HospitalInspections.org

Based on interview and documentation review it was determined the Hospital failed to ensure patients received care in a safe setting.

Findings included:

The Hospital policy that addressed the use of sharps by patients was reviewed. The Policy stated all sharps will be signed out by clinical staff person and returned to a clinical staff person. Staff will dispense sharps/hazardous materials. The patient's name, item, time signed out, and sign of return will be initialed by the staff member in the sharps book at the nurses station. Hazardous items should not be signed out unless the patient's mental status and risk issues are known. A staff member may remain in close enough proximity when a patient is using the sharp item should the need to intervene occur

The Staff Registered Nurse (RN#1) assigned to provide the Patient's care on 8/15/10 was interviewed in person on 8/25/10 at 2:15 PM. RN #1 said the Patient reported not feeling safe and he was anxious and agitated. The Patient had reported a coping strategy for him/her was taking a shower. RN #1 said the Patient had contracted with him/her that if feeling worst the Patient would come to him/her. The Patient agreed to 5 minute safety checks and to taking a shower. RN #1 said MHW #1 was at the linen cart handing out towels and he/she called down the hall to MHW #1 that the Patient needed towels and soap.

MHW #1 was interviewed in person on 8/27/10 at 4:35 PM. MHW #1 said I was still in training and normally would be working with/shadowing an experienced MHW who would be watching his/her work; however that evening the unit was short staffed by one MHW so he/she was not with an experienced MHW when the Patient shower supplies were handed out. MHW #1 said at the closing meeting of the day the Patient had stated he/she felt about to kill him/herself. MHW #1 said about 30 minutes to 1 hours after the closing meeting one of the nurses had told him/her to give the Patient everything that the Patient needed to take a shower. MHW #1 said the Patient had asked for a razor and although he/she questioned, it since he/she had observed other patients with razors and another patient said it was okay to give the Patient the razor, he/she gave the Patient the requested razor. MHW #1 said at the time he/she did not know the Hospital policy regarding sharps and that there was a sign out log for sharps.

The Nurse Manager was interviewed in person of several occasions on 8/25/10, 8/26/10 and 8/27/10. The Nurse Manager said nursing staff did not realize the Patient had a razor unit the Patient's roommate recognized what the Patient was doing and alerted staff members.

Based on interview and documentation review it was determined the Hospital failed to ensure there adequate numbers of nursing staff to provide care to all patients as needed.

Findings included:

The Nurse Manager was interviewed in person at various times on 8/25/10, 8/26/10 and 8/27/10. The Nurse Manager said the census on the nursing unit on the evening of August 15, 2010, during the Patient's cutting episode, was 22. The Nurse Manager said MHW #1 was still in training/orientation on August 15, 2010..

Review of the nursing unit staffing plan indicated for a census of 22 patients during the evening shift the staffing included 2 LPN or MHW.

Review of August 15, 2010 evening shift staffing schedule indicated there was one MHW (MHW #2) who worked during the evening shift and MHW #1.

Based on interview and documentation review it was determined the Hospital failed to ensure nursing care was assigned to nursing personnel in accordance with the competency of the nursing staff available in one of one applicable medical record reviewed.

Findings included

See Tag # 0144 and # 0392.