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Based on medical record review, facility policy review, and staff interview, the facility failed to ensure three patients (Patient #2, Patient #4, and Patient #5) were placed on level I privilege status, restricting access to the unit, to ensure the safety of patients, failed to ensure staff notified a psychiatric physician of a patient's (Patient #4) elevated aggression score and verbal sexual advances and lewd comments, and failed to ensure staff performed and documented every 15-minute observations for two patients (Patient #2 and Patient #4) hospitalized in the facility Psychiatry Services unit (A0144). The cumulative effects of this systemic practice resulted in the facility's inability to ensure the safety of patients. This has the potential to affect all patients receiving services at the facility. The total hospital census was 486.

Based on medical record review, facility policy review, and staff interview, the facility failed to ensure staff followed the current facility policies related to privilege levels, every 15-minute observations, and physician notification of an elevated aggression score. This affected three (Patient #2, Patient #4, and Patient #5) of six patient medical records reviewed. The total hospital census was 486.

Findings include:

1. The facility policy titled "Observation and Privilege Levels" was reviewed on 08/03/18 at 11:45 AM. According to the policy every patient admitted to psychiatry is assigned a privilege level (safety status) to promote privacy and independence while ensuring a safe and therapeutic milieu for patients and associates. The policy defined the 3 privilege levels. With a level I privilege level the patient is restricted to the unit. With a level II the patient may leave the unit to participate in treatment groups. And with a level III designation, a patient may leave the unit to participate in treatment groups and may also leave the unit with family or a case manager with a physician's order. On admission to the Psychiatry Services unit, all patients must be placed on level I privilege status for a minimum of 24 hours. A patient must be on a level at least 24 hours before considering advancement to the next higher privilege level.

a. Patient #2, the Specified Patient, presented to Psychiatric Emergency Services (PES) on 07/10/18 at 12:44 PM for paranoia, bizarre behaviors, and medication noncompliance. The patient, having a history of paranoid schizophrenia, was noted to have multiple similar visits to the Psychiatric Services unit in the recent past. The patient was admitted under a 72 hour hold. On 07/10/18 a psychiatric physician ordered a level II privilege level for the patient. The patient remained a level II privilege level his/her entire hospitalization. He/She was discharged from the hospital on 07/19/18.

b. The medical record of Patient #4 revealed he/she was brought to PES on 07/05/18 at 09:00 PM by police. A Case Manager's Progress Note stated the patient was found walking in and out of traffic yelling and threatening others. A psychiatric physician ordered a level II privilege level.

c. Patient #5 was brought by police to PES on 07/13/18 at 10:43 PM. The patient was noted to be "rambling about vampires taking his/her blood and mixing it with wine" when approached by police. The patient had a history of bipolar disorder with antisocial personality disorder. The psychiatric physician's triage screening noted the patient had severe altered mental status of psychosis. A Nursing Note on admission stated the patient became acutely agitated, threatening physical violence against another patient and staff. The patient told another patient he/she would claw the patient's eyes out. Staff placed patient in two point restraints. When the patient continued to yell obscenities, staff administered Thorazine 100mg intramuscularly. It was noted that staff continued to have a difficult time calming the patient down. The patient was subsequently placed in four point restraints. The psychiatric physician ordered this patient to be placed in a level II privilege status.

Staff N was interviewed on 08/03/18 at 12:45 PM. He/She explained that all patients are given a level I privilege level for at least 24 hours to give clinicians time to assess the patient to determine if the patient is appropriate to attend treatment groups and if it is safe for the patient to attend treatment groups. As the patient progresses through treatment the level can be adjusted by the physician. It was confirmed on 08/03/18 at 12:50 PM that Patient #2, Patient #4, and Patient #5 should have all been placed on a level I privilege status.


2. The facility policy titled "Observation and Privilege Levels" was reviewed on 08/03/18 at 11:45 AM. According to the policy the minimum level of observation is standard observation. Standard observation requires every 15-minute observation and documentation on the Patient Activity Checklist.

a. The medical record of Patient #4 revealed staff assessed the patient for aggression every shift as required by facility policy. At 07/11/18 at 11:30 AM the aggression assessment noted an elevated score of 16. This score included a 2 for verbal sexual advances and lewd comments. The medical record lacked documentation a psychiatric physician was notified. Nursing Notes revealed the patient was accused of sexual assault approximately 3 hours later.

Further review of the medical record of Patient #4 revealed every 15-minute observations and documentation from 07/05/18 through 07/11/18. It was noted that the patient was in the hallway on 07/11/18 at 02:45 PM, 03:00 PM, 03:15 PM, 03:30 PM, and 03:45 PM. The patient was noted to be in his/her own room at 04:00 PM and 04:15 PM. The patient was discharged from the facility on 07/13/18. The medical record lacked documentation of every 15-minute observations on 07/12/18 and 07/13/18.

The facility protocol for aggression screening was reviewed with Staff P, Clinical Pharmacy Specialist for Psychiatry, on 08/03/18 at 02:45 PM. According to Staff P the scale captures behavior observed in the last hour. If a patient scores 1-9, nursing staff should consider medicating him/her with an as needed medication by mouth. In bold type the behavior tool stated if the patient scores a 10 or greater, the psychiatric physician must be contacted.

b. Review of the medical record of Patient #2 revealed staff was ordered to perform every 15-minute observation and documentation on the Patient Activity Checklist. The 15-minute checks were noted with activity codes and staff initials. On 07/11/18 checks at 02:45 PM, 03:00 PM, 03:15 PM, 03:30 PM, 03:45 PM, 04:00 PM, 04:15 PM, 04:30 PM, and 04:45 PM noted the patient was in the hallway. Although the patient was hospitalized until 07/19/18, the medical record lacked documentation of 15-minute checks from 07/12/18 through 07/15/18 and 07/18/18 and 07/19/18.

Staff N was interviewed on 08/03/18 at 03:00 PM. It was confirmed that the medical record lacked documentation a physician was notified of the patient's elevated aggression score. These facts were confirmed with Staff C, Manager Accreditation and Regulatory Compliance on 08/02/18 at 03:45 PM.

Based on observation and staff interview the facility failed to ensure sewage was not backing up into the hospital patient care areas (A701). The cumulative effects of this systemic practice resulted in the facility's inability to ensure the safety of patients. This has the potential to affect all patients receiving services at the facility. The total hospital census was 486.

Based on observation, and staff interview the facility failed to ensure sewage was not backing up into the hospital patient care areas. This has the potential to affect all patients receiving services at the facility. The facility census was 486.

Findings include:

During tour of the 2nd floors for the Main Building and the Critical Care Pavilion completed on 08/01/18 at 1:25 PM observation was made of a current sewage line leak that is dripping above the ceiling in the cathlab control room, a catch pan was noted in the ceiling with a line running to a sealed 50 gallon drum.

Interview with Staff A at 1:25 PM revealed that there was a back up in the scrub sink in the catheterization lab control room a few weeks ago and when they unclogged the stack pipe they had to do it from the 4th floor. After unclogging the pipe, a leak was noted later. After investigating, a crack in the pipe was noted on the 3rd floor and that is where the current leak is coming from.

Observation of the pipe on the 3rd floor revealed a large section of wall was removed exposing the pipe and the leak. The area had been sealed off with plastic to control any odors or particles so plumbers can fix the leaking pipe.

Interview with Staff A completed on 08/01/18 at 3:00 PM revealed the facility is getting back "Butt" wipes, Clorox wipes, and peroxide wipes when the plumbing is snaked and all three items are used in the facility. Staff A stated it is an issue with people (staff) putting these items in the toilets which is clogging the stack (drain pipes for the sewage system). Staff A stated that he has been tracking it through memory and it seams to float throughout the building. No way to pinpoint to where it is coming from. If the sewage backups and starts to flood a space then it is all hands on deck to take care of it. Staff A stated that he/she remembers 7 backups in the 13 months he/she has been at the facility. Most recent was in room 4152 around Monday or Tuesday of last week. Staff A stated that it has not happened to a water fountain since he/she has been at the facility. But does not know if it happened before that.

When a back up (flood) happens the unit staff call the Service Response Center (SRC) which will contact the plumber on duty and the plumber will grab their tools and check it out. The plumbers report to the managers and the managers report to Staff A. Wipes have been identified as the problem due to pulling them out with the pipe snake after a clog.

There was no documented evidence the hospital has attempted to put a plan in place to reduce the problems associated with the plumbing, no evidence the hospital is tracking the frequency of the line breaks/leaks, no evidence staff have been educated or advised not to flush disposable wipes due to the effect the wipes have in regard to plumbing issues, and no signage educating/reminding persons not to flush wipes has been posted.