HospitalInspections.org

Based on interviews and record review, the Hospital failed for one (Patient #1) patient out of ten sampled patients, to prevent Patient #1 from obtaining items multiple times that could pose serious harm if ingested while on continuous observation by a staff member throughout the Patient's Emergency Department hospitalization.

The Hospital's policy titled, Screening, Assessment and Clinical Care of the Patient at High Risk of Self Harm, including Suicide, or Harm to Others: Clinical Management of the Patient Exhibiting Harmful behavior, Actual or Potential, dated June 2017, indicated that:

-Consideration should be given regarding the safest and most appropriate environment/facility in which to care for the patient.

- Modify the room as necessary to achieve environmental safety.

- Observation by designated clinical staff tailored to the individual patient needs.

- Safety tray as provided by Food Services is served. Tray includes finger foods only and delivered on Styrofoam plates. No utensils are provided. Tray should be used with continual staff supervision.

- Check the patient's room for potentially harmful items at least once every shift.

Review of attachment B of the policy: "Safe Room" guidelines for the Patient at Risk for harm to Self or Others Emergency Department Room environmental Modification - To be completed each shift are:

- Check patient's bed/bedding for items that could be used for self harm, including sharps and medications.

- Use paper cups, plates (count and remove after use).

Record review indicated that Patient #1 was admitted to the Emergency Department on 9/28/19 under observation after swallowing/ingesting foreign objects in his/her residential school program. Patient #1 was under observation of the Hospital's Emergency Department while waiting bed placement in an inpatient pediatric behavioral health facility.

Record review indicated that, on admission, Patient #1 had orders to be on constant observation precautions which required a safe food tray that does not permit utensils to be provided to the patient when food is served to them. The medical record did not indicate specific instructions to the observer as to the level of constant observation required to provide a safe environment for Patient #1 while being held in the Emergency Department while waiting for admission to an inpatient pediatric behavioral health facility.

Record review indicated that, on 10/1/19, Nurse #1 provided Patient #1 with a popsicle on a wooden stick. When Patient #1 was eating the popsicle, he/she was able to break the wood stick in half and ingested the foreign object.

Record review indicated that Patient #1 was sent to radiology for an x-ray to determine the location of the foreign object. Upon return from radiology, Patient #1 was also able to obtain a needle cap and a paper napkin and ingested these items.

Record review indicated that, on 10/1/19, Patient #1 was seen in consult by a Gastroenterologist and it was determined that Patient #1 required transfer to a higher level of care to treat this patient for the ingestion of foreign objects that took place in the Emergency Department at the Hospital.

The Surveyor interviewed Nurse #1 at 12:45 P.M. on 10/22/19. Nurse #1 said that she was aware of Patient #1's history of ingesting foreign objects. Nurse #1 said that she did not anticipate that Patient #1 would break the wooden popsicle stick in half and swallow it.

The Surveyor interviewed the Risk Manager at 12:14 P.M. on 10/21/19. The Risk Manager said that the medical record documentation did show how quickly Patient #1's behaviors changed and that Nurse #1 acknowledged a lapse when providing the popsicle to Patient #1. The Risk Manager said that the Hospital was not able to determine where Patient #1 found the needle cap that he/she ingested and it could have been found on his/her trip to radiology.

The Surveyor interviewed Security Officer #1 at 11:30 A.M. on 10/22/19. Security Officer #1 was assigned on multiple occasions to provide continuous observation of Patient #1. Security Officer #1 was aware that Patient #1 had a history of ingesting foreign objects. Security Officer #1 was present during transportation from radiology and said that, when Patient #1 was brought to his/her room, he/she jumped off the bed, saw the cap, picked it up and quickly swallowed it. Security Officer #1 said that there was no follow up by administration or education provided to her to prevent a like incident from occurring again.

The Surveyor interviewed Security Officer #2 at 12:30 P.M. on 10/22/19. Security Officer #2 was present and providing constant observation of Patient #1 during transportation from radiology. He said that the needle cap was in Patient #1's room when he/she picked it up and swallowed it. Security Officer #2 said that there has been no formal policy changes or education provided to the employees to prevent a like incident from occurring again.

The Surveyor interviewed the Director of the Emergency Department and the Senior Director of Health Care Quality and Patient Safety at 1:40 P.M. on 10/21/19. The Director of the Emergency Department and the Senior Director of Health Care Quality and Patient Safety said that they are working on updating their education provided to staff members to prevent a like incident from occurring again. The Director of the Emergency Department and the Senior Director of Health Care Quality and Patient Safety acknowledged that education and policy changes had not been instituted yet to prevent a like incident from occurring again.

Based on records reviewed and interviews, the Hospital failed to ensure that all security staff, whose job requires assistance in the application of restraints, were trained in the use of first aid techniques and certification in the use of cardiopulmonary resuscitation.

Findings include:

Review of the Hospital's policy titled Use of Restraints, dated October 2017, revealed that:

Staff members who either apply restraints or assist the registered nurse (RN) or provider in the application of the restraint, and/or who monitor and/or assess patients while in restraints receive education and training in the following areas as appropriate to their assigned responsibilities and to the patient population served.

vi. The use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic re-certification.

Review of Security Officer #1's personnel record indicated that Security Officer #1 was not trained in the use of first aid techniques or certification in the use of cardiopulmonary resuscitation.

Review of Security Officer #2's personnel record indicated that Security Officer #2 was not trained in the use of first aid techniques or certification in the use of cardiopulmonary resuscitation.

Review of the Hospital's incident reporting log revealed that, on 9/30/19, Security Officer #1 participated in the application of restraints for Patient #1 by using physical hold of the patients left arm and put on left side restraints.

Review of the Hospital's incident reporting log revealed that, on 9/30/19, Security Officer #2 took control of Patient #1's legs and applied soft restraints.

The Surveyor interviewed the Senior Director of Health Care Quality and Patient Safety at 2:20 P.M. on 10/21/19. The Senior Director of Health Care Quality and Patient Safety said that she did not believe security officers participated in the application of restraints.

The Surveyor interviewed Security Officer #1 at 11:30 A.M. on 10/22/19. Security Officer #1 said that she had to apply restraints at times when patients required them.

The Surveyor interviewed Security Officer #2 at 12:30 P.M. on 10/22/19. Security Officer #2 said that when verbal de-escalation does not work with aggressive patients, he has had to use hands on restraints and has had to apply restraints on patients.

The Surveyor interviewed Nurse #1 at 12:45 P.M. on 10/22/19. Nurse #1 said that security put restraints on the patients. Nurse #1 said that if the patients had to go into four point restraints, security applied them.

The Surveyor interviewed the Director of Security and Safety at 1:30 P.M. on 10/22/19. The Director of Security and Safety said that security officers applied restraints. The Director of Security and Safety said that the security officers are not trained in first aid techniques and are not certified in cardiopulmonary resuscitation.