HospitalInspections.org

Based on interview and document review, the hospital failed to protect a patient's right to receive care in a safe setting for 1 of 20 patients reviewed, (P1), when P1's physicial environment was not adequately assessed for immediate safety needs. The hospital was found not in substantial compliance with the Condition of Participation of Patient Rights at 42 CFR 482.13.

Findings include:

The hospital failed to protect and promote a patient's right to receive care in a safe setting for 1 of 20 patients reviewed, (P1), when staff failed to implement adequate safety precautions in P1's room. P1 went into the bathroom, found an empty plastic syringe that was left in the waste basket, and immediately ingested it. Refer to the deficiency issued at A144.

Based on interview, and document review, the hospital failed to promote a patient's right to receive care in a safe setting for 1 of 20 patients reviewed (P1), when staff failed to implement adequate safety precautions in P1's room. P1 went into the bathroom, found an empty plastic syringe that was left in the waste basket, and immediately ingested it.

Findings include:

P1's hospital record was reviewed on 4/10/17 and 4/11/17 and indicated P1 has been an inmate at a correctional facility for seventeen months. P1 had thirteen similar hospital admissions for foreign body ingestion since October 2015. P1 arrived at the hospital's emergency department at 10:26 a.m. on 11/28/16 from the correctional facility with diagnoses of foreign body ingestion (paper clips), depression, and ibuprofen overdose.

A 12/1/15 document titled Unique Treatment Plan, which pertained to P1 and P1's 11/28/16 hospital admission was reviewed. Safety precautions that were to be in place for P1 included: 1) Everything will be removed from the patient's hospital room that is not attached to the wall or the bed. 2) Correctional officers will search the patient prior to her changing out of her prison attire and into hospital. Female hospital staff will be present in the room if only male correction officers are present. 3) The patient will remove all of her undergarments including underwear and bra. 4) No utensils, no Styrofoam cups/plates/trays. No plastic cups/plates/trays/straws/utensils. No condiment packets. 5) Meals/food needs to be placed directly on patient's lap. No pop-patient may have finger foods only-staff to order food for patient and limit to 2 food choices. Water to be given to patient in paper medicine cup. 6) No narcotics will be provided to the patient while in the emergency department (ED) or hospital, especially Benzodiazepines. 7) If the patient requires a procedure such as an endoscopy, use lidocaine. 8) No television.

A document titled Continuing Observation Order, dated 12/3/15 which was in effective on 11/28/16, indicated P1 was to be physically observed by staff every thirty minutes per the hospital's policy.

A physician's order (standing order), dated 11/28/16 and present in P1's hospital record, indicated P1's physical environment was to be assessed for immediate safety needs.

An 11/29/16 physician's progress note indicated P1 was placed on suicidal/self harm precautions and admitted for a pain evaluation, x-rays, CT scan, and a general surgery consultation (laparoscopy) related to P1's ingestion of two uncoiled paper clips in April 2016 and was placed on the hospital's medical surgical unit.

An 11/30/16 physician's progress note indicated a laparoscopic procedure was performed, and two uncoiled paper clips were removed from P1's colon. On 12/3/16, while P1 was recuperating from surgery, two correction officers accompanied P1 into P1's bathroom at approximately 12:30 p.m. P1 found an empty plastic syringe in the waste basket and immediately ingested it. P1's physician was notified about the incident. In addition, a code green, which is an emergency alert and request for immediate staff assistance with a patient, was called. P1 required an immediate upper endoscopy on 12/3/16 for removal of the syringe and to prevent the syringe from passing to P1's small bowel which would make operative removal necessary. P1 was discharged from the hospital and transported back to the correctional facility during the afternoon of 12/3/16.

An interview with Director of Quality (DQ/B) was conducted on 4/10/17 at 9:00 a.m. DQ/B stated P1 has had several admissions to the hospital for ingestion of various objects while P1 has been an inmate at the correctional facility. Correction officers were present with P1 at all times during the 11/28/16 admission. P1 required an 11/30/16 surgical removal (laparoscopy) of the paper clips that P1 ingested several months prior at the correctional facility. P1 signed a consent for the 11/30/16 surgery. The identity of the staff person and department of the staff person who put the empty plastic syringe in P1's waste basket is unclear at this time. P1 consented to the 12/3/16 endoscopy which was done to remove the plastic syringe, and it was performed under anesthesia.

An interview with Certified Nursing Assistant (CNA/F) was conducted on 4/11/17 at 12:30 p.m. CNA/F stated she was assigned to P1 (day shift) on 12/2/16 and 12/3/16. CNA/F stated two correction officers were in P1's room and when P1 ingested the syringe. CNA/F stated she was not in the room at the time of the ingestion but heard a voice in the room say "we need help in here." In response to the ingestion of the syringe, a code green (request for staff assistance) was called on the unit. CNA/F stated she thought all personal care items had been removed from P1's room prior to the ingestion. CNA/F stated P1's room was a safe room except for the syringe being in the waste basket.

The facility policy titled Suicidal/Self-Harm Patient Management, with an effective date of 9/2014 and a review date of 9/2017, was reviewed. The policy addressed inpatient interventions and included the directive for staff to remove or secure all potentially dangerous and medically non-essential supplies and equipment from the patient's room.