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Based on review of hospital policies and procedures, observation, review of patient clinical records, and staff interviews, it was determined the hospital failed to ensure the physical environment on one of their psychiatric inpatient units was safe and free from ligature points which poses a high potential risk a patient could use the ligature point to harm themselves by asphyxiation.

Findings include:

The hospital's patient rights include: "...You have the right to expect reasonable safety and security in the hospital practices...."

A tour of the inpatient psychiatric unit, 5 Northwest (NW) was made on 01/12/2016 with the hospital's Associate Director of Nursing. The unit was described as the "Geropsych" Unit to which patients over the age of 55 with psychiatric diagnoses were admitted. The patient census at that time was reported to be 11. Obvious ligature points were observed throughout the unit. A ligature point is any point which is load bearing that can be used to tie or secure a cord, sheet or other tether that can then be used as a means of hanging. Hanging is the main method of suicide for psychiatric inpatients. The observed obvious ligature points on this unit included: v-type leverage bars at the top of each door to each patient room; lever-type handles on the faucets; exposed plumbing behind the toilets; open side rails on the hospital beds. Some of the rooms had mobile hospital beds which a patient could move and lock against a closed door which would block entrance and delay assistance if there was an emergency. All of these were examples of ligature points easily accessible to most patients and could be used to tie and secure a sheet, for example, for the purpose of self harm by asphyxiation.

Patient #16 who was under the age of 50 was admitted to the 5NW Geropsych unit during the survey. The patient's admitting diagnoses included suicidal ideation. The nurse's admission note included that the patient: "...reported less than 5 prior S/A (suicide attempts), last one being a couple of months ago when she tried to hang herself...." The patient was admitted to the unit with physician orders for "routine patient checks" (every 15 minutes).

Patient #17 was also admitted to this unit during the survey. The patient was under the age of 20 and had a recent history of attempted suicide.

Patient #3 was another patient admitted to the unit during the survey with a diagnosis including suicidal ideation.

The hospital has other inpatient psychiatric units which were designed without ligature points.

The Associate Chief Nursing Officer and the Clinical Nursing Director of the psychiatric units acknowledged the ligature points on the unit, but that placement of the psychiatric patients was temporary pending remodeling of another unit which included modifications to remove ligature points. The surveyor asked if there were policies and procedures developed and implemented that specifically addressed the increased safety risk of the ligature points on the unit and they responded "no". They stated that patients were checked every 15 minutes unless they were "high risk" and then they would be placed on 1:1 observation. They acknowledged this was the same policy as the other inpatient units that did not have ligature points.

Based on a review of electronic documented incident reports and interview, it was determined the hospital failed to document analysis of incident reports, which has the potential risk of missed opportunities for early intervention/prevention of errors to occur in the future.

Findings include:

One of the quality indicators identified in the Quality Plan is that of the monitoring, tracking, and analyzing event reporting.

A random review of the electronic incident reports from January 2015 through December 2015 was completed. Each individual report documents the facts of the event, the location of the event, and the clinical services where the event occurred. The electronic system includes the extent of harm with a harm score, notifications, and other detailed information related to each event.

Each individual report has a space for the quality manager review and the department manager review of the event. Some of the reports had a manager's review and some had a quality review documented. There was no documented evidence of analysis related to the cause of the event, and if the event may have been prevented. This was inconsistent throughout the review of the reports.

A few examples of the reports were reviewed with the Director of Quality and the Chief Medical Officer.

A review was done of a documented event at 0045 where there was consensual sexual activity between two patients. A review of the report revealed there was no description of the event, no evidence of police being notified and/or if this was appropriate to do and there was no quality review. There was no documented review as to how two patients were able to have contact with each other on a behavioral health unit without the staff knowing the patients were together.

A review done of a documented event in the intensive care unit revealed an order for fresh frozen plasma, however, the staff administered packed red blood cells. This would have been a failure for the laboratory and nursing and a failure to follow policy and procedure for checking out the blood products and administering the blood products. There was no documented review of the incident.

A discharged inpatient presented to the hospital clinic in October of 2015 and requested medication refills. The documented reason for need for refills was that the patient could not get an appointment to follow up with the Psychiatry department until November. During the visit to the clinic, the patient and the patient's spouse expressed concerns the patient was discharged to soon from the hospital. The clinic offered the crisis phone number and community services resources at this time. The hospital found out in November the patient had expired. The documented report revealed management aware and investigating. There was no documented follow up or action available to the surveyor at the time of the survey, 2 months later. There was no quality follow up or review documented.

A review of two fall incidents revealed the managers restated the events. One with no action taken or documented evidence the event was reviewed by management or quality, and the second event only had a statement that the patient was reminded to call for assistance.

The surveyor conducted an interview with the Director of Quality and the Chief Medical Officer on 01/14/2016 to review the sample reports; and to confirm there was no documentation missing that would demonstrate compliance to the the regulations for analysis of the events. Both the Director of Quality and the Chief Medical Officer confirmed that there was no documentation available that would demonstrate the reports were analyzed and a determination of action or no action required to minimize the risk to patients.

A call was also placed to the Director of Patient Safety at the request of the Chief Medical Office. The Director of Patient Safety will be the new person accountable for coordinating the review of the reports and ensuring the appropriate review was completed. This call was placed and the surveyor informed the Director of the findings.

Based on review of hospital document, medical record and staff interview, it was determined that the hospital nursing staff failed to properly administrator the titrated insulin medication according to hospital protocols for 1 of 1 patients (Patient #15); which poses a high potential health and safety risk to patients if titrated insulin medications are not given according to specific insulin parameters.

Findings include:

Patient # 15 was admitted on 01/09/16, with complaints of chest pain for 10 days. The patient's medical history includes type 2 diabetes, hypertension, congestive heart failure (CHF) and morbid obesity. The patient became short of breath and was transferred to the ICU. The patient received an emergent angioplasty with stent placement.

On 01/11/16 at 1445 hours the patient was ordered: "...Titration Instructions- Adult Insulin Infusion insulin regular (HumuLIN, NovoLIN) 100 Units in sodium chloride 0.9% 100 milliliters infusion for adult MED/SURG ICU. Glucose goal: 110-160; insulin bolus 1-4 Units Route: IV bolus from bag...." The patient's finger stick blood glucose (FSBG) revealed the reading of 559. The patient received a bolus of 4 units regular insulin .

Review of the hospital document titled "ADULT Medical-Surgical ICUs INSULIN INFUSION Adjustment TABLES" revealed: "...Titrate using insulin adjustment Tables to maintain FSBG at 110-160...." Table 3 was indicated for "Last Insulin Infusion Rate greater than 8 units/hour. TABLE 3 revealed a grid with horizontal rows listing a range of current FSBG and vertical rows listing a range of prior FSBG.

The patient's insulin was increased by 2 units approximately every hour for FSBG's of 590 to 338 per Table 3. According to the Insulin Adjustment grid provided, when the patient's prior blood sugar is above 300, and the current blood sugar is above 300; the infusion rate shall be increased by 2 units of insulin.

On 01/12/16 at 0507 hours the patient's insulin rate was at 32 units per hour. The patient received the maximum 32 units per hour until 01/12/16 at approximately 1800 hours.
According to the patient's medical record the patient's prior blood sugar was 185 and the patient's current blood sugar was 145. According to the Insulin Adjustment grid provided, when the patient's prior blood sugar is between 171-200, and the current blood sugar is between 131-150; the infusion rate shall be decreased by 2 units of insulin. However, the nursing staff documented that the insulin rate was decreased by 4 units per hour.

The Senior Manager of ICU confirmed during an interview conducted on 01/13/16, that the IV infusion pumps have a "guard rail" set up for each titrated medication, meaning 32 units of regular insulin per hour is the maximum amount of insulin that can be delivered through the infusion pump safely for the patient. The Senior Manager also confirmed during the same interview the correct decrease in the insulin drip should have been 2 units. The nursing staff did not follow the hospital protocol for titrated regular insulin.

The Senior Manager of ICU confirmed during an interview conducted on 01/20/16, that no incident report was completed for the above medication error.

Based on interview, tour, document review and observation, it was determined the hospital failed to meet the requirements for the Life Safety Code. This poses the high potential for risk of harm to patient receiving services and employees providing services within the hospital setting.

Findings identified in the Life Safety survey include:

K Tag 56:
Based on observation, document review, and tour, the hospital failed to comply with the NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.3.5.1 requiring the hospital be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. NFPA 13 Section, 5-13.11. There was no sprinkler protecting one of the radiology rooms, which placed the patients and staff at risk if there were a fire.

K Tag 134
Based on observation and interview with the laboratory staff, it was determined the facility removed the emergency shower in the laboratory, which places the employees at risk for exposure to injurious corrosive materials that were stored and utilized by the laboratory personnel.

K Tag 136
Based on staff interview, and record review it was determined the laboratory staff did not have a working emergency procedure plan implemented to ensure Material Safety Data Sheets (MDS) were immediately available to the staff and the staff knew how and where to obtain them immediately. This has the potential risk for exposures to not be treated appropriately and timely.

The cumulative effect of these deficient practices resulted in the hospital's failure to provide a physical environment that ensures patient safety.