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Based on interview and document review the hospital failed to ensure patients were provided care in a safe setting for 3 of 31 patients reviewed. As a result the hospital was found not in substantial compliance with the Condition of Participation of Patient Rights at 42 CFR 482.13 related to case #H4002084 and #H4002086.

Findings include:

See A144 The hospital failed to provide adequate supervision to 3 of 31 patients (P1, P2, and P3) reviewed resulting in patient injuries.

Based on interview and document review the hospital failed to provide adequate supervision to 3 of 31 patients (P1, P2, and P3) reviewed resulting in patient injuries.

Findings include:

Medical record review revealed P1 was admitted to the hospital on 6/30/2016 with diagnoses that included Schizoaffective Disorder and Polysubstance abuse disorder. P1 was under civil commitment to the hospital related to Mental Illness dated 6/9/2016 and had a commitment order for forced use of Neuroleptic Medication dated 6/9/2016.

P1's violence risk assessment dated 10/17/2016 revealed P1 was at a moderate risk for violence.

P1's Psychiatric Assessment dated 6/30/2016 revealed P1's history included being committed in 2011 as Mentally ill and Dangerous after she stabbed a significant other/boyfriend. From 5/5/2016 - 5/13/2016 she was hospitalized in Duluth with an episode of psychosis and homicidal ideation and threats.

An RN nursing notes, dated 11/21/2016 revealed P1's supervision level was Gold level, meaning she had every 15 minute checks on normal rounds and independence to go off the unit escorted by staff and move about the building unescorted during specific times.

P2 was admitted to the hospital 10/18/2016 with diagnoses that included Antisocial Personality Disorder and Borderline Traits.

P2's psychiatric assessment dated 10/18/2016 revealed P2 was civilly committed to the hospital on 6/3/2016 with a rule 20 commitment (criminal charges had been filed) related to Mental Illness and risk of harm to self and others, and had a commitment order for forced use of Neuroleptic Medication dated 6/3/2016. P2's history included a history of volatile and disruptive behavior and previous mental health hospital admissions.

A progress note dated 11/21/2016 revealed the Cloquet County Law enforcement commander called the hospital staff on 11/21/2016 on the evening shift, stating P1 made several phone threatening phone calls to police and an on-line threat indicating she hated cops and that she was going to kill them and blow up the police station.

P2's progress notes dated 11/22/2016 revealed P2 was in her room trying to take a nap when P1 attacked her. P2 experienced three stab wounds from the attack and was sent to the local acute care hospital where she received three stitches to her left leg.

An incident report dated 11/22/2016 revealed while doing rounds a staff person heard screaming coming from a different hallway. The staff member ran toward the sound as did another staff member where they found P1 on top of P2 on P2's bed. P2 was screaming "Help, get her off me." Staff pulled P1 off of P2 and P2 stated, "She stabbed me." After P1 was removed, staff noted P2 had 3 stab wounds that were bleeding. One stab wound was just below her right eye, and two were in her left lower leg. Medical staff assessed P2 and sent her to the Emergency Room for further treatment.

During an interview on 12/2/2016 at 10:15 a.m., RN-Z stated she worked on 11/22/2016 with P1. When she received report in the morning she was told P1 had been calling a police department on 11/21/2016 threatening to kill police and blow them up. RN-Z asked staff to bring P1 to a team meeting to discuss her calls to the police. In the meeting at about 9:00 a.m. on 11/22/2016 P1 was informed her independence level was changed to restricted so that she could not leave the unit. P1 responded to this by yelling, swearing and pacing the unit off and on for the next three hours, often near the nursing desk. P1's supervision level was not increased at that time. P1 came up to the nursing desk get her Adderall at about 12:00 p.m. on 11/22/2016 and she was told it was discontinued. P1 became angry, hyperverbal, and pacing. P1 refused a PRN (as needed) oral medication. RN-Z stated she requested a forced emergency medication for P1 from NP-CC related to P2's escalating behavior and her refusal of a PRN medication, but NP-CC stated she did not like to use those and declined an emergency medication. P1's supervision level was not increased at that time because P1 often paced and became loud and often calmed down with coffee, additionally RN-Z had not known P1 to become violent before this day.

During an interview on 12/2/2016 at 10:45 a.m., Nurse Practitioner (NP)-CC stated she was the provider for P1 on 11/22/2016, but she had never worked with P1 before. P1 presented on 11/22/2016 as manic and had made threats to a local police department. She and the on-call psychiatrist and the pharmacist met to discuss P1's medication regime and decided to discontinue her Adderall, as they felt that medication could be contributing to her hyper-verbal, manic behavior. NP-CC stated the supervision levels at the hospital were complicated to her and she was new to the hospital, but she could not recall any conversation about increasing P1's supervision level related to her escalating behavior. During the conversation on 11/22/2016 P1 stated she wanted to tell the police were the dead bodies were. NP-CC stated she was not aware P1 had a history of assault/stabbing prior to her hospitalization because she had not worked with P1 before this day.

During an interview on 12/2/2016 at 12:45 p.m., Dr-FF, psychiatrist stated, he was covering for P1's psychiatrist on 11/22/2016. On 11/22/2016 P1 presented on 11/22/2016 as manic, psychotic and agitated. The team made the decision to change her medication regime. Dr. FF told P1 her medication Adderall would be discontinued and P1 was angry with that news. On 11/22/2016 staff indicated P1 was escalating. Dr. FF stated it would have been reasonable under the circumstances to increase P1's supervision due to her escalating behavior, but that was not implemented. Dr-FF stated he was not aware of why her supervision had not been increased. Any staff member can increase a patient's supervision level if they think it is necessary. If P1's supervision level had been increased to a 1:1 staffing, P1 would not have been able to get into P2's room to stab her.


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Medical record review revealed patient #3 was admitted to the facility on 07/27/16 and was treated for swallowing various inedible objects, depression, aggressive behavior to others. The physician admission report indicated P2 was admitted under court commitment to the intensive care area (ICA) with two staff (2:1) monitoring with 1:1 eyes on P3 at all times. (Close 1:1 monitoring occurs when a staff person watches the P3's face at all times.) The patient had a vascular port on the right side of the chest to be used for procedures following many episodes of swallowing objects. P3 has an extensive history of ingesting foreign objects as recent as 06/19/16. P2's treatment has included electroconvulsive therapy (ECT) receiving 34 treatments, two times a week since March of 2016. The history and physical dated 07/27/16, indicated P3 swallowed some metal in 01/16/16, and swallowed a fork 06/19/16, report goes on the say it is known P3 had multiple admission in 2015 because of swallowing various foreign bodies and surgery was needed at least once. A provider progress note dated 10/12/16, indicated because P3 is an unreliable source to explain what the triggers caused the swallowing of objects.

A comprehensive care plan dated 10-5-16, indicated P3's supervision level was one staff to provide close direct observation of P3 while awake and distant one on one (1:1) monitoring while asleep. A hand written note on the side of the comprehensive care plan indicated P3 had swallowed tips from glasses on 10/11/16. There was no change in the intervention of 1:1 on the care plan. The comprehensive care plan dated 11/23/16, indicated P3 required the supervision of two staff while in the ICA.

An incident report dated 10/11/16 revealed P3 swallowed the temple tips off prescription eye glasses. P3 also said he swallowed items like this before and needed to go to the hospital. P3 was sent to the acute care hospital and an x-ray was done and confirmed the patient ingested portions of his glasses. An outpatient procedure, endoscopy was completed that evening to remove the portion of the glasses ingested and P3 was returned to the hospital with an increase of two staff monitoring him at all times.

During an interview on 11/30/16 at 9:20 a.m., registered nurse (RN)-E stated she worked on 10/11/2016 with P3. P3 approached her about 4:45 p.m. and informed RN-E that he had "done something bad" even with a direct supervision by staff. P3 stated he swallowed the the tips of his eye glasses and showed RN-E the glasses. RN-E said P3 was under direct supervision by one staff (1:1 monitoring).

During an interview on 11/30/16 at 1:30 p.m. human service technician (HST)-C reported he was responsible for the 1:1 direct supervision of P3 on 10/11/2016 from 4:00 p.m.-5:00 p.m. HST-C stated he did not see the swallowing event but said he thinks P3 may have swallowed the eye glasses tips while raising both arms to remove a t-shirt. Saying that is the only possible time it could have happened.

A provider's order for P3 dated 10/12/16 indicated: P3 has a GI consult (10/13/16) and during the consult the patients supervision was down graded from 2:1 monitoring to 1:1 monitoring and that staff can offer the patient mitts to wear on his hands prior to departure if patient would agree.

The continuous observation documentation indicated P3 was received 1:1 monitoring while in the ICA and the documentation is every 15 minutes on 10/11/16, 10/12/16 until 4:35 p.m. on 10/13/16, the document instructions direct staff to monitor P3 with two staff (2:1).

The incident report dated 10/13/16, indicated P3 was escorted to a physician's appointment with 1 RN supervising the patient. P3 was observed putting a hand in the mouth, The nurse repeatedly asked P3 why P3 was doing that, P3 stated stated I'm itching my throat. At 10:50 a.m. P3 approached the nurses station and told the nurse at the station about swallowing a key. P3 also stated the key was from the paper towel dispenser at the doctor's office. P3 was sent to the acute care hospital for evaluation with 2:1 staff supervision.

The nurses note dated 10/13/16 indicated RN-H offered the mitts to P3 and they were declined. RN-H did a visual scans of all rooms before entering them. When in the examination room, the doctor entered the room and did a brief examination. The physician asked for some information out of the medical record, which RN-H obtained for the physician. The physician ordered laboratory tests and left the room. RN-H monitored P3 continuously in the laboratory. Many times while in the laboratory, P3 would put his hand in his mouth and each time RN-H would ask P3 what he/she was doing. RN-H also asked questions about P3's agitation level. P3 would deny swallowing anything, say I was itching my throat and denied being agitated. After returning to P3's hospital, RN-H was told by another staff that P3 had told staff he/she swallowing a key at the physician office. RN-H was also informed he/she would be escorting P3 to the acute care hospital to be evaluated. An x-ray was completed and the physician told P3 they could see the key but it would pass by itself. P3 became teary eyed and stated he/she was worried that it will get stuck. An outpatient endoscopy was completed and P3 was sent back to his hospital.

During an interview on 12/1/16 at 1:30 p.m. RN-H stated he escorted P3 to his physician's appointment on 10/13/2016. P3 refused to wear mitts on his hands to his physician appointment. RN-H stated it was unusual to go to the physician appointment with only one staff person. RN-H said at one point in the appointment, the physician needed help finding information in the medical record and RN-H was unable to visualize P3 at all times. RN-H said it was very difficult to observe the area, observe P3 and assist the doctor in finding information in the record all at the same time. During the appointment P3 started acting unusual by putting his hand in his mouth.

During an interview on 11/30/16 at 8:25 a.m. CNP-D stated the decision to send P3 to the appointment was discussed at morning meeting. CNP-D was unable to elaborate on the reason for only sending one staff person with P3 after his recent ingestion of the eye glass tips and was unable to provide documentation of the rationale for this decision, stating the team made that decision. There was no documented rational to support the decision to down grade the patient's supervision level on an outing to see a physician.

During an interview on 11/30/16 at 2:15 pm P3 declined to state how he was able to swallow the eye glasses tips without staff seeing the ingestion on 10/11/2016. P3 did state that when he swallowed the key on 10/13/2016, the staff person was busy in the doctors office showing the physician papers. P3 said he was very fast and when they weren't looking he grabbed the key and swallowed it.

During an interview on 11/29/16 at 11:10 am , RN-G said the hospital had a physician's order to send P3 with one staff person to the physician appointment, but was unable to find any documentation of an assessment or explanation of the rationale for decreasing the patients supervision and only send one staff person with P3 to the physician office appointment, after P3 had just ingested the eye glass tips.

The policy entitled therapeutic observation dated 03/28/16, indicated close one to one observation (close 1:1) staff assigned must observe the patient with no physical barrier between staff and patient allowing for immediate physical access and staff must maintain continuous visual observation. Distant one to one (distant 1:1) staff assigned will keep the patient within unobstructed visual contact at all times.

The policy titled Access to Outdoors and Independence Levels, dated 07/05/16 revealed: Under Definitions: Independence Level: The level of freedom a client has, with and without supervision, to move within the hospital; Escort/Independence Levels: Gold Level Movement around AMRTC: Client may go off the unit for all centralized activities escorted to and from by any AMRTC staff. Unit staff does not need to stay at the activity. These clients are allowed to move unescorted throughout the building during Gold Time.