S/he stated that on 9/20/10 when leaving the patient hallway that contained the bedroom of sample patient #1, s/he had a problem opening the door between the hallway and the day hall and had to have another staff member use his/her key to open the door.

Based on staff interview, the facility failed to ensure staff were equipped and educated on the proper uses of emergency equipment to rescue a patient from a locked room. The facility also failed to ensure staff acted properly in an emergency situation placing staff and patients at increased risk of injury or death when a staff member used an oxygen cylinder to break a patient's door lock.

The findings were:

Reference Tag A0115 for findings related to failure to provide a safe setting for patient care delivery, specifically failure to provide staff with the tools and knowledge to rescue a patient from a locked room when the lock had been jammed. Reference also findings related to the use of an oxygen cylinder in breaking the door lock.