HospitalInspections.org

Based on medical record review, document review and staff interview, the hospital's governing body did not ensure that the Hospital's Quality Assessment and Performance Improvement (QAPI) program and Patient Rights were reflected in the complexity of the hospital's organization and services which involves the psychiatric department and services and focuses on indicators that are related to improved health outcomes and the prevention of adverse events related to patient abuse, suicide and suicidal gestures/attempts.

Findings include:

The hospital failed to adequately supervise patients at risk for suicide and failed to evaluate their approach for preventing suicides once a patient attempted suicide. For current patients, since the facility failed to evaluate their failure to prevent suicide attempts by 5 previously hospitalized patients, the 9 patients currently on the unit who are at risk for suicide, continue to be at risk at the IJ level. This affected five of ten patients whose medical records were reviewed, (Patient #1, 4, 5, 6 and 10).

The facility also failed to protect Patient #9 from physical abuse by a staff member, and failed to put measures into place to protect the current 18 patients from abuse by staff.

Please refer to A0049.

Based on medical record review, document review and staff interviews, the hospital failed to ensure the governing body was accountable for patient care and safety in regards to preventing one of twelve patients from causing harm to themselves (Patient #1) from preventing four of twelve patients from attempting to cause harm to themselves, (Patient #4, #5, #6 and #10) and preventing staff from causing harm to one of ten patients (Patient #9).

Findings included;


The performance improvement plan for 2010 was reviewed on 12/16/10. The plan revealed the ultimate responsibility for a comprehensive and integrated performance improvement program rests with the organization's leaders, deriving their authority from the Board of Directors.

There was no evidence that the hospital focused on preventing suicidal gesture/attempts to ensure patients were safe from harming themselves. The hospital lacked any actions taken in response to the suicidal events of Patient #1, #5, #6 and #10 or the physical abuse of Patient #9. No policy and/or procedures were implemented to remedy the events and/or prevent the occurrences. There was no system in place for improving processes that would improve the quality of care of suicidal patients. These high risk patients are problem prone. However the hospital did not consider the incidents, prevalence and/or severity of the identified problem areas. No actions aimed at performance improvement had been taken by the hospital. The hospital healthcare system further lacked a safe, effective, patient centered, timely efficient and equitable care of the specified patients and further patients presenting to the hospital with suicidal gesture and/or attempts. The hospital lacked documentation the governing body had taken any action to ensure the safety of these patients.



In an interview conducted 12/14/2010 at 12:43 P.M. staff stated that there is no ongoing, hospital wide data driven response to the suicidal gestures/attempts. Employee A and B confirmed no changes have been made in response to four patients who attempted to harm themselves while admitted to the behavioral health unit in July, August and October, (Patient #1, #5, #6 and #10).

Employee A and B were interviewed again on 12/17/10 at 11:00 A.M. regarding the reported abuse to Patient #9 by Employee E. Employee A and B confirmed no policies and procedures had been put into place to prevent a reoccurrence, and were unable to provide documentation of any actions taken to protect patients upon Employee E's return to work.

Based on medical record review, staff interview and document review, the hospital failed to adequately supervise patients at risk for suicide and failed to evaluate their approach for preventing suicides once patients attempted suicide. For current patients, since the facility failed to evaluate their failure to prevent suicide attempts by 5 previously hospitalized patients, the 9 patients currently on the unit who are at risk for suicide, continue to be at risk at the IJ level. This affected five of ten patients whose medical records were reviewed, (Patient #1, 4, 5, 6 and 10).

During this investigation the Vice President of Clinical Services and the Clinical Nurse Manager were notified on December 14, 2010, at 2:05 PM that a determination was made that immediate jeopardy (IJ) existed at this facility in regard to patients attempts at suicide and lack of action taken by the facility to ensure that suicide attempts were prevented. This failure to provide a safe environment placed the current nine patients identified as a suidcide risk on the unit (Patient #s 13-17 & 19-22) at risk for immediate jeopardy. A plan for immediate action was requested.

The hospital census at the time of survey was 107. The census on the 30 bed adult behavioral health unit was 18.

The facility also failed to protect Patient #9 from physical abuse by a staff member, and failed to put measures into place to protect the current 18 patients from abuse by staff.

Findings included:

Patient #4 was admitted to the adult behavioral health unit on 05/21/10 after threatening to commit suicide. The patient was placed on every fifteen minute checks per facility policy. On 05/22/10, the patient was successful in committing suicide by hanging while on the unit. The facility failed to put any measures in place to protect the patient's safety, and prevent him/her from doing harm to him/herself during the time in which staff was not present.

Following the incident with Patient #4, the hospital put preventive measures in place to prevent a reoccurrence. These measures included an additional assessment at the time of admission to identify patients at risk. The assessment was not put into use until August, 2010, over two months after Patient #4 committed suicide. Additional measures were identified to decrease risk to patients, such as changing the bathroom doors, but these measures were not put into effect as of the 12/17/10 exit date of this survey.

Four additional patients attempted to harm themselves on the unit after Patient #4's successful attempt. Patient #1, #5, #6 and #10 all attempted to harm themselves by placing objects around their necks. The medical records revealed additional staff observations had been instituted for one of the four, although all four were identified as being at risk for suicide. The hospital failed to document any additional measures taken based on these four additional patients attempted to harm themselves to prevent patients from committing these acts.

In an interview conducted on 12/14/10, Hospital administrative staff, including Staff A, B and C confirmed no interventions were put into place to prevent further recurrences after the original plan of correction in response to the 5/22/10 incident.


Please refer to 42 CFR, 482.13(c)(2); Tag A144 - Care in a Safe Setting.

Additionally, the hospital failed to protect Patient #9, who was admitted to the hospital for behavioral disturbances and an organic disorder due to dementia, from being physically abused by hospital staff.

Please refer to 42 CFR, 482.13(c)(3), Tag A145 - Free from Abuse/Harassment.

Based on medical record review, staff interview and document review, the hospital failed to ensure patients were protected from harming themselves, or attempting to harm themselves while being cared for on the mental health unit. This affected five of ten medical records reviewed, (Patient #1, 4, 5, 6 and 10). The adult behavioral health unit census at the time of survey was 18.


Findings included;

Patient #4 was admitted to the hospital on 05/21/10 after presenting to the Emergency department. The patient had been taken to the hospital after threatening to jump off a bridge to attempt suicide. Fifteen minutes checks were instituted upon admission per facility policy. A fifteen minute check was documented on the patient at 3:30 P.M. On 05/22/10 at 3:50 P.M., Patient #4 was found with a noose made out of a sheet hanging over the bathroom door. The patient had apparently tied part of the sheet around his/her neck, tied the other side into multiple knots visible on exterior top of bathroom door with the door shut tightly. The door was opened by staff, and the patient was witnessed to have oral cyanosis and agonal breathing and no pulse was able to be felt. The record revealed CPR was initiated and the sheet was removed by security personnel. EMS was called and staff continued CPR using the AED and ambu bag to provide artificial respirations and attempt to re-start the patient's heart. The patient was transferred to the emergency department, admitted to SICU and died on 05/26/10.

The hospital conducted an investigation of the incident; date unknown and an action plan was developed and submitted to the Ohio Department of Mental Health with a completion date of 7/20/10. The action plan included:
1) Risk assessment of the environment was to be completed which included plant engineering. Plant engineering was to design a door with a collapsible top section and safe door knobs.
2) Develop a plan which would further evaluate high risk psychiatric patients to determine best practices for 1:1 care, revise code blue/pink and ER policies to reflect the behavioral medicine center's patient population, and review/revise one to one policy to determine best practices for 1:1 care with medical director approval. (a new policy was developed for a unit level assessment. The physician is called with the results of the assessment - which has no standardized form of identifying patients at increased risk. The physician then makes a clinical judgement of the patient's risk and orders the appropriate level of observation).
3) Staff education regarding code and assessment policies.

The hospital lacked evidence the environmental assessment was done. A tour of the unit was conducted on 12/14/10 and 12/15/10. The doors to the patient rooms and the patient bathrooms are solid wood with no collapsible top section. The new policy developed for a unit level assessment titled "Unit Level Observation" was reviewed on 12/14/10 and 12/15/10. The policy lists the categories which are to be taken into consideration. These categories include; suicidal risk, elopement risk, homicidal risk, fall risk, assault risk, seizure risk, chemical dependency and psychotic/confusion. The triggers identified on this policy, include but not limited to observe for suicide risk where there is a concrete plan to commit suicide, verbalization to harm self, recent history of suicide attempt, ambilivent about engaging in a verbal or written contract not to harm self, and unwilling to make contract with staff currently. The policy stated the assessment is to be completed upon admission to the unit and reviewed with the admitting physician. The physician determines the level of observation based on the assessment. A physician's order will be obtained placing the patient on a unit level observation based on clinical need. The policy lacked any means by which to standardize the ordering of unit level observations. The assessment lacked a means to determine if a patient is at high or low risk for suicide based on this assessment.

Patient #5 was admitted on 07/16/10 with a diagnosis of major depressive disorder. On admission the patient was placed on every 15 minute checks. The patient was admitted after being brought to the emergency department by the police department. The patient was described as suicidal by the emergency department staff. The patient was noted on the emergency department record to have a history of previous suicide attempts. On 07/17/10 at 10:35 A.M., security staff reported responding to a call for assistance on the behavioral health unit. The security guard stated he was informed a patient had attempted to hang himself, and was noted to be sitting outside of the bathroom door of his assigned room, with a nurse present. The patient was sitting on a chair with hospital pants tied around his neck. The pants were positioned over the bathroom door. Behavioral health unit staff stated this was a suicide "gesture" only "no incident occurred." No further investigation or follow up was completed. The patient was placed on 1:1 observation after the incident. The medical record lacked documentation of interventions put into place upon admission to protect the patient from causing harm to himself.


Patient #1 was admitted on 08/16/10 after presenting to the emergency department with complaints of suicidal ideation. The patient was placed on every 15 minute checks on admission to the behavioral medicine unit. The medical record lacked documentation of interventions put into place upon admission to protect the patient from causing harm to himself. The patient had been discharged from the mental health unit on 08/09/10. The history and physical completed on the 08/16/10 admission stated the patient had a history of serious suicide attempts in the past. On 08/19/10 Patient #1 was reported to have obtained an approximate 6-7 inch rubber tube that is used with the blood pressure machine. The report stated the patient had attempted to wrap it around his/her neck. Through the process of the every fifteen minute checks, the patient was found laying on the patient's room floor, and had begun to show discoloration. The tubing was removed and the patients breathing returned to normal. The patient was placed on 1:1 observation. Staff were directed to leave all spare blood pressure cuffs in a room and only take one out, returning it to the bin immediately after use. Documentation revealed no further investigation was done because the case was determined to be a "suicide gesture". The clinical nurse manager stated, "It was felt that the patient's airway could not have been completely closed off by this piece of equipment, as it did not stretch very far and the patient had a very thick neck. It was believed that the patient was holding his/her breath..."


Patient #6 was admitted on 10/14/10 with a diagnosis of schizo-affective disorder and borderline personality disorder. The patient was taken onto the unit and changed into a hospital gown. The documentation by the admission nurse stated the patient grabbed her bra and attempted to put it around her neck. The patient was then taken to the quiet room with the nurse present. The patient obtained a sheet from the bed in the quiet room. The patient later put the sheet around his/her neck and attempted to choke self with the sheet. The incident report revealed the patient's physician was contacted after the second incident and ordered 1:1 monitoring. The incident report further described the second incident, stating; "Several staff were required to assist in removal of the sheet due to the patient's resistance" The nurse manager of the unit reported the patient had frequent admissions to the mental health unit and each time she is admitted she makes similar gestures in front of staff. The nurse manager reported the patient behavior was discussed with the team and the patient will be given hospital pajamas and will be on 1:1 observation in the future.

Patient #10 was admitted 10/22/10 with a diagnosis of bipolar disorder. The physician's note from the emergency department noted the patient to be suicidal and at risk for causing " harm to self". The patient was on every 15 minute checks upon admission. Review of the medical record revealed a nursing note dated 10/24/10 at 07:45AM, that another patient reported to staff that Patient #10 was in the day room attempting to place a telephone cord around his/her neck. The staff responded and noted the patient did have a reddened area to the neck. The nurse manager stated she did not feel the cord is long enough to go around a person's neck and is covered in heavy metal to avoid injury. The case was closed on 12/01/10 because four requests for follow-up had resulted in no further information being received by the patient relations department. In interview on 12/14/10, the nurse manager stated the supervisor did not write any follow-up. The nurse manager stated she was having the supervisor write up a more intensive review of the case.

In an interview conducted on 12/14/10, Hospital administrative staff, including Staff A, B and C confirmed no interventions were put into place to prevent further recurrences after the original plan of correction in response to the 5/22/10 incident.

The documentation regarding the incidents for Patient #1, #5, #6 and #10 revealed the incidents were referred to as suicide gestures, so no further investigation or interventions were put into place. An interview was conducted with the medical director of the Kettering Behavioral Medical Center, Employee K, on 12/13/10 at 10:00 A.M., regarding the difference between a suicide gesture and a suicide attempt. Employee K stated a suicide gesture would be done in plain view of staff, and likely presented no harm to self. The medical records for these patients revealed Patient #1, #5 and #10 were not in plain view of staff at the time of attempts to harm him/herself.

A confidential interview was conducted with Patient #12 on 12/14/10 at 11:00 A.M, in the patient's room. Patient #12 reported he/she was admitted on 12/10/10 (confirmed by medical record review) after receiving care in the hospital critical care unit after attempting suicide. Patient #12 reported he/she frequently went long periods of time without seeing staff, including one incident in which it was eight hours between staff checks. During the course of the interview with Patient #12, it was noted a blood pressure cuff, with the flexible tubing attached, was lying on a stand next to the patient's bed within easy reach.


27700

On 12/15/10 at 11:05 AM this surveyor interviewed Patient #11 regarding the overall care provided on the unit. Patient #11 was admitted on 12/13/10 with major depression with a diagnosis of overdose. Patient #11 complained in regards to the morning medication administration. Patient #11 stated that this AM he/she was brought their medications by the Registered Nurse. Patient #11 stated that one of the pills which is a time released heart medication was damaged when the nurse brought the medications to the bedside. Patient #11 stated that he/she refused the heart pill due to the outer capsule of the pill being damaged and the granules inside had fallen out. Patient #11 stated the nurse had then asked if he/she wanted a pill to replace the damaged one. Patient #11 consented and a replacement pill was provided. At the time of the interview which was conducted in Patient #11's room, Patient #11 showed this surveyor granules which as reported by the patient had spilled from the capsule and was located on the bedside table of the bed next to Patient #11's, in plain view of, and accessible to any patient entering the room. This was confirmed with Staff A and Staff C on 12/15/10 at 11:08 AM.

Based on medical record review and staff interview, the facility failed to protect Patient #9 from excessive force by a staff member (Employee E). Although, Employee E was suspended during the investigation, the facility failed to address the lack of staff reporting of previous excessive force issues prior to the complaint from Patient #9's family and failed to put measures in place to ensure Employee E, who returned to work on the unit, was competent to care for patients that display violent behavior.

Findings included:

The medical record for the Patient #9 was reviewed on 12/14/10 - 12/17/10. A second medical record for the patient's emergency department admission at a second facility was also reviewed. The medical record contained evidence the patient was admitted to the facility on 08/03/10 due to concerns of extreme paranoia and behavioral dysregulation due to dementia. The medical record revealed he was discharged from the facility on 08/18/10 and sent to the emergency department of a second hospital due to concerns of dehydration. The medical record contained evidence of numerous physician progress notes and nursing notes which reported the patient had episodes of violent behavior including being aggressive towards staff in the form of hitting, kicking, pushing and punching staff. The staff's response to this behavior was the use of manual restraint, which means staff physically held the patient's arms and legs to keep the patient from moving and/or 4 point leather restraints.

The medical record for the emergency department admission at Kettering Memorial hospital on 08/19/10 revealed documentation by the physician which described bruising to the patient's body. The notation stated "The patient does have a right lateral thigh bruise extending to the gluteal area. There is also a left inner thigh bruise and right upper extremity bruise." The medical record revealed the patient's family was concerned about the bruises and felt someone was hurting the patient. The record revealed the family contacted patient relations and the police department.

The facility presented documentation of their investigation into the patient's bruising. The documentation included statements from staff members working on 08/17/10 on the evening shift. The first witness report was from a mental health technician (Employee F) who was assigned to be observing the patient along with a second mental health technician (Employee E). Employee F described an incident he witnessed on 08/17/10 at 4:45 P.M. involving Employee E and Patient #9. The statement says the patient was physically putting hands on Employee E and Employee E stated "Why are you bullying people?" and stated "I am not scared of you". The statement revealed the patient continued to physically and verbally threaten staff, but does not give details of the threats. Employee E then "referenced incident from previous day and patient continued to escalate." No details were given regarding the incident from the previous day. The report stated attempts to calm the patient were unsuccessful and the patient attempted to physically attack Employee E again. Employee E then, "forcefully pushed patient into the wall next to the bathroom door in the quiet room area. (Employee E) restrained patient up against wall and (nurse) and (Employee F) stepped in attempting to de-escalate patient by restraining hands in order to avoid any injuries to the patient or staff. (Nurse) then told (Employee E) to 'back off' ".

The statement also described a second incident occurring on 08/17/10 at 6:30 P.M. The second incident occurred in the lounge area near the nurse's station. The report stated the specified patient attempted to sit on couch next to a female peer. Employee E and F attempted to redirect the patient because "we did not feel that it was an appropriate place for the patient to sit." The statement lacked any information regarding why it was felt this was an inappropriate place for the patient to sit. The statement went on to state the patient attempted to punch Employee E in the abdomen. Employee E "grabbed patient and started to take patient down to the floor" Employee F stated he held the patient's arm to prevent the patient from hitting staff and to ease the patient to the ground. The statement went on to say "Fellow staff and I had patient safely restrained on ground and we proceeded to carry patient to quiet room."

The second incident was also described in a witness statement by Employee G. Employee G is a Registered Nurse working on the unit. Employee G stated he/she was not caring for the specified patient, but was caring for the female peer referenced in the earlier statement. The statement revealed the specified patient was observed to "lunge towards her and then saw (Employee E) come up between them on (specified patient's) left side and he wrapped his arms around (Patient #9's) waist and said 'take him down, take him down.' And along with the momentum from coming at him from the side, began to lower (specified patient) to the floor, almost like a football tackle. During this time, (Employee E's) shoulder or watch caught (specified patient's) bottom lip and busted open the scab that had been there since Saturday and it began to bleed......As (Employee E) was taking his down, (Patient #9's) arms were rubbed on the floor and the areas he had to his arms that had been like blood pooled under the skin into bruised areas, was torn open into several skin tars that also began bleeding."

A witness statement was also reviewed from Employee H. Employee H was the nurse caring for the specified patient on 08/17/10. Employee H was referenced in the witness statement of Employee F as telling Employee E to "back off". The witness statement from Employee H lacked a description of the incident, stating, "One of the employees (Employee E) appeared to use excessive force to gain control of the patient. When I saw this, I asked (Employee E) to let go of the patient and allow me to intervene, which he did.

Documentation lacked evidence the incident was reported by Employee H at the time of the incident, and Employee E continued providing care to the specified patient, leading to the second incident in the lounge area. The nursing note for 08/17/10 at 4:45 P.M., written by Employee H stated, "Pt began pacing around quiet room and pushing staff" The note stated the patient was administered as needed medication.

A witness statement from Employee I, a nurse at the facility described a complaint he/she received from another patient on 08/18/10. Employee I stated the patient reported he/she had felt (Employee E) had been "overly rough" with the specified patient on 08/17/10. The patient described the incident as occurring in the common area when the specified patient attempted to sit next to a female patient. The patient further stated he/she had overheard Employee E refer to the incident in what the patient described as a "corny joke kind of way", stating he would "take him down again if he needed to."

Another witness statement was reviewed from Employee J. Employee J did not describe witnessing any of the incidents, but stated Employee F reported that (Employee E) overreacted when the specified patient reached for a female peer and "tends to instigate many of (specified patient's) behaviors. The statement goes on to say Employee G stated she had observed Employee F being short-tempered with the specified patient. The statement reported Employee E was then taken off the duty of observing the patient and replaced with another employee. The specified patient was bathed that evening and a "large purple bruise was noted in back of the right thigh."

The medical record revealed no documentation in the progress notes or nurse's notes of either incident. The medical record further lacked an order to restrain the patient at any time on the evening shift of 08/17/10. The medical record lacked documentation of the large purple bruise to the back of the right thigh.

Facility documentation revealed Employee E was placed on suspension and an investigation was conducted. The witness statements were part of the facility investigation. Employee E received a written reprimand and was permitted to return to work. An interview was conducted with Employee C, the Clinical Nurse Manager of the behavioral health unit, on 12/15/10 at 3:30 P.M. Employee C stated Employee E received coaching and counseling regarding the take-down of Patient #9, as this procedure is to be done with two staff members, and Employee E attempted the procedure by himself. The written reprimand, and all documentation of the investigation and correspondence with the patient's family lacked mention of the first incident in which Employee E was described as forcefully pushing the patient into the wall, and restraining him/her. The documentation further lacked follow up with the nurse who described Employee E's behavior as "excessive force."

Further review of the facility documentation lacked evidence of any measures put into place to protect patients from abuse by staff members.

This substantiates the complaint.

Based on medical record review and staff interview, the hospital failed to ensure an order was obtained to restrain one patient (Patient #9) when he/she was restrained against

The medical record for the Patient #9 was reviewed on 12/14 - 12/17/10. The medical record contained evidence the patient was admitted to the facility on 08/03/10 due to concerns of extreme paranoia and behavioral dysregulation due to dementia. The medical record revealed he/she was discharged from the facility on 08/18/10 and sent to the emergency department of a second hospital due to concerns of dehydration. The medical record contained evidence of numerous physician progress notes and nursing notes which reported the patient had episodes of violent behavior including being aggressive towards staff in the form of hitting, kicking, pushing and punching staff. The medical record revealed the patient was placed in restraints multiple times including 08/14/10, 08/15/10 at 5:37 P.M. and again at 7:30 P.M., 08/17/10 at 4:05 A.M. and 4:50 A.M.

Facility documentation regarding an investigation into the care of this patient was also reviewed. The documentation included statements from staff members working on 08/17/10 on the evening shift. The first witness report was from a mental health technician (Employee F) who was assigned to be observing the patient along with a second mental health technician (Employee E). Employee F described an incident he witnessed on 08/17/10 at 4:45 P.M. involving Employee E and Patient #9. The report stated attempts to calm the patient were unsuccessful and the patient attempted to physically attack Employee E. Employee E then, "forcefully pushed patient into the wall next to the bathroom door in the quiet room area. (Employee E) restrained patient up against wall and (nurse) and (Employee F) stepped in attempting to de-escalate patient by restraining hands in order to avoid any injuries to the patient or staff. (Nurse) then told (Employee E) to 'back off' ".

The statement also described a second incident occurring on 08/17/10 at 6:30 P.M. The second incident occurred in the lunge area near the nurse's station. The report stated the specified patient attempted to sit on couch next to a female peer. Employee E and F attempted to redirect the patient because "we did not feel that it was an appropriate place for the patient to sit." The statement lacked any information regarding why it was felt this was an inappropriate place for the patient to sit. The statement went on to state the patient attempted to punch Employee E in the abdomen. Employee E "grabbed patient and started to take patient down to the floor" Employee F stated he held the patient's arm to prevent the patient from hitting staff and to ease the patient to the ground. The statement went on to say "Fellow staff and I had patient safely restrained on ground and we proceeded to carry patient to quiet room."

The medical record for Patient #9 lacked documentation of either incident. The medical record further lacked documentation of an order to physically restrain the patient, or any notification to the patient's physician of these two incidents, despite documentation the patient had bleeding to his/her lip, several skin tears to the arms and bruising to his/her right thigh as a result of the second incident.

These findings were confirmed by Employee C on 12/15/10 in an interview beginning at 3:30 P.M.

Based on review of medical records, quality assessment and performance improvement (QAPI) reports and staff interviews, the hospital failed to take a proactive approach to improve their performance in regards to patient care and safety. The hospital failed adequately supervise patients at risk for suicide and failed to evaluate their approach for prevention of suicide once patients attempted suicide. This affected 5 previously hospitalized patients and the 9 patients currently in the unit who are at risk for suicide.

Findings include:

The hospital failed to ensure it's performance improvement council received specific information regarding patient suicide attempts and staff physical abuse of patients in order to ensure an ongoing, effective QAPI program that showed measurable improvements in patient safety and care. This affected six of twelve medical records reviewed, (Patient #1, #4, #5, #6 and #10), and all 18 patients currently admitted to the adult behavioral health unit. Please refer to A285.

Based on document review and staff interview, the hospital failed to ensure it's performance improvement council received specific information regarding patient suicide attempts and staff physical abuse of patients in order to develop a specific system wide plan to prevent further occurrences. This affected six of twelve medical records reviewed, (Patient #1, #4, #5, #6 and #10), and all 18 patients currently admitted to the adult behavioral health unit.

Findings included;

The Performance Improvement counsel meeting minutes were presented as evidence of quality assurance/performance improvement activities related to the two identified adverse events. The meeting minutes from the 10/20/10 meeting were reviewed on 12/16/10. The meeting minutes revealed an adverse events report was submitted to the committee. The details of this report included the total number of events which "meet the criteria for a threshold investigation to be performed." The report stated 14 events met the threshold and a root cause analysis was conducted. The report gave no details of what these events were, or what measures were put into place to prevent reoccurrence. The report gave no details regarding the suicide of Patient #4. The report also lacked any details specific to the physical harm to Patient #9 by Employee E while he/she was assigned to the patient's care. The documentation lacked evidence of the performance improvement council's participation in developing a plan to prevent patients from causing harm to themselves while admitted to the adult behavioral health unit. The documentation further lacked documentation of the council's participation in developing a plan to prevent patients from being harmed by staff members on the behavioral health unit.

The hospital did not have any documented data and/or monitoring system in place for the identified suicidal gestures/attempts in response to the actual gestures and/or attempts. There was no system to collect data, analyze data, implement a plan and/or evaluate suicidal gestures/attempts.


The hospital's performance improvement plan for 2010 was reviewed on 12/16/10. The plan stated the performance improvement council "has the responsibility to design, implement, oversee, and evaluate the performance improvement program for the organization, inclusive of the medical staff and medical center."

There was no evidence that the hospital focused on preventing suicidal gesture/attempts to ensure patients were safe from harming themselves. The hospital lacked any actions taken in response to the suicidal events of Patient #1, #5, #6 and #10 or the physical abuse of Patient #9. No policy and/or procedures were taken in to action to remedy the events and/or prevent the occurrences. There was no system in place for improving processes that would improve the quality of care of suicidal patients. These high risk patients are problem prone. However the hospital did not consider the incidents, prevalence and/or severity of the identified problem areas. No actions aimed at performance improvement had been taken by the hospital. The hospital healthcare system further lacked a safe, effective, patient centered, timely efficient and equitable care of the specified patients and further patients presenting to the hospital with suicidal gesture and/or attempts.


In an interview conducted 12/14/2010 at 12:43 P.M. staff stated that there is no ongoing, hospital wide data driven response to the suicidal gestures/attempts. Employee A and B confirmed no changes have been made in response to four patients who attempted to harm themselves while admitted to the behavioral health unit in July, August and October, (Patient #1, #5, #6 and #10).

Based on review of the medical record and confirmation with staff and policy review it was determined that the hospital failed to ensure that the care plan for the patient was kept up to date as the patient condition changed. This was noted in 1 out 10 medical records, Patient #5. The patient census is 18.

Findings included:

The medical record for Patient #5 was reviewed on 12/14/10. Patient #5 was admitted on 07/16/10 with overdose and depression. The medical record revealed that on 07/17/10 at 10:35 AM Patient #5 was found sitting in a chair with hospital pants tied around his/her neck and over the bathroom door. Following this incident there was no changes made to Patient #5's Individual Treatment Plan that was developed on 07/16/10, there was no further change made until 07/19/10. This was confirmed with Staff A on 12/15/10 at 3:05 PM who stated that the plan of care should have been updated following the suicidal gesturing that was exhibited by Patient #5 on 07/17/10. A review of the policy and procedure entitled "Individual Treatment Plan" stated that the treatment team meets regularly to assess progress and to update and modify the plan.

Based on medical record and facility documentation review and staff interview, the facility failed to ensure that staff were competent to manage the care for a behavioral patient (Patient #9) without using excessive force.

Findings included:

The medical record for Patient #9 was reviewed on 12/14/10 to 12/17/10. The medical record revealed the patient was admitted to the behavioral health unit on 08/03/10 for Organic Disturbances and Mental Retardation. The medical record for Patient #9 revealed multiple episodes of violence and disruptive behaviors by the patient both before and during hospitalization. Further review of the medical record revealed the patient was assigned two staff on 08/17/10, who were responsible for observing and assisting in his/her care at all times.

Review of hospital documentation revealed the hospital conducted an investigation regarding the patient #9's care during his/her stay on the behavioral health unit in response to family concerns regarding possible abuse of the patient. The documentation included a witness statement from one of the two mental health technicians assigned to the patient on 08/17/10. The witness statement detailed an episode that occurred at 4:45 P.M. in which one of the mental health technicians (Employee E) "pushed (Patient #9) back into the quiet room". The statement went on to say the mental health technician then "forcefully pushed pt. into the wall next to the bathroom door in the quiet room area. (Employee E) restrained pt. up against wall..." The statement went on to say the nurse caring for the patient (Employee H) and the mental health technician writing the statement had to step in to help calm the patient and restrain his/her hands to prevent injury to the patient or staff. The witness statement further stated the nurse, (Employee H), told Employee E to "back off". A witness statement completed by Employee H stated he/she felt Employee E used "excessive force". Review of the medical record revealed there was no documentation that Employee E was removed from the care of Patient #9.

A second incident was then detailed by the witness statement. The second incident occurred at 6:30 P.M., and Employee E was noted to grab the patient and take the patient down to the floor. The medical record documented injuries to the patient from the second incident, including several skin tears that were bleeding, bleeding to an old injury on his/her bottom lip, and a large purple bruise to the back of the right thigh.

These findings were reviewed with Employee A and Employee C on 12/15/10, in an interviewing starting at 3:30 P.M. Employee C stated Employee E was suspended after the incident, receiving counseling and coaching and was allowed to return to work. Employee C further stated Employee E had some "PTSD (Post Traumatic Stress Disorder) stuff" and went to outside counseling for this. The personnel file for Employee E lacked documentation of the status of his/her counseling or ability to safely provide care to patients on the behavioral health unit.