HospitalInspections.org

Based on observation, interview and document review, the hospital failed to protect and promote patient rights to care in a safe setting for 3 of 12 (P1, P2, P3) patients reviewed when P1 and P2 swallowed foreign objects requiring medical intervention with sedation for removal, and P3 attacked staff which caused a serious head injury to a staff member. This resulted in an immediate jeopardy situation for P1 and P2.

Findings include:

The hospital did not meet §482.13 Condition of Participation: Patient's Rights-A hospital must protect and promote each patient ' s rights. This deficient practice had the potential to impact all patients at the hospital.

An immediate jeopardy (IJ) was called on 5/17/19, at 4:36 p.m.. The hospital director of nursing and chief nursing officer were notified of the IJ at that time. The IJ began on 5/4/19, at 3:08 p.m. when hospital staff failed to adequately supervise P2 with a history of swallowing disorder, and continued on 5/16/19, at 5:20 p.m. for P1 who also had a history of swallowing disorder, both patients swallowed foreign objects which required medical intervention with sedation to remove. The hospital's established protocols for supervision of patients were not implemented by staff. The failure to ensure staff followed the hospital's protocols related to patient supervision resulted in the hospital's inability to protect patient health and safety therefore, the hospital was unable to meet the Condition of Participation of Patient Rights.

The IJ was removed on 5/18/19, at 4:40 p.m. when an acceptable IJ removal plan was verified as implemented to ensure the health and safety of patients. Observation, interview, and document review verified hospital leadership had begun a process of reeducating staff regarding supervision of patients with a history of swallowing disorder. However, the hospital remained out of compliance with the Condition of Patient Rights at 42 CFR 482.13.

Refer to A144: Based on observation, interview and document review, the hospital failed to protect and promote each patient's right to care in a safe setting for 3 of 12 patients (P1, P2, P3) reviewed when hospital staff failed to provide adequate supervision. P1 and P2 each swallowed foreign objects resulting in medical intervention with sedation in an acute hospital setting. P3 physically attacked a staff member causing a serious head injury while the other staff provided little and/or delayed response to P3's violent behavior. Staff also failed to provide adequate supervision when P3 was subsequently placed in a restraint chair.

Based on observation, interview and document review, the hospital failed to protect and promote each patient's right to care in a safe setting for 3 of 12 patients (P1, P2, P3) reviewed when hospital staff failed to provide adequate supervision. P1 and P2 each swallowed foreign objects resulting in medical intervention with sedation in an acute hospital setting. P3 physically attacked a staff member causing a serious head injury while the other staff provided little and/or delayed response to P3's violent behavior. Staff also failed to provide adequate supervision when P3 was subsequently placed in a restraint chair.

Findings include:

P1's medical record review revealed P1 was admitted to the hospital on 4/3/19, as a mental health commitment with diagnoses that included; schizoaffective disorder, borderline personality disorder, borderline intellectual functioning and an eating disorder. P1 was admitted to the psychiatric hospital following an acute hospital stay after the patient ingested a foreign object and required a medical procedure, EGD, with sedation to remove the object. During this removal the patient sustained complications which were treated during the acute care hospital stay. The patient had a history of foreign object ingestions.

P1's Psychiatric Assessment dated 4/3/19, revealed P1 had an extensive psychiatric history, and an onset of self-injurious behaviors and suicidal ideation after a sexual assault at age 10 or 11. The hospital placed P1 in the intensive care area (ICA) of unit B on 2:1 staffing with 1:1 observation. P1 lacked insight into her illness. P1's Person Centered Treatment Plan updated 5/6/19, indicated P1 needed a safe, secure environment in the intensive are area with close monitoring, eyes on at all times, to provide treatment/engagement. On 4/12/19, P1 swallowed the plastic cover from a dinner tray. On 5/2/19, P1 attempted to ingest a piece of a gator ball (designed to be indestructible).

P1's Vulnerability Risk Reduction Plan (VRRP)/Initial Treatment Plan initiated on 4/3/19, and updated as changes occurred, included P1 exhibited self-injurious behaviors such as hitting/banging head on the wall, and ingestion of foreign objects. The VRRP revealed P1 was at current risk of self-harm.

A review of P1's hospital record from an acute care hospital stay dated 5/16/19, revealed P1 had a history of numerous ingestions of foreign objects that required medical intervention for removal of the objects. The record revealed P1's most recent visit to the acute care hospital was when P1 swallowed a plastic cup lid that required an emergent laryngoscopy for removal in the operating room. On 5/16/19, staff who escorted P1 to the hospital told the hospital staff that P1 swallowed the plastic battery cover on a remote control, and a battery. P1 became unresponsive, and the Heimlich maneuver was performed by staff. P1 expectorated part of the plastic cover. During the ambulance ride to the acute care hospital, P1 expectorated another part of the plastic cover. P1 reported abdominal pain, rated 10/10. Abdominal X-ray revealed a battery in the distal stomach. An endoscopy with sedation was performed and a AAA battery was removed from the patient's stomach. The acute care hospital transferred P1 back to the psychiatric hospital that night.

On 5/17/19, at 6:15 PM an interview with executive director (ED)-A, administrator-B, and chief operating officer(COO)-G. COO-G verified staff did not provide supervision of P1 in the manner they should have, and according to her treatment plan P1 should never have been allowed to gain access to the media cabinet where she obtained the remote control.

On 5/17/19 at 6:25 PM an interview was conducted with registered nurse (RN)-D who also observed the video of the incident. RN-D said it was not hospital practice to let P1 have access to any equipment or foreign objects due to her behavior of swallowing of foreign objects. RN-D stated staff in the ICA were supposed to provide 1:1 observation with eyes on P1 at all times. RN-D stated the two staff in the ICA shouldn't have been talking between themselves unless it was patient oriented. RN-D verified P1 should never have been allowed access to the media cabinet due to P1's high risk for self injurious behavior with swallowing foreign objects. RN-D verified the video footage was not consistent with what staff had reported about the incident.

On 5/17/19, at 6:38 PM chief nursing officer (CNO)-C was interviewed and verified staff had not followed the facility protocols for supervision of P1. CNO-C stated staff took their eyes off P1 which allowed P1 the opportunity to obtain foreign objects and ingest them twice in 2-3 minutes. CNO-C stated P1 had sustained some difficulty breathing and was transferred to an acute care hospital. CNO-C stated the facility had swept the ICA with a wand used for detecting contraband twice. CNO-C also stated review of the video revealed the verbal description of the incident provided by the two staff in the ICA was inconsistent with what the video showed. After the CNO had reviewed the video, both staff members were immediately removed from the unit and suspended due to noncompliance/failure to provide safe patient care which led to patient harm of P1.

P2's medical record revealed P2 was admitted to the hospital on 2/26/19, with diagnoses which included; schizoaffective with substance abuse disorder, impulsive ingestion of inedible objects with auditory hallucinations telling her to swallow foreign objects. Psychiatric Service Updated Behavioral Recommendations dated 4/23/19, noted behaviors of concern: self injurious behaviors of ingesting foreign objects and cutting, physical aggression, and elopement attempts. P2 had multiple and recurrent swallowing of foreign objects with multiple emergency department visits to an acute care hospital for medical procedures to remove the foreign objects. P2's observation level was 1:1 observation. P2 was admitted as a mental illness/chemical dependency commitment with court ordered neuroleptic medication. A progress note from 5/4/19, at 9:09 a.m. indicated P2 had reported she'd swallowed a spoon and wash cloth a couple days previously, and part of a t-shirt on the previous shift. The medical provider was notified and ordered the patient to be sent to the acute care hospital. Staff removed the ripped t-shirt from P2 and assessed P2 for complaint of low abdominal pain. P2 was transferred to the acute care hospital emergency department for evaluation of the foreign object ingestion.

Review of P2's acute care hospital notes from the emergency room visit 5/4/19, revealed P2 had been seen multiple times at the hospital for ingested foreign objects and removal. The note further indicated the patient had to have an endoscopy under general anesthesia, where the physician found tightly compacted cloth of about 6 x 3 cm and debris in the stomach which was removed. The chief complaint/reason for procedure was noted to be recurrent intentional foreign body ingestion, and bipolar disorder. P2 returned back to the psychiatric hospital that same day.

On 5/15/19, at 10:05 a.m. an interview was conducted with nurse practitioner (NP)-N. NP-N stated P2 wore medical scrubs due to her ingestion history. On 5/3/19, P2 was preparing to go for a housing interview/tour and needed additional clothing for dignity and comfort. P2 went to the store with staff. Since no bras without underwires were available at the store, staff verified whether or not P2 could have a t-shirt. NP-N stated she told staff via email to have P2 give back the t-shirt after returning from the housing interview/tour. NP-N stated staff had not followed through with the directive and the next morning, P2 reported to staff she had ingested torn pieces of the t-shirt. NP-N stated the directive had not been followed even though it had been discussed at the morning team meeting 5/3/19. The staff who were given the directive were no longer working at the hospital, so the NP was unable to follow up further.

On 5/15/19, at 10:20 a.m. an interview was conducted with medical director (MD)-M. MD-M said the observation level for P2 was increased to a modified 1:1 observation with eyes on hands and mouth, hands outside of blankets to balance. MD-M stated staff should have taken P2's t-shirt when she returned back to the hospital, and said the increased observation by staff did not happen.

P3's medical record revealed P3 had been admitted to the hospital on 4/23/19, with a mental illness commitment and court authorized neuroleptic medication orders. Diagnoses included; schizophrenia, anxiety disorder, depression, eating disorder, and fetal alcohol syndrome.

P3's Nursing Assessment dated 4/23/19, indicated P3 had arrived from jail with handcuffs on, escorted by deputies. P3 had previously been in a group home, and at an acute care hospital, where he had assaulted staff at both facilities. The assessment further indicated P3 had an extensive history of violence against staff, and property destruction.

P3's Person Centered Master Treatment Plan reviewed 4/30/19, noted P3 was transferred to Unit C two days after admission for a lower stimulus, therapeutic environment. The plan indicated P3 was on frequent observations due to impulsive behaviors. P3 had psychosis and neurocognitive disorder, with a historical risk of self-harm. P3 had a risk of aggressive behavior toward others, both verbal and physical, and property destruction. On 4/24/19, P3 grabbed a computer mouse and hit staff.

P3's nursing progress notes were reviewed. On 5/9/19, at 4:13 p.m. P3 had stated his mood was good for the day shift. P3 had also laughed out loud to himself but had refused to say whether he heard voices. A progress note from 5/9/19, at 7:15 p.m. noted at approximately 5:20 p.m. P3 approached staff and requested a Tylenol for a headache. Staff-I told P3 he needed to try an ice pack before Tylenol. The notes indicated when staff-I told this to P3, P3 immediately got angry and started attacking Staff-I. As a result, Staff H, went and positioned in between P3 and Staff-I to protect Staff-I. P3 punched and kicked at Staff-I knocking Staff-I to the ground. The notes indicated staff and patients placed P3 in a manual hold for five minutes, and P3 was placed in a restraint chair for 41 minutes.

A review of the facility video of the 5/9/19, incident was conducted on 5/16/19, at 10:52 a.m. The video footage from 5:24 p.m. until 5:36 p.m. was observed. The video showed staff I and staff H walking up to P3 and speaking with him. At 5:24 p.m. P3 began to swing at Staff I. Staff I and Staff H both went to the floor. P3 continued kicking, punching, and stomping on feet/ankles and at the head of Staff I with Staff H hovering over Staff I. Three patients grabbed at P3 and tried to pull P3 away from Staff I. Within 4 seconds, P3 resumed punching, kicking, and stomping on Staff I. No staff attempted to redirect or restrain P3 until the Incident Command Coordinator (emergency response system staff) responded to the area, and organized to take control and assist for manual restraint of P3 at 5:25 p.m.. Although five staff were standing and watching, none attempted to intervene for P3's assault on Staff I. Staff on the unit did not attempt to redirect P3 or those patients who were attempting to aid Staff I. This delay in staff response gave P3 additional opportunity to continue to physically assault and provide increased harm, and put other patients at risk. Due to the angle of the camera and position of staff, there was insufficient visibility to determine the total number of punches and kicks by P3 however, there appeared to be at least nine punches and six kicks/stomps to Staff I. Staff placed P3 in a restraint chair at 5:28 p.m.

On 5/15/19, at 12:28 p.m. registered nurse (RN)-S was interviewed and said P3 had been on the high risk list until a couple of days prior to the incident on 5/9/19. RN-S was not sure how or why P3 was taken off the high risk list during shift report. RN-S stated when there is a behavioral or medical emergency, there is now less staff response as it is not paged overhead anymore. Staff on the unit are suppose to try to get patients into the day room for safety. RN-S said patients tend to respond differently when staff are small women rather than when there are larger men or staff in uniform. RN-S stated often staff are off the unit escorting patients to an activity, walking in the courtyard, in the ICA, or 1:1 with a patient, so when other patients have behavioral outbursts the amount of staff available to respond is really diminished from the number of the staff on the unit's schedule. RN-S also stated when the designated ICS response staff leave to go to a call, they may be off the unit for 30-45 minutes. RN-S stated staff noted on the schedule are not consistently available on the unit to assist patients, and it was very difficult to try to keep 3 staff available for patients on the unit.

On 5/15/19, at 12:59 p.m. RN-T was interviewed and said staff available on the unit is inconsistent, especially with staff call ins, breaks, and escorts. RN-T stated since the code response of the past had now changed to the new system, there was decreased response time by staff responding to an emergency. RN-T stated response time should be 1-2 minutes, but was now delayed. RN-T stated sometimes staff scheduled on the unit are not available on the unit due to emergencies elsewhere, and stated the new system takes staff off the unit for longer periods of time.

On 5/17/19, at 2:30 p.m. RN-E was interviewed. RN-E stated the video of the restraint chair episode was viewed by hospital corporate quality staff, and found that the unit staff stood behind P3 while he was in the restraint chair, and failed to face P3 in order to assess and monitor him.

The facility's Seclusion and Restraint Policy #215-4090 revised 10/18, page 6, item 1, included: "Direct care staff monitoring patient in restraints: 1. Monitor and attend to restrained patient continuously, on a one to one basis, with no physical barriers between the staff and the patient."

The hospital immediately retrained the staff involved with monitoring P3 on 5/9/18, and sent a memo on 5/14/19, to staff regarding visualizing a patient's face when they are restrained.