HospitalInspections.org

The Hospital was out of compliance for the Condition of Participation for Patient Rights.

Findings included:

The Hospital failed to ensure for two (Patient #1 and Patient #7) of ten sampled patients that the Hospital provided care in a safe setting.

Refer to Tag: A-0144

Based on interviews and record review, the Hospital failed to ensure for two (Patient #1 and Patient #7) of ten sampled patients, to provide care in a safe setting to prevent a patient from obtaining items that could pose serious harm if ingested or placed in the body while on continuous observation by a staff member at multiple times throughout inpatient hospitalization.

The Hospital's policy titled, Suicidal (Harm to Self)/ Homicidal (Harm to Others) Patient, Environment of Care, approved 2/14/19, indicated that it is the responsibility of all team members to provide a safe environment for the patient and assure collaboration and communication of patient safety needs among all team members including unlicensed staff providing continuous observation.

The Hospital's policy titled, Continuous Observation - Inpatient, approved 1/2019, indicated that patients who are exhibiting confusion, agitation, delirium or other behaviors that may impact their safety are evaluated for constant observation. Continuous observations is the direct, continuous unobstructed visual observation of the patient at all times by an appropriately trained staff member.

1. Patient #1 was admitted to the Hospital with diagnoses of depression, anxiety and a history of suicidal thoughts and attempts.

During Patient #1's inpatient hospitalization from 2/16/19 - 3/6/19, Patient #1 was able to obtain objects three separate times while on 1:1 patient observation. (A, B and C)

Patient #1 had an order, dated 2/16/19, for 1:1 patient observation due to ingesting razor blades and requiring surgical intervention to remove them. This order remained in place for the length of Patient #1's inpatient admission.

A. A Nurse's Safety Report, dated 2/24/19 (no time stamp is on the report), indicated that Patient #1 complained of abdominal pain and stated that he put a shampoo bottle into his/her rectum while showering the night before. Patient
#1 was on suicide precautions and had a 1:1 observer at all times. The Medical Doctor was notified and a CT Scan was obtained which confirmed the presence of the bottle in the rectum.

A Physician's Progress Note, dated 2/24/19 at 3:16 P.M., indicated that the CT Scan showed that the shampoo bottle was seen sitting above the pelvic floor in the rectum.

A Physician's Operating Note, dated 2/26/19 at 4:22 P.M., indicated that the shampoo bottle was surgically removed from Patient #1's rectum on 2/24/19.

A Nurse's Progress Note, dated 2/24/19 at 1:40 P.M., indicated that Patient #1 continued on 1:1 observation and that the observer was educated about the Patient's safety.

The Surveyor interviewed Nursing Assistant #1 at 10:08 A.M. on 4/3/19. The Nursing Assistant said that, on 2/23/19, Patient #1 asked to take a shower. The nurse obtained an order for the shower and brought some towels and a shampoo/body wash bottle into Patient #1's room and handed them to Nursing Assistant #1. Nursing Assistant #1 said she accompanied Patient #1 into the bathroom for continuous observation of Patient #1 while showering. Nursing Assistant #1 said that, upon inspection of the shower, she saw a pile of used face cloths on the floor and she did not remove the face cloths from the floor of the shower because she didn't have gloves on. Nursing Assistant #1 said she kept the door open and watched Patient #1 the whole time he/she was showering. Nursing Assistant #1 said that she handed Patient #1 the shampoo/body wash bottle and he/she washed his/her body. Nursing Assistant #1 said that, at one point, Patient #1 was facing her and was bending forward vigorously cleaning his/her bottom. Nursing Assistant #1 said that Patient #1 returned the bottle to her and she personally placed it in the covered trash bin. Nursing Assistant #1 said that at no time did the patient return to the bathroom while she was with him/her. Nursing Assistant #1 said that at no time did she see Patient #1 place the bottle into his/her rectum. Nursing Assistant #1 said she was not sure where he/she got the bottle or when he/she would have placed the bottle into his/her rectum.

The Surveyor interviewed Nurse #1 at 10:24 A.M. on 4/3/19. Nurse #1 said on the morning of 2/24/19 Patient #1 told her that he/she could not take his/her medication because he/she had placed a bottle in his/her rectum the night before in the shower.

B. A Nurses's Progress Note, dated 3/2/19 11:50 P.M., indicated that Patient #1 reported to Nurse #2 that he/she could not urinate because he/she had inserted a piece of paper cup into his/her urethra.

A Physician Progress Note, dated 3/3/19 at 1:06 A.M., indicated that Patient #1 reported that he/she inserted a piece of a paper cup and a piece of plastic into his/her urethra and "milked it down". Patient #1 was unable to get it out and was unable to urinate.

A Nurses Progress Note, dated 3/3/19 at 6:05 A.M., indicated that Patient #1 told the writer that he/she could not urinate. He/She admitted that he/she inserted plastic and paper into his/her urethra and "worked it down" He/she complained that it was painful and repeatedly asked when the doctor would come take it out. The Nurses Note further states that the 1:1 sitter was at the Patient #1's bedside.

A Physician Note, dated 3/3/19 at 6:49 A.M., indicated that Patient #1 will now need a 2:1 sitter .

A Urologist's Note, dated 3/3/19 at 1:04 P.M., indicated that Patient #1 said that he/she found a piece of plastic at his/her bedside and placed it in his/her urethra and milked it in retrograde fashion over a period of two hours that was accompanied by significant pain and some bleeding. Patient #1 also reported that he/she placed a piece of a rim of a paper cup into his/her urethra. Patient #1 reported white urethral discharge and inability to urinate. The Urologist made the determination to perform a cystourethroscopy (a procedure that allows the physician to visually examine the inside of the bladder and urethra) and removal of the foreign body in the Operating Room.

A Psychiatrist's Note, dated 3/4/19 at 10:12 A.M., indicated that he agrees with the 2:1 sitter and safety plan including constant observation of Patient #1's hands at all times.

The Surveyor interviewed Nurse #2 at 11:51 A.M. on 4/3/19. Nurse #2 said that Patient #1 told her that he/she couldn't urinate because he/she put paper and plastic in his/her urethra. Patient #1 told Nurse #1 that he/she did this while he/she was using the urinal. Patient #1 said that he/she got the paper from a paper cup. Nurse #2 said she went into the kitchen and found his/her old dinner tray and found that there were bite marks on the paper cup. Nurse #2 said Patient #1 did not indicate when exactly he/she did insert the objects in his/her urethra.

The Surveyor interviewed Nursing Assistant #1 at 10:08 A.M. on 4/3/19. Nursing Assistant #1 said that she provided continuous observation of Patient #1 on 3/2/19 from 11:00 A.M. through 3:00 P.M. Nursing Assistant #1 said that she did give Patient #1 his/her lunch tray which had food and multiple cups of soda. Nursing Assistant #1 said that she removed the tray prior to leaving at the end of her shift and there were still some cups of soda left on the bedside table. Nursing Assistant #1 said that she did not notice that any of the cups on the tray were chewed or missing pieces of paper.

The Surveyor interviewed Nursing Assistant #2 at 1:10 P.M. on 4/3/19. Nursing Assistant #2 said that she worked with Patient #1 only one time as a continuous observer and that was on 3/2/19 from 3:00 P.M. - 7:00 P.M.. Nursing Assistant #2 said that she had been told that Patient #1 required continuous observation and she did just that. Nursing Assistant #2 said that she did help him/her wash up and most of the time she was there he/she layed in the bed and didn't have covers on. Nursing Assistant #2 said she never saw Patient #1 insert paper/plastic in his/her urethra.

C. A late entry Nurse's Progress Note, dated 3/4/19 at 12:07 P.M., indicated that when doing a room sweep, Patient #1 was found to have a metal screw in his/her hospital gown pocket. Patient #1 said that he/she wasn't going to do anything with it. Patient #1 said that it was on the floor and he/she picked it up.

A Psychiatrist's Consult Report, dated 2/17/19 at 2:50 P.M., indicated that Patient #1 said that about two weeks ago he/she swallowed some screws.

The staff schedule for 2/22/19-3/2/19 at 7 A.M., indicated there was always a continuous observer in the room with Patient #1. The staff schedule for 3/3/19 at 7:00 A.M. through discharge on 3/6/19 indicated there was always two staff members assigned to Patient #1 for continuous observation.

The Surveyor interviewed Risk Manager #3 at 9:22 A.M. on 4/3/19. Risk Manager #3 said they do not know how Patient #1 was able to obtain these objects and insert them in his/her body without the Continuous Observer noticing.

2. Patient #7 was admitted to the Hospital during October 2018 with a diagnoses of Pica (an eating disorder that involves eating items that are not typically thought of as food), autism, and gastritis.

Record Review indicated that, on 10/16/19, an order for 1:1 patient observation was placed by the physician.

A Nurse's Progress Note, dated 11/1/19 at 8:11 A.M., indicated that Nurse #3 performed a safety assessment in Patient #7's room. The Note indicated that Nurse #3 found a tray left from a previous shift at the bedside with a plastic knife present. The 1:1 observers were unable to confirm or deny if any other utensils were at the bedside at any point.

The Hospital's Suicidal (Harm to Self)/Homicidal (Harm to Others) Patient, Environment of Care policy, approved 9/7/17 and 2/14/19, indicated that the dietary precautions for a patient on safety precautions is that only plastic spoons are to be placed on the trays.

The Surveyor interviewed Risk Manager #3 at 2:00 P.M. on 4/3/19. Risk Manager #3 said that review of the incident revealed that there was a plastic knife on the tray.

The Surveyor interviewed the Clinical Nurse Educator and the Chief Nursing Officer of Inpatient Nurse Education at 9:22 A.M. on 4/3/19. The Clinical Nurse Educator and the Chief Nursing Officer of Inpatient Nurse Education said that no changes have been made to the Continuous Observation Policy since 2/24/19 and no new education has been provided to the staff members involved in the 1:1 continuous observation of Patient #1 or Patient #7. The Clinical Nurse Educator and the Chief Nursing Officer of Inpatient Nurse Education said the only education that the staff members get regarding constant observation takes place at orientation upon hire.

Based on records reviewed and interview, the Hospital failed to ensure that all security staff, whose job requires assistance in the application of restraints, were certified in first aid techniques.

Findings include:

The Hospital policy titled, Restraint and Seclusion, last approved 11/5/18, indicated that Hospital staff members who assist in applying restraints shall receive training in the use of first aid techniques and certification in the use of cardiopulmonary resuscitation.

The Surveyor interviewed the Security Supervisor at 2:06 P.M. on 4/3/19. The Security Supervisor said that the Security Guards employed by the Hospital assist with the application of restraints in the Emergency Department. The Security Supervisor said that the none of the Security Guards employed by the Hospital were trained in the use of first aid techniques.