HospitalInspections.org

Based on the number and nature of deficiencies cited, the hospital failed to comply with the Condition of Governing Body. The Governing Body and 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.

The facility failed to meet the following standards under the Condition of Governing Body:

A 0057 Chief Executive Officer
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.

A 0093 Emergency Services
The facility failed to ensure that emergency responders were able to respond in a timely manner without unnecessary delays.

Reference additional findings under the following Conditions of Participation and Standards that also contributed to an unsafe patient environment:

A 0115 Condition of Patient Rights, A 0144 Patient Rights: Care in a Safe Setting

A 0263 Condition of Quality Assessment/Performance Improvement (QAPI) and Standards A 0275, A 0287, A 0288,
A 0309, A 0313, A 0314, A 0315 and A 0316.

A 0385 Condition of Nursing Services and Standards A 0386 and A 0392.

A 0700 Condition of Participation of Physical Environment and Standards A 0701 and A 0724.

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 the number and nature of deficiencies cited, the hospital failed to comply with the Condition of Patient Rights. The facility failed to ensure that patients received care in a safe setting. Specifically, the facility failed to ensure that patient safety was maintained with patient accountability rounds, safety searches, reliable door locks/hardware, control of linen and patient belongings and properly sized mattresses in the seclusion rooms.

On 9/29/10 at 4:30 p.m. (day 3) of the survey, the determination was made that an Immediate Jeopardy (IJ) situation existed related to unsafe patient door locks/hardware, inadequate staff accountability on rounding to check for patient safety, problematic emergency response by outside fire and ambulance services, and ill-fitting mattresses in the seclusion rooms. The facility provided the surveyors with an acceptable corrective action plan and the Immediate Jeopardy (IJ) status was removed just prior to the survey exit on 9/30/10 at 4:45 p.m. (day 4).

The facility failed to meet the following standards under the Condition of Patient Rights:

A 0144 Care in a Safe Setting
The facility failed to ensure that patient safety was maintained with patient accountability rounds, safety searches, reliable door locks/hardware, control of linen and patient belongings and properly sized mattresses in the seclusion rooms.

Reference additional findings under the following Conditions of Participation and Standards that also contributed to an unsafe patient environment:

A 0263 Condition of Quality Assessment/Performance Improvement (QAPI) and Standards A 0275, A 0287, A 0288,
A 0309, A 0313, A 0314, A 0315 and A 0316.

A 0385 Condition of Nursing Services and Standards A 0386 and A 0392.

A 0700 Condition of Participation of Physical Environment and Standards A 0701 and A 0724.

Based on staff/physician interviews, review of facility documents, medical record review and facility tour, the hospital failed to ensure patients were receiving care in a safe setting. Specifically, the facility failed to ensure patient safety was maintained with patient accountability rounds, safety searches, reliable door locks/hardware, control of linen and patient belongings and properly sized mattresses in the seclusion rooms. The failures contributed to a negative patient outcome for sample patient #1 and the potential for other negative patient outcomes. The failures were detailed in the following findings:

1. Patient Room Locks/Hardware:
The hospital failed to ensure hospital staff was able to rescue patients from a locked room when locks were tampered with. Specifically, the hospital failed to ensure that, in the case of sample patient #1, staff would be able to open a door if the door lock was jammed and keys failed to unlock the patient door, resulting in a delay in rescuing sample patient #1.
The findings were:

Staff Interviews:
An interview with the Director of Quality Support Services on 9/27/10 at approximately 1:00 p.m. revealed that, in response to Sample Patient #1's suicide attempt and the difficulty entering his/her room, the hospital had identified that staff needed education on door opening devices and that facilities management had worked on tools that may be needed for emergency extraction of patients if a similar situation would arise.

Staff members #1, #3, #4, #5, #6, and #7 were interviewed on 9/28/2010 separately. The interviews revealed none of the staff members interviewed stated they had personally used the device shown to the surveyors on 9/27/2010 by hospital staff to toggle the door lock switch on the latch portion of the door identified as being the current tool available for gaining entry into a locked patient room.

An interview with staff member #3 was conducted on 9/28/10 at approximately 9:00 a.m.. S/he stated s/he had been conducting accountability checks at approximately 1:00 a.m. on 9/20/2010. S/he stated s/he had arrived at sample patient #1's door and could not visualize the patient when looking in the window. S/he stated that at that point s/he knocked on the patient's door to have him/her present him/herself for visual inspection, when the patient did not respond; s/he stated s/he pounded on the door. S/he stated s/he then placed his/her key in the lock and noted it would not "go in all the way". S/he stated s/he then could see the patient to the left, next to the door and that s/he "was not right".

An interview with staff member #7 was conducted on 9/28/2010 at approximately 6:40 a.m.. S/he stated s/he was at the nursing station when staff #3 had discovered sample patient #1 hanging. S/he noticed staff member #3 was knocking on sample patient #1's door and had tried opening the door with his/her key. Then s/she stated staff member #3 yelled for help. S/he stated staff activated a duress alarm and obtained emergency supplies. Once staff returned to the door, s/he stated staff tried their keys and then began to kick the door and use body weight to try to open the door. S/he stated staff then used a ratchet tool to remove the anti-barricade devices from the door to allow the door to swing into the hallway. S/he stated the door still did not open. S/he stated at that point an unknown staff member used an oxygen cylinder to break the lock and entry was gained. S/he stated after that day, s/he had received training, as had all other staff, on the use of a door lock release device. S/he stated s/he was not sure if the device was available at the time sample patient #1 was locked in his/her room nor was s/he sure staff was aware of such a tool at that time.

An interview with staff member #5 was conducted on 9/28/2010 at approximately 3:45 p.m.. S/he stated that after s/he was alerted to the need to open sample patient #1's door on 9/20/10, s/he had retrieved the emergency tool kit from the nursing station. S/he stated s/he thought that after the anti-barricade devices were removed from the door frame the door would swing open, but it wasn't the case. S/he stated s/he was aware of the door lock release device and how to use it, but s/he didn't use it since s/he had thought staff member #1 had tried to use it and it hadn't worked. S/he stated staff member #2 then hit the lock with an oxygen cylinder 10-15 times and gained entry to the room after breaking the lock.

An interview with staff member #1 was conducted on 9/28/2010 at approximately 3:00 p.m.. S/he stated s/he was in another part of the hospital and had arrived to the unit to respond to the duress alarm and "code 0" emergency call. S/he stated before s/he arrived, staff had been attempting to gain entry to sample patient #1's room and they had tried keys and the anti-barricade devices had been removed from the door frame. S/he stated s/he thought staff had tried to use the door lock release device, but did not witness the tool's use. S/he stated staff then proceeded to kick the door and the handle in attempts to gain entry to sample patient #1's room. S/he stated s/he had turned around and then heard someone using an oxygen cylinder to break the lock.

Review of Facility Documents:
According to facility documents, on 9/20/2010, the hospital's operator received a staff duress alarm at approximately 1:07 a.m. It was reported to the operator at approximately 1:08 a.m. that a patient (sample patient #1) had been found hanging in his/her room and a Code 0 (cardiopulmonary arrest emergency) was activated. According to the hospital's operator's log, entry to the patients room occurred at 1:14 a.m. The local fire department was reported to be on scene at 1:17 a.m. and the ambulance service was reported to be on scene at 1:19 a.m. Emergency treatment (including CPR) took place and the patient was reported then to have a pulse and was intubated and transported to a local hospital emergently at 1:40 a.m. The patient later died on 9/25/2010.

According to a written statement by Staff Member #1, dated 9/21/10 and obtained by the hospital Department of Public Safety officers, staff had reported the patient's door lock had been jammed and entry with keys as well as other emergency tools that were available had not worked to gain entry to the patient's room. A metal oxygen tank was then used by another staff member (#2) to break the lock which did allow entry to the patient's room.

A written statement by staff member #3, dated 9/20/10 and obtained by the hospital Department of Public Safety officers, stated the patient's door lock was jammed and staff attempted to use their keys to unlock the door and had removed anti-barricade devices from the door to allow the door to swing out, but the door did not open. S/he wrote that staff then tried kicking the door and using their bodies to try to breach the door, until one staff member used an oxygen cylinder to break the door lock, which opened the door.

A written statement by staff member #4, dated 9/20/10 and obtained by the hospital Department of Public Safety, stated "nobody's keys would open the lock due to the fact that it seemed as though the lock and/or door handle had been jammed"

A written report from hospital Department of Public Safety stated that when the lock was examined by structural trades staff, paper was discovered in the lock cylinder that accounted for staff's inability to utilize a key in the door lock.

The surveyors were provided the educational handouts and agenda for staff orientation to the High Security Forensic Institute building that was provided prior to the building's opening. The education materials did not mention the door lock release device shown to the surveyors on 9/27/2010.

Medical Record Review:
The medical record of sample patient #1 was reviewed and revealed the following, in pertinent parts:

The patient had been admitted to the hospital initially in 1990 and remained a long term patient. A nursing note was entered in the patient's record on 9/19/2010 at approximately 10:10 p.m. that indicated the patient had "cleaned out his/her room today (9/19/10) and carried and emptied multiple trash can loads of papers and trash from his/her room to the day hall..." A nursing note entered on 9/20/2010 at approximately 1:05 a.m. stated the patient was "found with door jammed lock inoperable", a subsequent note by the responding physician on 9/20/2010 at approximately 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 10 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..."

Facility Tour:
A tour of the facility, specifically the room that sample patient #1 was found hanging, was conducted on 9/27/2010 at approximately 2:45 p.m. The unit consisted of 24 patient rooms in three hallways that branched out from a shared day hall with nursing station. Each patient hallway was separated from the day hall by a door that can lock, requiring staff key or operation from the nursing station console. Each patient hallway had a quiet living area equipped with chairs and a computer. Adjacent to the quiet living area were bathrooms and showering facilities. Each hallway had eight patient rooms equipped with a "patient privacy lock" the patient could engage or disengage from the latch side of the door which would lock the outer door knob but would continue to allow exit/door operation by the patient inside the room. Each patient door could swing into or out of the patient room. However, patient doors were equipped with anti-barricade devices that prevented the doors from swinging out into the hallway unless removed. Sample patient #1's room was located in the third patient hallway and was the closest to the nursing station in that hallway. When viewed by the surveyors, the door to the patient's room was locked with the patient privacy lock and evidence tape was present. Entry into the room was made by hospital staff and hospital Department of Public Safety with a metal device to disengage the patient privacy lock on the latch side of the door. The lock cylinder was noted to be absent at that time.

On 9/29/2010, the facility informed the surveyors that a solution to enabling staff to rescue a patient from a room with a tampered lock had been found. The strike plates of the doors would be replaced with ones that allow the door to open outwards immediately after the anti-barricade devices were removed. The facility informed the surveyors the strike plates would be ordered and would be replaced once they arrived.

The facility was informed on 9/29/2010 at 4:30 p.m. that an immediate jeopardy situation existed and a plan to correct the current situation that posed immediate jeopardy to all patients would be needed. On 10/1/2010 at 4:30 p.m., the facility provided a plan to correct the immediate jeopardy items, which included prohibiting the use of patient door locks until the strike plates could be replaced, patients and staff were notified of this change prior to that time. At 4:45 p.m. the facility was notified the immediate jeopardy situation had been resolved at that time.

In summary, the hospital failed to ensure staff was equipped with the tools and knowledge to easily rescue a patient from a locked room when the lock was jammed. This failure resulted in a situation where patients were not provided a safe environment in which they received care. This failure also delayed emergency care and response to a patient (sample patient #1) found hanging in his/her room.

2. Patient Accountability Rounds:
The facility failed to ensure staff followed the "Patient Accountability" policy/procedure when conducting accountability checks to locate and assess the welfare of patients. The findings were:

Policy/Procedure Review:
On 9/27/10 the facility policy/procedure "Patient Accountability," dated 7/28/10 was reviewed and revealed the following, in pertinent parts:

"I. DEFINITION/PURPOSE
It is the policy of CMHIP that the behavior, location and well being of patients are consistently checked, and the information collected during patient accountability checks be documented and verified. Any clinical information of note shall also be documented in the patient record.

II. ACCOUNTABILITY
All clinical staff on inpatient-care units and their supervisors are responsible for conducting and verifying patient accountability checks. Staff making entries onto the Patient Accountability Sheet (form 5604) are responsible for the accuracy of the entries.

III. PROCEDURE
A. Patient Accountability Checks
1. Patient accountability checks shall occur at the frequency appropriate to the level of risk of the patient population on the unit...
2. The Charge Nurse will assign responsibility for patient accountability checks at the beginning of each shift. The responsibility for patient accountability checks shall be assigned among the staff on the shift so that no staff person has sole responsibility for patient accountability for an entire shift.
3. Patient accountability checks will be assigned at the beginning of the shift. Staff will not be assigned to more than two consecutive hours of patient accountability checks to increase likelihood of accurate checks and consequent documentation.
4. Staff must directly observe patient behavior and verify patient's physical condition (e.g., including presence of respirations, color, movement, and absence of acute injury, illness, or death). If the patient is asleep, staff must enter into the patient's bedroom to "listen" and must see the patient's face (i.e., no covers over head). If the patient has a window in his/her bedroom door large enough to observe the patient head-to-toe, AND the patient is awake walking around his/her bedroom with no signs of distress or physical injury, staff do not have to enter the room to "listen." ...Staff on Shift III shall use a flashlight when necessary in order to observe patients who are sleeping...7. If staff have concerns about a patient's condition (e.g., cannot observe respirations, a change in general appearance is noted, or bleeding or injury/illness is detected), a more thorough assessment of the patient's condition shall be immediately initiated...
13. During change of shift, the staff person transferring responsibility for the Patient Accountability Sheet shall conduct a patient accountability check with the staff person assuming responsibility for the Patient Accountability Sheet by the oncoming shift in order to verify the behavior, location and condition of all patients, ensure locked trash can is locked, egress doors are closed and locked, laundry room door is closed and locked, fabric laundry bag is accounted for, and the environment scan is completed.
14. A patient accountability check shall be conducted during fire drills, disaster drills, or bona fide emergencies, and, if there has been a security breach such as an unlocked door...

B. Patient Accountability Sheets
...5. Staff conducting accountability checks shall:
...b. All staff doing observations will:
...?Staff must directly observe and verify patient's physical condition (e.g., including presence of respirations, color, movement, and absence of acute injury, illness, or death). If the patient is asleep, staff must enter into the patient's room to "listen" and must see the patient's face (i.e., no covers over head). If the patient has a window in his/her bedroom door large enough to observe the patient head-to-toe, AND the patient is wake walking around his/her bedroom with no signs of distress or physical injury, staff does not have to enter the room to "listen."...Staff on Shift III will use a flashlight when necessary in order to observe patients who are sleeping...
7. The Patient Accountability Sheet is used to document that egress doors have been checked as well as to conduct and environmental scan for immediate safety concerns (e.g., water on the floor, fire exit blocked, exit sign not lit, doors unlocked that should be locked, contraband)..."

Staff Interviews:
On 9/27/10 at approximately 3:40 p.m., the director of nursing was interviewed about the duties, schedule and routines for the night shift (11 p.m. - 7 a.m.) for the C-1 (Assessment and Stabilization Unit - Male) for the forensics complex. S/he stated the unit usual staffing was for three staff, including one registered nurse. S/he stated additional staffing would be added if they had patients that were on precautions that required 1:1 supervision of a patient. An additional staff would be added for each patient requiring a 1:1. S/he stated all staff shared in the accountability rounds by taking turns with one- to two-hour blocks of being assigned to do the checks. S/he stated the patient rooms are always lit at night, but the light is dimmed. S/he stated patients can lock their doors from the inside, but the nurse can open the door to check on the patient by using a key in the lock. S/he stated at least one staff member makes the rounds, with another staff member watching as a back-up from the locked doorway to the quiet living area and hallway. If the staff member does not stand in the open doorway watching the other staff member make rounds in each of the three hallways, then the staff member sits in the dayroom or the nursing station/security console area and observes the staff member who is making rounds through the glass wall of windows leading into each of the three "quiet living areas" that lead into the patient hallways. The third staff member might be in the back area behind the nursing station doing other work. S/he stated there was a sliding window that was usually kept open, so the staff member could hear what was going on in the nursing station and dayroom. The wall of windows behind the nursing station leading to the back room also allowed visualization of the nursing station, dayroom and all three "quiet living areas" and patient hallways that radiate out from the nursing station/dayroom area like wheel spokes. The layout of the area was confirmed by a tour of the C-1 unit by surveyors on 9/27/10 at approximately 2:45 p.m.

Further interview of the director of nursing revealed staff were not required to unlock/open the patient's bedroom door if the patient could be fully seen through the window and was up and moving around in the room. In addition, staff did not have to enter the room if the patient appeared to be asleep, but head was uncovered and respirations were able to be seen. In other situations, if patient responds verbally when asked if "okay" and/or if patient will remove cover over head when asked, staff need not enter the room. S/he stated staff should enter room if unable to get verbal response if patient appears asleep or if respirations not visible, or if head covered and patient did not respond to request to uncover head, or if there were other concerns about the welfare of the patient. S/he stated the nursing supervisor rounds on all of the units during the shift and also makes sure checks are being done, by review of the Patient Accountability Sheet.

On 9/28/10, staff member #7 was interviewed and revealed that during accountability rounds on C-1 on the night shift (III) of 9/19-20/10, s/he did not see staff enter any patient rooms while making routine accountability rounds. S/he stated s/he did see some staff talking to patients through the door window. S/he stated she was oriented to check patients through the windows and only enter the room if the patient did not respond verbally or was asleep and breathing not visible or audible, or there was some other concern about the patient's welfare. S/he further stated that patients were not allowed to cover their heads, and would be asked to remove sheets if head covered. S/he stated that could be accomplished by talking to the patient through the door window."

On 9/28/10, staff member #4 was interviewed about accountability checks on the night shift (III) on unit C-1. The interview revealed the following findings: The staff member stated "At night, make sure heads uncovered. Watch for breathing movements and head uncovered. If can't see, listen, if door closed. Some (patients) leave doors open, so you leave them open. (Patients) lock doors at night. 50% of those that close doors lock them. Look through the window and if breathing, don't open door."

When asked about how rounds are made, s/he stated they "don't have enough staff to make rounds in pairs. (Staff) only do rounds in pairs if they feel uncomfortable or if a patient is on precautions, such as assault precautions."

On 9/28/10, staff member #5 was interviewed about accountability rounds on C-1 unit and the night shift (III) and revealed the following findings:

S/he stated "there are usually three staff working on the night shift (III). Someone is always supposed to sit at the monitor (security console) in the nursing station. When making accountability rounds on one of the three hallways, the staff members usually leave the locked door to the "quiet living area"/patient hallway ajar while rounding in that hallway. You look at the window (in each patient's door) to see if the patient is breathing. If the patient has his head covered, you knock on the door and tell the patient to 'uncover your head so I can see you're okay.' You open the door if you can't see or tell if the patient is breathing, if you see an object or something the room that doesn't look right." Staff member #5 stated that doors are opened infrequently during accountability rounds at night.

Review on 9/28/10 of a one-hour segment of video tape (9/20/10, approximately 12:15 a.m. - 1:15 a.m.) from a mounted camera on C-1 unit with a view of the nursing station, dayroom and glass-enclosed "quiet living areas" that served as the entry way each of the three patient hallways, revealed the following findings:

Review of the tape revealed the staff made accountability rounds approximately every 15 minutes, but in some cases, the time spent checking each patient hallway was extremely brief. Per interviews with the director of nursing during the tour on 9/27/10 and staff interviews on 9/28/10, a check of each hallway included eight patient rooms that were frequently locked and a locked shower area and two bathrooms that were unlocked, unless in use by a patient. They estimated that checks usually took no more than seven minutes from start to finish, including all hallways. In one case, the C hallway was checked in 12 seconds and later in 22 seconds. The longest check viewed in any hallway during this period was one minute, 17 seconds.

In summary, review of the facility policy, tours, staff interview and review of video tape of staff making rounds revealed the staff on the night shift (III) on unit C-1 failed to follow facility policy/procedure by entering patient rooms to check on the patients and taking the time to make a thorough check of the patients, their rooms and other living areas while completing accountability rounds.

3. Safety/Environmental Checks of Patient Rooms:
The facility failed to ensure patient rooms and other patient areas were checked thoroughly and frequently to ensure a safe therapy environment for patients, staff and visitors. The findings were:

Policy/Procedure Reviews:
On 9/29/10 the facility policy/procedure "Searches of Patients, Staff and Visitors" dated 4/26/06, was reviewed and revealed the following, in pertinent parts:

"I. DEFINITION/PURPOSE:
It is the policy of (the facility) to provide the safest environment possible for patients, staff and visitors. All individuals and their ...possessions are therefore subject to search at any time...
(The facility) respects the need of patients for confidentiality, privacy and security...Respect for privacy shall not be construed as a right to privacy, however.
The purpose of this policy is to describe when, in the interest of patient, staff and public...searches of staff, visitors and patients are conducted.

II. ACCOUNTABILITY
Individuals responsible for implementing this policy include...unit staff.

III. PROCEDURE
...D. Searches of Patient Rooms
1. Staff may search patient rooms at any time...
3. Searching a patient, patient's room or belongings is considered a clinical intervention; thus, clinical staff shall complete the search..."

On 9/29/10, the facility policy/procedure "IFP (Institute for Forensic Psychiatry) Unit Searches," dated 7/13/07, provided by the IFP division director, was reviewed and revealed the following, in pertinent parts:

"I. PURPOSE
It is the policy of the Institute for Forensic Psychiatry (IFP) to maintain safe an secure patient living units by insuring prohibited items, including contraband, are not present. To accomplish this searches of the unit are required.

II. ACCOUNTABILITY
Individuals responsibility for implementing this policy include the IFP Division Director, Clinical Team Leaders and all direct-care personnel.

III. PROCEDURE
1. Staff will conduct a search when there is any indication or cause to believe there is a breech in safety or security with regard to prohibited items.
2. Staff will search all patient living areas at least monthly on the Maximum Security and Medium Security units. These searches will be unannounced with no set pattern as to when or where they will be conducted. The Clinical Team Leader or designee will coordinate when the searches will be performed...
4. Staff will attempt to search patient's belongings in the presence of the patient. The search may be completed in the absence of the patient when staff conducting the search determine it would be dangerous to delay the search or the patient is uncooperative. At least two staff members must be present when belongings are searched in the patient's absence..."

On 9/27/10 the facility policy/procedure "Patient Accountability," dated 7/28/10 was reviewed and revealed the following, in pertinent parts:

"...7. The Patient Accountability Sheet is used to document that egress doors have been checked as well as to conduct an environmental scan for immediate safety concerns (e.g., water on the floor, fire exit blocked, exit sign not lit, doors unlocked that should be locked, contraband)..."

On 9/29/10, the facility's nursing policy/procedure "Procedure for Patient Room Searches" dated 10/30/09, was reviewed and revealed the following, in pertinent parts:

"...II. SUPPORTIVE DATA: On the civil (non-forensic) side, just cause is needed to do a room search. On IFP, room searches are done on a routine basis as well as when circumstances dictate. If all patient rooms are to be searched, prior to the beginning of the search, all patients are to gather in the day hall...

IV. CONTENT:
STEPS/KEY POINTS
1. Put on gloves - Infection Control
2. Explain to patient that room and belongings will be searched - Staff need to demonstrate respect and sensitivity to patient's personal and religious beliefs. Handle patient's personal items with care.
3. Depending on purpose of search and level of patient stability/cooperation, allow patient to observe room search and/or work in tandem with a second staff member - The second staff person increases level of safety and protection against allegations.
4. Working the room systematically, left to right and top to bottom to ensure all areas of search are inspected - If working with partner, maintain communication to ensure that all areas of search are inspected.
5. Inspect ceiling tiles for tampering; if tampering is evident, take steps to further inspect for contraband.
6. Inspect vent covers and grates (screws and bolts intact).
7. Inspect windows (panes, sills) (screws and bolts intact).
8. Inspect doorways (sills) and doors (screws and bolts intact).
9. Inspect walls for defects.
10. Inspect patient personal property and respectfully return the items to their original location - Patient complaints tend to occur from the manner in which the search is done, not the search itself.
11. Inspect bed frame, mattress, pillows and bedding, including under the mattress.
12. Feel mattress and pillows for tears or unusual texture.
13. Inspect personal hygiene items.
14. Remove drawers from bed or dresser and inspect bottoms, sides and backs of drawers.
15. Inspect dressers, cabinets and shelves.
16. As needed, move furniture away from wall to inspect the back of furniture and wall decorations.
17. Remove any contraband discovered during the search.
18. Notify Public Safety of any dangerous contraband. Handle other nuisance contraband appropriately..."

Review of facility Documents:
Review on 9/28/10, of a report of all monthly environmental searches conducted in the IFP complex (all Maximum Security and Medium Security units) in 2010 revealed the following findings:

Units E-1 and E-2 and J-2 had conducted searches for each month, as required.
Unit C-2 had no searches conducted for January, February, March, April, June, July, September.
Unit F-1 had no searches conducted for March, May, June, July.
Unit F-2 had no searches conducted for January, February, March, May, June, July, August, September.
Unit J-1 had no search conducted for March.
Unit L-1 had no search conducted for January, March, June, July, August.
Unit C-1, the location of the suicide (sample patient #1) on 9/20/10, had no monthly searches in March, May and June. The September search was conducted on 9/20/10, after the patient hanged him/herself in the bedroom. Per review of the accompanying search report and staff interview with staff #1 on 9/28/10, the search only involved the rooms of sample patient #1 and one other patient who was know to associate with him/her.

Per review on 9/28/10 of a "Daily Activity Report" 9/19-20-10 for the night shift (III) for the Department of Public Safety, officers found "2 suspected weapons - 2 plastic tubes believed to be 'shanks.'"

Review of the Department of Public Safety "Evidence/Property Control Form" for sample patient #1's room after the suicide revealed the following, in pertinent parts:

"2 - 34 inch strips of torn white sheet
1 - 8 inch strip black nylon
1 - 8 inch strip white sheet
1 - 16 inch strip white sheet
1 - envelope holding 2 - 6 inch black nylon watch bands
1 - package dental floss
1- envelope titled (sample pt #1 "legal paperwork/confidential" which contained 2 - 50 inch pieces of torn white sheet and 2 - 16 inch pieces of torn white sheet.
2 - pieces of plastic containing an unknown white powder (that was sent to a police lab for analysis)..."

Staff/Physician Interviews:
On 9/29/10 at approximately 2:30 p.m., the superintendant of the hospital was interviewed with other management and quality staff and stated that staff did not do more frequent searches because of numerous threats of lawsuits by patients claiming that their rights were being violated when their rooms and belongings were searched. S/he stated that on the non-forensic units, staff only searched patients/rooms for "probable cause," per the terms of a legal settlement. The surveyors reviewed the difference between a search for patient/staff/visitor safety, conducted by a staff member for clinical reasons, and a search conducted by a law enforcement officer with potential legal consequences if illegal items were discovered. The surveyors clarified that the facility has the responsibility to ensure that clinical staff conduct adequate searching of patients, their belongings and the patient areas to ensure a safe environment where effective treatment can take place.

In summary, the facility failed to ensure clinical staff conducted adequate searches of patients, their belongings and patient areas to ensure a safe therapeutic environment for patients, staff and visitors.

4. The facility failed to control patient linens and patient belongings to prevent multiple suicide attempts (sample patients #2, #4, #6 and #7) and successful suicide by sample patient #1 utilizing linen or a combination of linen an

Based on the number and nature of deficiencies cited, the hospital failed to maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program.

The hospital failed to meet the following standards under the Condition of Quality Assessment and Performance Improvement (QAPI):

A 0275 QAPI Quality of Care:
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.

A 0287 QAPI Improvement Activities
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.

A 0288 QAPI Feedback and Learning
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.

A 0309 Executive Responsibilities
The Governing Body and 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.

A 0313 Executive Responsibilities
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.

A 0314 Executive Responsibilities
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.

A 0315 Executive Responsibilities
The Superintendent and executive staff failed to ensure adequate resources were allocated for measuring, improving, and sustaining the hospital's performance. Specifically, quality improvement personnel encountered difficulty in interviewing staff that were present on 9/20/10 when sample patient #1 had hanged him/herself and were unaided in their efforts by executive staff.

A 0316 Executive Responsibilities
The Superintendent and executive staff failed to ensure adequate resources were allocated for reducing risks to patients.

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 interview, the Superintendent and executive staff failed to ensure adequate resources were allocated for measuring, improving, and sustaining the hospital's performance. Specifically, quality improvement personnel encountered difficulty in interviewing staff that were present on 9/20/10 when sample patient #1 had hanged him/herself and were unaided in their efforts by executive staff. The findings were:

An interview with the Director of Quality Support Services on 9/27/2010 at approximately 12:45 p.m. revealed staff present on 9/20/10 when sample patient #1 had hanged him/herself had not all been interviewed. S/he stated appointments were made to speak to staff members, but the staff members had not shown up and would not answer their phones. When asked if the Director of Quality Support Services was aided in his/her efforts to have staff come in to give their accounts of the event, s/he had disclosed s/he was not aided by executive staff in these efforts.

On 9/28/2010 between 6:00 a.m. and 4:00 p.m., surveyors interviewed all staff that were present on the patient care unit on 9/20/10 when sample patient #1 had hanged himself. Two (staff members #1 and #5) of the seven (Staff members #1, #2, #3, #4, #5, #6, and #7) staff members interviewed had been interviewed by Quality Support Services staff prior to 9/28/10. The remaining five staff members were interviewed after surveyors had interviewed them.

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 the nature of deficiencies cited, the hospital failed to comply with the Condition of Nursing Services. The facility's nursing department failed to ensure there was adequate nursing staff on the night shift (III) for unit C-1 of the forensic psychiatry complex, to ensure that environmental and patient accountability rounds could be conducted in a thorough manner to ensure the safety of all patients and staff. In addition, the hospital failed to ensure there were adequate staffing of nursing supervisors available to support and consult with nursing staff on the night shift (III) for the forensic psychiatry complex. The failure created a situation in which the only nursing supervisor for the night shift (III) was not readily available to guide staff through an emergency situation when sample patient #1 hanged him/herself at approximately 1:00 a.m. on 9/20/10 on unit C-1.

The facility failed to meet the following standards under the Condition of Nursing Services:

A 0386 Organization of Nursing Services
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 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.

A 0392 Staffing and Delivery of Care
The director of the nursing service failed to provide adequate supervisory nursing staff for the forensic psychiatry complex for the night shift (III) on 9/19-20/10. The director of nursing also failed to ensure there were adequate staff personnel for the night shift (III) for unit C-1 of the forensic psychiatry complex to complete all of the assigned secretarial tasks assigned, as well as the more crucial completion of thorough environmental and patient accountability rounds every 15 minutes to ensure patient and staff safety. The failure may have been contributory to the negative patient outcome for sample patient #1 and created the potential for other negative patient outcomes.

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 on review of facility documents/materials and staff interviews, the director of the nursing service failed to provide adequate supervisory nursing staff for the forensic psychiatry complex for the night shift (III) on 9/19-20/10 when timely response to an emergency was needed to guide staff when sample patient #1 hanged him/herself on unit C-1. The director of nursing also failed to ensure there were adequate staff personnel for the night shift (III) for unit C-1 of the forensic psychiatry complex to complete all of the assigned secretarial tasks assigned, as well as the more crucial completion of thorough environmental and patient accountability rounds every 15 minutes to ensure patient and staff safety. 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:

Reference Tags A 0386 - Organization of Nursing Services and A 0144 - Patient Rights - Care in a Safe Setting for findings related to inadequate supervisory and nursing staff.

Based on the nature of deficiencies cited, the hospital failed to ensure the building was constructed, arranged, and maintained to ensure the safety of patients.

The facility failed to meet the following standards under the Condition of Physical Environment:

A 0701 Maintenance of Physical Plant:
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.

A 0724 Facilities, Supplies, Equipment Maintenance:
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.

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.