HospitalInspections.org

Based on record review and staff interviews, it has been determined that the hospital failed to ensure nursing personnel follow hospital policies relative to a patient who was placed on constant observation status due to their risk for swallowing foreign objects for 1 of 1 patient, (ID # 1) reviewed who swallowed a battery while hospitalized.

Findings are as follows:

The hospital's policy titled, "Categories of Observation" effective 8/10/2021 states in part,

"...1) Constant Observation shall be ordered for any patient who needs to have a staff member with him/her at all times...

a. An assigned staff member must be with the patient at all times, including in the bathroom.

b. The staff member must be able to visually observe the patient at all times and be able to quickly intercede should it become necessary..."

Record review revealed that Patient ID #1 presented to the hospital in June of 2022 due to increased auditory hallucinations. Patient ID #1's diagnoses include, but are not limited to developmental delay, borderline personality disorder, pseudotumor cerebri s/p shunt, psychogenic non-epileptic seizure and epilepsy. This patient has had multiple admissions to this hospital. Patient ID #1's medical record reveals the patient had previously been hospitalized from 8/28/2023 to 9/1/2023 for swallowing a battery while under the care of Butler Hospital. Upon the patients return to Butler Hospital s/he was placed on constant observation status for safety. On 10/3/2023, Patient ID #1 who was under constant observation status reported to the staff she had swallowed a battery from the TV remote control.

On 10/3/2023 a physician progress note, indicates that the patient reported s/he had swallowed a AAA battery from the television remote control around 6:30 AM on 10/3/2023. The patient was sent to the Rhode Island Hospital, and it was confirmed via an x-ray that s/he had swallowed a battery. Patient ID #1's constant observer on 10/3/2023 was Staff A, a mental Health worker when the patient was in control of the "TV remote control". Staff A was unavailable for interview.

During surveyor interview on 10/18/2023 at 2:30 PM with Staff B, the unit Nurse Director, she informed the surveyor that Staff A, was the Mental Health Worker assigned as the constant observer to Patient ID# 1 during the timeframe she swallowed the battery. Staff B stated that she interviewed Staff A relative to the patient swallowing the battery. Staff B stated that Staff A said the patient was under constant observation and she did not observe the patient swallow a battery. She did report that Staff A left the patient in the bathroom unattended for a moment when she left to obtain an incontinence brief for the patient. Staff B stated she addressed this with Staff A once she became aware. Staff B informed the surveyor that per the hospitals policy, staff assigned to observe constantly need to be able to observe the patient visually always and quickly intercede if necessary. Staff B also acknowledged that Staff A violated the observation policy.