HospitalInspections.org

Based on observation, interview, and record review, the facility failed to ensure patients on suicide precautions received care in a safe setting:

A. Observation of exposed or loose screws/bolts in two (2) of 15 rooms in the adolescent hallways (rooms 412 and 608); staff demonstrated use of the ligature tie-off points.

B. Toliets were not mounted flush to the wall and floor creating a loopable hole/gap between the toilet bowl and the wall. During the observation in room # 409, staff demonstrated use of the ligature tie-off point. These same toilets were observed on 5 of 7 patient hallways.

C. Items that could be used for self-harm were available to patients currently on suicide precautions: large heavy-duty bolt removed from cabinet, pencils (3 rooms);markers, loose screws and bolts (5 rooms), and non tamper-resistant screws ( 7 rooms) ;

D. Suicide risk assessment: current facility "suicide risk re-assessment" form showed significant typographical errors. Interviews with three (3) registered nurses (RN) showed inconsistent understanding of suicide risk assessment.

Refer to Tag A- 0144

Based on observation, interview, and record review, the facility failed to ensure that 47 (Patients # 1- 47) of 47 patients currently on suicide precautions received care in a safe setting.


A. Observation of exposed or loose screws/bolts in two (2) of 15 rooms in the adolescent hallways (rooms 412 & 608) showed ligature tie-off points.


B. Toilets were not mounted flush to the wall and floor, creating a loopable hole/gap between the toilet bowl and the wall. Observation in room # 409 showed this gap was a ligature tie-off point. These same toilets were observed on 5 of 7 patient hallways.


C. Items that could be used for self-harm were available to patients currently on suicide precautions: pencils (3 rooms), markers, large heavy-duty bolt removed from cabinet, loose screws and bolts ( 5 rooms), and non tamper-resistant screws ( 7 rooms) ;


D. Suicide risk assessment: current facility "suicide risk re-assessment" form showed significant typographical errors. Interviews with three (3) Registered Nurses (RN) showed inconsistent understanding of suicide risk re-assessment form and process.


Findings:


Review of facility policy titled "Patient Rights," dated 4/2019, showed, " Delineation of Patient Rights..These rights shall include:....2.c the right to a humane treatment that ensures protection from harm..."


A. Loose screw/bolt: ligature tie-off points:

Record review of facility on-going and current "2019 Environmental Safety Risk Assessment" showed, "Bedroom wardrobes/closets are securely anchored and are without...loopable fixtures or hardware..." ("yes" was checked).

Room 412:

Observation on 07/22/19 at 9:45 AM, in room 412 showed two (2) identical large plastic shelving units, approximately 6 feet high. They were affixed to the wall with metal bolts and screws: two(2) at the top and two(2) at the bottom.

The unit on the right side had a "heavy-duty" bolt (upper right side) that was loose & un-screwable to approximately 3 inches in length. Upon surveyor request, Staff O, Mental Health Tech (MHT), placed a pair of disposable scrub pants (as given to patients) over the large exposed bolt. The bolt held in place when Staff O applied forceful downward pressure on the scrub pants. Staff O said a patient could choke himself that way.

Patient # 1 was assigned this room. Record review of Patient # 1's medical record "Intake assessment," dated 07/21/19 showed, "pt is very depressed and wanted to kill himself by hanging or overdose." Further record review showed, Patient # 1 had a current physician order for "suicide precautions."


Room 608:

Observation on 07-22-19 at 10:20 AM, in room 608 showed two (2) identical large plastic shelving units, approximately 6 feet high. They were affixed to the wall with metal bolts and screws: two (2) at the top and two (2) at the bottom.

The unit on the left had a loose screw & washer on the upper left side. Upon surveyor request, Staff P, MHT, was able to loosen the screw out to approximately 2 1/2 inches. Staff P placed a pair of disposable scrub pants over the exposed screw. The bolt held in place when Staff P applied forceful downward pressure on the scrub pants. Staff P said, he was surprised by this and it was a safety issue to be reported.

Record review of the patent census showed there were two (2) patients assigned to room 608: Patient # 2 and # 3.

Record review of Patient # 2's medical record showed, she was assessed as "high risk" for suicide on the intake assessment dated 7/19/19. Impulsive behaviors and attempted suicide by overdose (OD) prior to admission.

Record review of Patient # 3's medical record (intake assessment dated 07-19-19) showed recent history of aspirin OD and cutting behavior.

Patient # 2 and # 3 both had current physician orders for suicide precautions.


B. Toilets : ligature tie-off point :

Room 409 :

Observation on 07/22/19 at 11:10 AM, in the bathroom of room # 409 showed a toilet that was not mounted flush to the wall and floor. It had a loopable hole/gap between the toilet bowl and the wall.

Further observation showed, Staff F, Registered Nurse (RN), obtained 2 disposable scrubs (pants & shirt) from Patient #4's labeled belongings bag. Upon surveyor request, Staff F tied the shirt and pants together and located the gap opening at the back of the toilet. She looped the scrubs through the opening and around the toilet. She tied a tight knot, there was approximately 2 1/2 feet of material remaining. The material held firm when Staff F applied firm pressure downward. Staff F said, this was a ligature risk.

Record review of Patient # 4's medical record showed a current physician order for suicide precautions.


Plant Operations Director

During an interview on 07/22/19 at 11:30 AM, with Staff E, Director of Plant Operations, he stated, he began his employment at Kingwood Pines in March 2019. He identified the toilets as a risk in June 2019. Staff E said, the facility he came from had the exact same issue. Staff E stated, he understood the risk, "you could tie a sheet around the back, sit down, lean back, and hang yourself."

Staff E went on to say, he had not yet obtained any construction quotes/bids to have the toilet risk corrected. He knew the man who corrected the issue at the other facility and would likely use him. Staff E said, the "fix" was to make a template for a complete enclosure of the back of the toilet by the wall. There would be no opening and no exposed screws or other hardware.

Staff E said, hallways 100, 300, 400, and 600 were in the older section of the building and had toilets that were mounted with an opening in the back between the toilet and wall. He said, the 200, 500, and 700 hallways were built in 2010 and had toilets that were mounted flush to the wall with no openings.

On 7/23/19, Staff E informed surveyors that five (5) of 8 bathrooms on the 500 hallway had the gap opening between the toilet and the wall.

Record review of facility current and on-going "2019 Environmental Safety Risk Assessment," undated, showed: "Toilets are wall or floor mounted with no exposed pipes" ("yes" was checked--with no mention of a gap or space between toilet and wall).


C. Hazardous items: potential for self-harm:

Record review of facility on-going and current "2019 Environmental Safety Risk Assessment," undated, showed, "HVAC grills have only small, non-loopable perforations secured by tamperproof screws: ( "yes" was checked);.. all electrical outlet covers, switch plates are secured by tamperproof screws...:..." left blank/not checked.


Observations on 07/22/19, during initial tour of the facility between 9:20 AM and 10:30 AM showed the following :

* large 4 inch bolt [with washer]-removed from wall : room 613

* loose screws in patient rooms (plastic shelving units) : rooms 407, 410, 412, 608, and 611

* non tamper-resistant screws on air conditioner: rooms 407 and 409

* small "golf" pencils: rooms 409, 412, and 414

* six (6) markers [with caps];one crayon: room 409


Record review of all current patient physician orders showed all of the patients housed in the above-mentioned rooms had orders for suicide precautions [Patient ID# 1, 2, 3, 4, 23, 25, 27, 40, 41, and 44].

During an interview at time of observation with Staff O, MHT, he stated that patients on suicide precautions cannot have pencils, markers, and crayons in their rooms; they are hazards.

During an interview at time of observation with Staff P, MHT, he stated that loose screws and removable bolts in patient rooms were safety issues because patients could use them to harm themselves.


D Suicide risk re-assessment form

Review of a facility form titled " Suicide Reassessment" showed the following:

*Six (6) numbered questions with directions for staff to follow based on the patient's answer.

*There were 2 columns to check "yes/no" answers (one column for 1st shift, one for 2nd shift). The questions and directions read as follows:

Question 1: "Have you wished you were dead or wish you could go to sleep and not wake up?"

(Bolded highlighted directions on the form read, "If YES to 1, ask questions 2, 3 ,4, and 5. If NO, go directly to question 5."

Question 5: "Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?"

Page 2 of this same "Suicide Reassessment" form had three (3) different levels of suicide risks listed and corresponding actions for staff to take. The suicide risk levels listed were: "low risk, moderate risk, and moderate risk (sic)"


Interviews with three (3) registered nurses (RN) showed an inconsistent understanding of the current suicide reassessment form used by the facility.

1. During an interview on 07-22-19 at 10:45 AM, with Staff L, RN, she stated, a nurse used her judgement of the suicide risk based on how the patient answered the questions. Staff L was unsure of the different suicide risk levels used by the facility.

2. During an interview on 07-22-19 at 11 AM, with Staff N, RN, she stated that the form did not make sense because if a patient said "no" to question one, you would not ask them about that plan they had. She was unsure if the colored boxes had significance.

3. During an interview on 07-23-19 at 11:15 AM, with Staff M, RN, she stated that she used the suicide risk reassessment form but could not explain the process flow from a "no" to question 1 to question 5. Staff M went on to say she did know how the questions at the top of page 2 factored in to the assessment of the suicide risk level.

During an interview on 07-23-19 at 3:00 PM with Staff C, Performance Improvement (PI) Director, she stated the revised suicide risk assessment/reassessment forms had been reviewed and approved by the Medical Executive Committee (MEC) in May 2019. Staff C said the current forms had some typos.

Review of the MEC meeting minutes dated 05/30/19 , with attachments showed the forms currently in use with typos were approved in that same format.


38015

Observation on 7/22/19 at 9:30 AM, of five patients rooms (#508, #509, #510, #511, and #512) showed that in the bathrooms of these rooms, there were return air vents that were secured by two regular flathead screws per vent, not tamper-resistant screws.

In an interview on 7/22/19 at 9:45 AM, Staff RM #D stated that the screws should not have been there and needed to be replaced with tamper-resistant screws, and added that the regular screws present posed a patient safety risk.

In an interview on 7/23/19 at 1:45 PM, with Director of Plant Operations (DPO) Staff #E, during observation of rooms 508, 509, 510, 511, and 512, he stated, the two screws securing each of the return vents in these rooms were not tamper-resistant, a potential danger to patients, and needed to be replaced.

Record review at time of survey of the patient doctor's orders for patients housed on Unit 500 on 7/22/19, showed the following: there were 9 patients residing in the rooms with unsafe screws who had doctor's orders to be on suicide precautions (Patient #'s 28, 29, 30, 31, 32, 33, 34, 35, and 36).

Based on interview and record review, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for 3 of 3 patients (Patient #51, #48, and #49).

Nursing failed to:

-Perform the required 1 hour face-to-face exam following a patient restraint (Patient #51).

-Document a required Nursing Discharge Summary (Patient #48).

-Conduct a fall risk assessment per policy (Patient #49).


Findings:


Patient #51

Record review at time of survey of facility's policy titled "Seclusion and Restraint," dated 2/8/05, policy #PC 154, stated that for all physical restraints, the RN (registered nurse) will immediately call the on-call physician or RN with specific training to perform a face-to-face evaluation within 1 hour after the initiation of a restraint.

Record review at time of survey of Patient #51's clinical records revealed he was restrained on 7/17/19. The restraint and seclusion documentation contained a completely blank form titled "Seclusion and Restraint-One hour Face to Face Evaluation". There was no evidence elsewhere in the chart that indicated the patient had a face-to-face evaluation by any staff after he was restrained.

In an interview on 7/22/19 at 10:30 AM, RN Staff #X stated "they didn't do it (the one hour face-to-face evaluation) ...they should've [completed the face-to-face evaluation]".


Patient #48

Record review at time of survey of Patient #48's clinical records revealed, nursing progress notes (author unknown) dated 2/1/19 at 6:30 PM that stated "Pt (patient) fell in dayroom, hit head, not responding verbally to staff .....responded to ammonia inhalant, awoke, and verbalized pain 7/10..supervisor notified ...transferred pt to (acute care hospital) for eval (evaluation) and CT scan".

Further record review of a nursing progress at time of survey dated 2/2/19 at 6:50 AM, showed that Patient #48 was sent to an acute care hospital emergency room to have a CT scan following the fall. The patient left Kingwood Pines Hospital at 10:15 PM (on 2/1/19) via ambulance. Per nursing progress notes, according to the RN at the ER, the patient left after she was medically cleared by the doctor. She had called her son to pick her up and left with him. "MD and supervisor made aware".

In an interview on 7/23/19 at 12:15 PM, Risk Manager (RM) Staff #D stated that after Patient #48 had a fall and was sent to the emergency room, she called her son to pick her up and never returned to the psychiatric facility. Because the patient was voluntary, there was no action able to be done to get the patient back. She was considered discharged AMA (Against Medical Advice) from current facility.

Further record review of Patient's #48's clinical records revealed there was no Nursing Discharge Summary paperwork done.

In an interview on 7/24/19 at 2:45 PM, PI Director Staff #C stated that there should have been a completed Nursing Discharge Summary in the patient's chart.


Patient #49

Record review at time of survey of facility policy titled "Falls", dated 4/20/17, policy # PC-199, stated that for patients who were considered high-risk for falls, the RN interventions done should be documented in the nursing progress notes each shift. In addition, the policy stated "7. Interventions should be documented as follows: ... ...c. Fall Assessment to be completed daily on all patients [who were on Fall Precautions]".

Record review at time of survey of Patient #49's clinical records revealed that the patient was assessed to be at "High Risk" for falls due to having a right hip replacement approximately six months prior to her admission to the facility. On 1/25/19, the patient had a witnessed fall at the nurse's station and was sent out to an acute care hospital. She was medically cleared and subsequently sent back to the facility.

Further record review of the patient's clinical records failed to reveal any Fall Risk Assessments performed, as the facility policy required.

In an interview on 7/24/19 at 3:00 PM, PI Director Staff #C stated that the patient was considered high-risk for falls and should have had daily Fall Risk Assessments performed, which did not occur.