HospitalInspections.org

Based on observations, interviews, and records review, it was determined that the Governing Body was not effective in its oversight of the hospital in that 2 of 2 patients (Patient #1 and Patient #11) were not provided a safe environment in that:

A) (Patient #1) had a diagnosis that included (schizophrenia) and was discharged without communication with (Patient #1's) court appointed legal guardian and was found wandering in the hospital after being referred to the 10 th floor psychiatric unit for an evaluation.

Refer to A0144.

B) (Patient #11) passed away from hanging over an unsecured closet door on 09/21/13 on the (PEC) unit. Current observations conducted on 11/07/13 on the (PEC) unit reflected continued presence of unsafe items accessible to psychiatric patients for potential harm which included, plastic liners in linen barrels, electrical cords (2) attached to dynamap machines, a bottle of alcohol gel, hard plastic clipboards (2) with metal clips and a plunger with an attached long wooden handle, covered with a plastic bag.

Refer to A0144.

Based on observations, interviews, and records review, it was determined that the hospital failed to ensure 2 of 2 patients (Patient #1 and Patient #11) were protected and provided a safe environment in that:

A) (Patient #1) had a diagnosis that included schizophrenia and was discharged from the Medical ED (Emergency Department) without communicating with (Patient #1's) legal guardian. (Patient #1)was found wandering in the hospital after being referred to the 10th floor psychiatric unit for an evaluation.

Refer to A0144.

B) (Patient #11) passed away from hanging over an unsecured closet door on 09/21/13 on the (PEC) unit. Observations conducted on 11/07/13 on the (PEC) unit reflected continued presence of unsafe items accessible to psychiatric patients for potential harm which included, plastic liners in linen barrels, electrical cords (2) attached to dynamap machines, a bottle of alcohol gel, hard plastic clipboards (2) with metal clips and a plunger with an attached long wooden handle, covered with a plastic bag.

Refer to A0144.

Based on interviews and records review, the hospital failed to ensure 4 of 33 patient complaints and/or grievances in the ED (emergency department) for (Patient #1, #13, #14 and Patient #15) were investigated and/or resolved prior to 10/29/13.

Findings Included:

1) (Patient #1's) Ambulance report dated 08/06/13, timed at 05:08 AM reflected "Patient found sitting in bed yelling at everyone...staff at nursing home states around midnight patient became violent and throwing things...transport to hospital for evaluation...chief complaint psychiatric problem...responsible party Guardianship...relationship Guardian...phone number..."

The pending case report log for the ED reflected, (Patient #1's) guardian filed a complaint on 08/09/13. The complaint reflected, "(Guardian) is with...services...she is the legal guardian of (Patient #1)...the patient became combative at the nursing home and the police were called...the patient was brought in and handed off to the ED staff...the patient was treated and walked to the 10th floor and left in the waiting area...the patient left the area...the guardian and nursing home administrator came to the hospital to try and find (Patient #1)...the guardian states there was a three hour window where no one could find the patient..." It was noted the guardian's complaint was never investigated by the hospital nor was any documentation presented which indicated the guardian was contacted with the results of the complaint filed.

2) The pending case report log for the ED reflected, (Patient #13) filed a complaint on 05/01/13 for care and treatment issues. It was noted that the status of the case remained opened. No documentation was presented which indicated the above complaint had been investigated.

3) The pending case report log for the ED reflected, (Patient #14) filed a complaint on 07/26/13 for coordination of care issues. It was noted that the status of the case remained opened. No documentation was presented which indicated the above complaint had been investigated.

4) The pending case report log for the ED reflected, (Patient #15) filed a complaint on 08/23/13 for coordination of care issues. It was noted that the status of the case remained opened. No documentation was presented which indicated the above complaint had been investigated.

On 11/01/13, at approximately 01:55 PM, Personnel #13 was interviewed. Personnel #13 was asked about the above complaints. Personnel #13 verified that the above complaints had not been addressed as of this investigation.

The policy entitled. "Office of the Patient and Family Experience" with an effective date of 10/25/12 reflected, "It is the policy of the...District to establish protect and promote each patient's rights and responsibilities...all patients and family or patient's representatives have a right to seek assistance when they have concerns about a patient's condition...investigation of a grievance or complaint is a high priority for District..."

Based on observations, interviews and records review, the hospital failed to ensure a safe environment for 2 of 2 patients (Patient #1 and Patient #11) in that,

1) (Patient #1's) Ambulance report dated 08/06/13, timed at 05:08 AM, reflected "Patient found sitting in bed yelling at everyone...staff at nursing home states around midnight patient became violent and throwing things...upon arrival ems (emergency medical system's) arrival patient was still upset...transport to hospital for evaluation...chief complaint psychiatric problem...responsible party Guardian...relationship Guardian...phone number..."

(Patient #1's) Court appointed Letter of Guardianship dated 02/08/07 reflected, "(Patient #1) is incapacitated and cannot care for herself...will no longer have the right to exercise the powers and authority over her person..."

The Nursing Home Admission record reflected, "Guardianship Services...contact person...office, home number..." The above document was provided to the hospital indicating (Patient #1's) guardian's contact information.

The Physician ED note dated 08/06/13, timed at 06:43 AM, reflected "44 year old female anoxic brain injury, schizophrenia, depression...brought to ED...nursing home for aggressive behavior...yelling and screaming and throwing things at the nursing home...patient currently calm sitting on the bed, but becomes agitated when asked questions...disposition discharge...ED attending attestation...I believe that patient disagreement at the nursing home is likely due to personality disorder...will offer psychiatric evaluation should she wish to have it...if not will transfer back to the nursing home..."

The All Flow Sheet Data document dated 08/06/13, timed at 11:19 AM, reflected "Discharge condition stable, ambulatory, discharge instructions reviewed..." No documentation was found which indicated (Patient #1's) guardian was involved in her discharge and/or contacted. The patient was discharged to herself.

(Patient #1's) (PEC) Psychiatric Emergency Center's nursing note dated 08/06/13, timed at 04:39 PM, reflected, "Accompanied with the administrator of the nursing home and the guardian..increased agitation...brought to medical ER (emergency room) when discharged by the RN (Registered Nurse) in the medical ER...told to go to the 10 th floor (PEC)...and became lost...staff from the nursing home came to the hospital and found the patient wandering through the ER..."

The History and Physical dated 08/07/13, timed at 12:54 PM, reflected "Past psychiatric history of schizophrenia...asked why she is here...confused as to situation...guardian has been court appointed for...years...patient was discharged from the ER. The ER was unaware the patient lived at a nursing home and was discharged without informing her residence...cognition and memory impaired...unsteady balance..."

On 11/05/13, at 08:35 PM, Personnel #5 was interviewed. Personnel #5 stated she was unaware that (Patient #1) was from a nursing home and knew nothing about a guardian. Personnel #5 stated she discharged (Patient #1) to herself. Personnel #5 stated that the guardian and nursing home administrator came to the ED and were upset because (Patient #1) was discharged without their knowledge. Personnel #5 stated that (Patient #1) was found, by the nursing home administrator and the guardian, wandering around and was missing for several hours . Personnel #5 stated she provided the guardian directions to the (PEC) unit.

On 11/06/13, at 04:45 PM, Personnel #9 was interviewed. Personnel #9 stated that she was on duty when the guardian and the nursing home administrator brought (Patient #1) to the (PEC) unit. Personnel #9 stated that they were upset that the ED lost (Patient #1). Personnel #9 said that (Patient #1) was seen and was admitted to the psychiatric inpatient unit.

The Policy and Procedure entitled "Provision of Care" with an effective date of 07/18/13, reflected, "Discharge planning...a dynamic process encompassing activities that prepares the patient and family or significant other for care following an inpatient stay or an ambulatory visit...assessment of the patient's family or significant others knowledge...assessment of the patient's psychosocial and physiological status...patient, family and/or significant other understanding of instructions and education provided...time, type and location of discharge and transportation method used to move the patient..."

2) (Patient #11's) Ambulance report dated 09/20/13, reflected "Chief complaint...suicidal ideations, attempting to jump..."

The ED provider (physician) note dated 09/20/13, timed at 07:55 PM, reflected "Emergency Department Psychiatric Screening note...32 year old female presenting for medical clearance for suicidal ideation, out of control behavior, self-mutilating behavior, depression and auditory hallucination...denies medical complaints...patient states I have no emotion, I need dopamine and serotonin to replace my emotion...flat affect, agitated, inappropriate to circumstances and depressed, insight/judgment limited...psychiatric evaluation...suicide attempted, suicidal thoughts, emotional crisis, unspecified psychosis..."

The Admission All Orders dated 09/21/13, timed at 04:23 AM, reflected "Suicide precautions, frequency continuous..."

The Hospital Encounter note dated 09/21/13, timed at 09:00 AM, reflected "Patient stated that she "can't find her emotions" and she "feels like a roach."

The Hospital Encounter note dated 09/21/13, timed at 04:00 PM, reflected "Pacing frequently around unit...asked her if everything was fine...patient stated "her emotions" were gone."

The Hospital Encounter note dated 09/21/13, timed at 06:56 PM, reflected "Patient was found on the door hanging. Tech (technician) brought patient on the floor and code blue was called by the nurse...patient found with jacket around her neck."

On 11/03/13, at 01:15 AM, Personnel #28 was interviewed by telephone. Personnel #28 stated on the evening of 09/21/13, he clocked in on the (PEC) unit. Personnel #28 stated he began to make rounds with Personnel #27 starting in the day area and then making their way to the patient rooms. Personnel #28 stated when they went into (Patient #11's) room they found her hanging from the closet door with her jacket sleeves knotted around her neck. Personnel #28 stated he started CPR, and a code blue was called. Personnel #28 stated the closet doors in the rooms were all bolted shut after the event. Personnel #28 said no other changes and/or in-services had been done since the event.

On 11/07/13, at approximately 10:40 AM, observation rounds were conducted on the (PEC) unit with Personnel #3 and Personnel #1. A bottle of alcohol gel was observed sitting on top of a table located in the day room. The label read "Keep Out of the Reach Children." Two dynamap machines with long electrical cords were plugged into the wall outlet. Sitting on top of a table were two hard plastic clipboards with metal clips, two laundry bins with blue plastic bags hanging from inside the bins, and the seclusion room bathroom had a plunger with an attached wooden handle. The plunger was covered with a plastic bag. The above personnel verified the items could be used for self-harm.

On 11/07/13, at 12:30 PM, Personnel #1 was interviewed. Personnel #1 was asked whether safety checks are completed each shift on the (PEC) unit. Personnel #1 stated currently the technicians do not have a form they document safety checks on for the (PEC) unit. Personnel #1 acknowledged the safety concerns found by the surveyor during observation rounds. Personnel #1 stated the hospital had no policy for safety checks.

The policy entitled, "Patient Rights and Responsibilities" with an effective date of 10/25/12, reflected, "It is the policy of...to establish, protect, and promote each patient's rights and responsibilities...considerate, dignified and respectful care, provided in a safe environment..."

Based on interviews and records review, the hospital failed to ensure 1 of 2 patient's (Patient #1's) discharge from the Medical ED (Emergency Department) was appropriate in that,

1) (Patient #1's) Ambulance report dated 08/06/13, timed at 05:08 AM, reflected "Patient found sitting in bed yelling at everyone...staff at nursing home states around midnight patient became violent and throwing things...upon arrival ems (emergency medical system's) arrival patient was still upset...transport to hospital for evaluation...chief complaint psychiatric problem...responsible party Guardian...relationship Guardian...phone number..."

The Nursing Home Admission record reflected "Guardianship Services...contact person...office, home number..." The above document was provided to the hospital indicating (Patient #1's) guardian's contact information.

The Physician ED note dated 08/06/13, timed at 06:43 AM, reflected "44 year old female anoxic brain injury, schizophrenia, depression...brought to ED...nursing home for aggressive behavior...yelling and screaming...will offer psychiatric evaluation should she wish to have it...if not will transfer back to the nursing home..."

The All Flow Sheet Data document dated 08/06/13, timed at 11:19 AM, reflected "Discharge condition stable, ambulatory, discharge instructions reviewed..."

The History and Physical dated 08/07/13, timed at 12:54 PM, reflected "Past psychiatric history of schizophrenia...asked why she is here...confused as to situation...guardian has been court appointed for...years...patient was discharged from the ER. The ER was unaware the patient lived at a nursing home and was discharged without informing her residence...cognition and memory impaired...unsteady balance..."

No documentation was found which indicated (Patient #1's) guardian was involved in her discharge and/or contacted. The patient was discharged to herself and signed The Education and Discharge Instruction Receipt Signature Form dated 08/06/13.

2) (Patient #1's) (PEC) Psychiatric Emergency Center's nursing note dated 08/06/13, timed at 04:39 PM, reflected "Accompanied with the administrator of the nursing home and the guardian..increased agitation...brought to medical ER (emergency room) when discharged by the RN (Registered Nurse) in the medical ER...told to go to the 10 th floor (PEC)...and became lost...staff from the nursing home came to the hospital and found the patient wandering through the ER..."

(Patient #1's) Court appointed Letter of Guardianship dated 02/08/07, reflected, "(Patient #1) is incapacitated and cannot care for herself...will no longer have the right to exercise the powers and authority over her person..."

On 11/01/13, at 03:15 PM, Personnel #11 was interviewed. Personnel #11 stated she remembered getting a phone call from the nursing home administrator and (Patient #1's) guardian informing her they were on their way up to the hospital to look for (Patient #1). Personnel #11 stated at the time of the phone call (Patient #1) was not on the (PEC) unit. Personnel #11 stated the (PEC) unit never did receive any communication from the medical ED regarding (Patient #1).

On 11/05/13, at 08:35 PM, Personnel #5 was interviewed. Personnel #5 stated she was unaware (Patient #1) was from a nursing home and knew nothing about a guardian. Personnel #5 stated she discharged (Patient #1) to herself. Personnel #5 stated (Patient #1) was found wandering around and missing for several hours by the administrator and guardian.

On 11/06/13, at 04:45 PM, Personnel #9 was interviewed. Personnel #9 stated she was on duty when the guardian and the nursing home administrator brought (Patient #1) to the (PEC) unit. Personnel #9 stated they were upset that the ED lost (Patient #1). Personnel #9 said (Patient #1) was seen and was admitted to the psychiatric inpatient unit.

The Policy and Procedure entitled, "Provision of Care" with an effective date of 07/18/13, reflected "Discharge planning...a dynamic process encompassing activities that prepares the patient and family or significant other for care following an inpatient stay or an ambulatory visit...assessment of the patient's family or significant others knowledge...assessment of the patient's psychosocial and physiological status...patient, family and/or significant other understanding of instructions and education provided...time, type and location of discharge and transportation method used to move the patient..."