HospitalInspections.org

Based on interview, review of the facility's incident report, and review of the facility's policies/procedures, it was determined the facility failed to ensure necessary care and services were provided to patients in order to meet their needs for one patient (Patient #1) in the selected sample of ten patients. The facility failed to ensure: staff was knowledgeable and trained regarding their room search policy which requires the rooms of patients on suicidal ideation (SI) and/or self injurious behavior (SIB) precautions to be searched daily; the policy and procedures were implemented; and, to ensure safety and appropriate supervision to prevent access to contraband or items that could be used for self-harm. The facility failed to have a system in place to ensure the patients did not bring contraband with them as they returned to the units from school.

Additionally. the facility failed to ensure appropriate supervision, to prevent access to contraband or items which could cause potential harm, for one patient (Patient #1) out of a selected sample of ten. The facility assessed patient #1 as requiring supervision due to suicidal ideation and self injurious behavior. Patient #1 was placed on Q15 minimal SI SIB precautions. On 09/19/12, Patient #1 reported to staff he/she found part of a pencil in the drawer in his/her bedroom. Patient #1 reported he/she removed the metal that was around the eraser, flattened the metal piece, and cut the word "forever" in his/her thigh during room time the prior day. Additionally, he/she reported the door to his/her room was left open and staff walked by several times.

These facility failures prevented the facility from ensuring a safe environment and appropriate nursing supervision to prevent patient access to contraband that could lead to potential self-injurious behaviors. These failures resulted in non-compliance with the Condition of Participation. Refer to Tag A-395.

Based on interview, review of patient medical records, and review of the facility's policy/procedure manual, it was determined the facility failed to notify the guardian of one patient (#2), in the selected sample of ten patients, regarding an abnormal Electrocardiogram (EKG). Additionally, the facility failed to have a system in place to ensure the patient guardians were being informed about the patient's health status. On 09/29/12, the facility received an abnormal EKG for patient #2 which was confirmed on 10/02/12; however, the facility failed to notify the patient or his/her guardian.

Findings include:

A review of the facility's policy/procedure manual, revealed no evidence of a policy and procedure regarding guardian notification of abnormal labs.

A review of Patient #2's medical record revealed. on 09/29/12 the facility received an EKG result which was abnormal. The facility forwarded the abnormal EKG result to pediatric cardiology on 10/01/12 to verify the abnormal reading. Pediatric Cardiology confirmed the EKG was abnormal and returned it to the facility on 10/02/12. There was no documented evidence in patient #2's medical record the facility notified guardian of the abnormal EKG.

An interview with the Medical Director, on 11/15/12 at approximately 7:45 AM, revealed the facility sent abnormal EKG readings to pediatric cardiology for verification because the EKG machine at the facility sometimes gave false negatives. Additionally, he stated if the EKG was confirmed as abnormal, we let the guardian know as Best Medical Practices; however, there was not a policy/procedure regarding guardian notification.

Interview with the Interim Administrator, on 11/15/12 at approximately 7:30 AM and 8:55 AM, revealed "we have no documented evidence the guardian was notified, and we have no policy which specifies what information we provide to the guardian regarding patient change of condition or lab results."

An interview with the Chief Executive Officer, on 11/15/12 at approximately 10:55 AM, revealed there was no policy/procedure in regard to informing a patient or guardian about abnormal labs.

Based on interview, review of patient medical records, review of the facility's policy/procedure manual, and review of the facility's incident report, it was determined the facility failed to ensure necessary care and services were provided to patients in order to meet their needs for one patient (Patient #1) in the selected sample of ten patients. The facility failed to ensure the policies/procedures were followed to ensure safety and appropriate supervision to prevent access to contraband or items which could be used for self-harm. The facility failed to ensure appropriate supervision to prevent access to contraband or items which could cause potential harm. The facility assessed Patient #1 assessed as requiring supervision due to a history of self injurious behavior (SIB) and suicidal ideation (SI). Additionally the facility failed to ensure the staff was trained and knowledgeable regarding facility policy which requires daily room searches for patients who are on Minimal Self-Injury Precautions. The facility failed to have a system in place to ensure the patients did not bring contraband to the unit from school.

On 09/19/12, Patient #1 reported to staff he/she found part of a pencil in the drawer in his/her bedroom, removed the metal that was around the eraser, flattened the metal piece, and cut the word "forever" in his/her thigh during room time the prior day. Additionally, he/she reported the door to his/her room was left open and staff walked by several times.

Findings include:

Review of the facility's policy/procedure, "Self-Injury Precautions", revealed minimal self-injury precautions will be implemented for patients who present with a significant level of risk of self-injury. The policy on Minimal Self-Injury Precaution, states, "Patients will have their person, room, and personal possessions examined for items which could be harmful. Room searches will be conducted every day and randomly while precautions are in place."

Review of the facility's policy/procedure, "Searches", revealed room searches must be conducted every 72 hours for patients who are on close observation, aggressive or suicidal precautions, or are actively exhibiting self-injurious behavior.

Review of the facility's policy/procedure, "Contraband Precautions", revealed the policy stipulated patients are not allowed to bring certain items on the unit, contraband may be considered any item(s) taken out of their appropriate area of use and/or items listed on the non-negotiable list.

Review of the non-negotiable list revealed pencils were included on the list.

Record review revealed the facility admitted Patient #1 on 09/05/12. Patient #1, a fifteen year old was referred to the facility due to danger to self. The police transported Patient #1 to the facility's emergency department after he/she had sent a text to a friend stating he/she was going to kill himself/herself. The patient reported he/she had suicidal thoughts and had a plan. The facility admitted Patient #1 with an Axis I diagnosis of Depressive Disorder, Not otherwise specified (NOS), Rule out mood disorder, NOS. The facility assessed the patient and placed him/her on special observations, every (Q) 15 minutes due to minimal suicidal risk, elopement, impulsivity, and unpredictability. Review of the facility policy requires room searches to be conducted daily and randomly while precautions are in place. Patient #1 remained on Q15 minutes checks and minimal SIB precautions. However, review of the record revealed no documented evidence that the facility staff conducted the required room searches from 09/06/12 through 09/13/12. Further review revealed a Physician's order dated 09/13/12 for the facility to continue Q 15 minute checks and minimal SIB precautions. Record review revealed no evidence that the facility conducted searches per the facility policies from 09/13/12 through 09/16/12. Review of the physician order dated 09/17/12 revealed staff was to continue Q 15 minute checks and minimal SIB precautions. Again, there is no documented evidence the facility staff conducted the policy required room searches from 09/17/12 through 09/19/12. The facility could provide no documented evidence that they conducted daily room searches (14 total) from 09/05/12 through 09/19/12 in accordance with facility policy.

Review of the facility's incident report, revealed on 09/19/12, Patient #1 reported to staff he/she found part of a pencil in the drawer in his/her bedroom. Patient #1 reported he/she removed the metal that was around the eraser, flattened the metal piece and cut the word "forever" in his/her thigh during room time the prior day. Additionally, he/she reported the door to his/her room was left open and staff walked by several times. Interview with Mental Health Technician (MHT) #7, on 11/15/12 at approximately 12:56 PM, revealed Patient #1 reported the incident to her. She stated Patient #1 asked if he/she could go to the quiet room and the patient handed her a piece of folded paper. She opened the paper, which read "I don't want to do this no more" and it contained the piece of metal Patient #1 used to cut himself/herself. MHT #7 asked Patient #1 if he/she wanted her to go with him/her, and Patient #1 replied yes, so she went. Additionally, she asked Patient #1 if he/she hurt himself/herself. Patient #1 replied yes and showed her the word "forever" cut into his/her thigh. Patient #1 also told her that he/she did this while the staff was doing their rounds. The patient revealed that he/she had a blanket over his/her legs and when the staff looked in the room, he/she would stop cutting. Patient #1 also told MHT #7 that he/she found the metal piece in his/her drawer. An interview with MHT #9, on 11/16/12 at approximately 9:00 AM, revealed she was the MHT who conducted the Q15 minute rounds. She stated she did not see Patient #1 cut himself/herself. While facility staff was conducting every 15 minute rounds for Patient #1, no staff identified that the Patient had access to contraband i.e. pencil and no staff observed the Patient cutting himself/herself, even though the facility had assessed and the physician had ordered supervision due to the patient's history and diagnoses.

Furthermore, continued interviews with MHT #7 revealed she did not know the facility's policy regarding room searches for patients on SIB precautions. An interview with Registered Nurse (RN) #2, on 11/15/12 at approximately 1:57 PM, revealed she was aware minimal SI SIB precaution patients' rooms were to be searched daily and she documents any searches she conducts in her nurse's notes. However, record review revealed no documented evidence the facility had conducted those searches for Patient #1. She also reported daily room searches for patients on SI SIB precautions were not being done. In an interview with RN # 1, on 11/15/12 at approximately 2:30 PM, she states she was not aware the facility had a policy which requires daily and random room searches to be conducted for patients on Q15 minimal SI SIB precautions. During an interview with MHT #5, on 11/15/12 at approximately 11:12 PM, she stated she does not usually do room searches and was not aware the policy states room searches are to be done daily if a patient is on SI SIB precautions.

During an interview with the Interim Director of Nursing, on 11/16/12 at approximately 11:55 AM, he stated he was not aware the room searches for patients on Minimal SI SIB precautions were not being completed. Additionally he stated the unit nurse should have oversight that the room searches were being completed per facility policy and room searches should be documented in the patient's chart upon completion.

An interview with the Chief Executive Officer and the Interim Administrator, on 11/15/12 at approximately 10:45 AM, revealed the facility had no policy or system in place to ensure patients did not have any contraband when they returned to the unit from school, and no checks or searches were completed as the patients returned from school to ensure they were free of any contraband. Additionally, they reported there was no documented evidence in the medical records regarding searches being completed for patients on Q 15 minute checks with minimal precautions for SI/SIB.

An interview with the Interim Administrator, on 11/15/12 at approximately 1:24 PM, revealed the school did not have a policy in regard to verifying the patients were not taking items considered to be contraband out of the school area and back to the units.