HospitalInspections.org

Based on observation, interview and record review, the facility failed to ensure nursing staff consistently followed the plan of care for enhanced supervision (1:1) for 3 (#'s 1, 3 and #4) of 10 patients reviewed for at risk for self harm from a total sample of 10 patients, resulting in the potential for the less than optimal outcomes.
Findings include:

--(See A 396)
The facility failed to follow the plan of care and/or update the plan of care with individualized interventions for 3 patients (#1, 3 and #4) that were identifed at risk for self harm and on (1:1) enhanced supervision.

Based on observation, interview and record review, the facility failed to ensure nursing staff followed the plan of care and/or update the plan of care with individualized interventions for enhanced supervision (1:1) for 3 (#'s 1, 3 and #4) of 10 patients reviewed for at risk for self- harm from a total sample of 10 patients, resulting in the potential for the less than optimal outcomes.
Findings include:

On 9/11/17 at approximately 1020 a tour of the inpatient residential care units (cottages) were conducted with the Director of Regulatory Compliance Staff B. At approximately 1130 on 9/11/17 during the tour of Cottage #15 Nurse Manager Staff C explained patient #3 was on "1:1" supervision. Staff C explained that staff was designated to be within arm's reach of the patient at all times.

On 9/11/17 at approximately 1150 while accompanied by Staff C, residential care assistant (RCA) Staff D was observed seated in a chair near the doorway entry of patient #3. Staff C was overheard as she asked Staff D where was patient #3. Staff D was overheard as he said he is in the bathroom brushing his teeth. At that time the patient #3 was not visible nor within arms reach of Staff C who was his designated RCA for (1:1) enhanced supervision.

On 9/11/17 at 1155 when further queried regarding patient #3 not being visible for (1:1) staff enhanced supervision/monitoring, Staff C confirmed that Staff D was not following the plan of care for enhanced supervision (1:1) for patient #3.

On 9/11/17 at 1210 during an interview when queried regarding (1:1) supervision for patient #3 Staff D explained that he knew that he was to have been within arms reach of the patient. Staff D said, he (#3) was brushing his teeth. Staff D said, I know my patient. I've worked with him long enough. I wanted to give him some privacy.

On 9/11/17 at 1230 a review of the medical record for patient #3 was conducted. Per record review patient #3 was a 27 year old male admitted to the facility on 1/12/2017 with a diagnosis of schizophrenia and a history of previous attempts of suicide. Per the patient's "At risk for violence directed at self" plan of care dated 1/12/2017 the patient was to be on close observation by staff at all times. However, on 9/11/17 at approximately 1155 patient #3 was observed without staff being within arms reach at all times.

On 9/11/17 at approximately 1245 while touring Cottage 16 an interview was conducted with patient #1 while accompanied by Nurse Manager Staff J, Staff B and RCA Staff M. The patient said that she did not feel good. She (#1) complained of stomach pain. She said that she was waiting to go to the clinic. She said that she did not want to talk at that time. The patient's left hand between her thumb and her left index finger was observed with hyperpigmented pink-reddish tissue in various stages of healing was noted and open to air.

On 9/11/17 at approximately 1300 an interview was conducted patient #4 while accompanied by Staff J, Staff B and RCA staff members (K and L). Patient #4 was on (2:1) enhanced supervision at that time. Patient #4 explained she was not always treated with dignity nor respect by staff. She said staff were inconsistent with meeting her needs and keeping her safe from harm. Patient #4 said choked on a paper medication cup while supposedly being on (1:1) observation on a previous occasion. At that time patient #4 was overheard as she asked Staff J about the paper medication incident. Staff J was overheard as she stated, "Yes, I'm aware. That's why we only give you hard cups now."

On 9/11/17 at 1500 a review of the medical record for patient #4 was conducted with Staff B. Per record review patient #4 was a 21 year old female admitted to the facility on 7/28/2017 with diagnoses that included unspecified mood disorder and borderline personality disorder. Further review of the medical record (psych evaluation dated 7/28/2017) revealed the patient had a history of violence to self for over the past previous 6 months. Per review of the patient's (#4's) "At risk for self mutilation" care plan initiated on 7/28/2017 documented that the patient was to be on close observation and within close proximity to staff. Additionally, the patient (#4) was to be observed 30 minutes after medications to avoid hoarding of medications.

A review of the electronic medication administration record (MAR) dated 8/30/17 was conducted with Staff B on 9/11/17 and revealed that the patient (#4) received Depakote (use for mood disorder or for seizure disorder) at 2015. There was no further evidence in the medical record that documented patient #4 was monitored for 30 minutes following the medication pass to ensure that the medications were not hoarded or that the medication cup was disposed of per protocol.

Per review of the "at risk for violence directed at self" care plan dated 7/28/17 documented the patient (#4) was to be on close observation and within close proximity of staff per current policy by the licensed staff and staff were to conduct environmental searches for items that could be used for harm towards herself.

Additionally, a review of a "Freedom of Movement" (physicians order for 1:1 supervision dated 8/30/2017 revealed the patient was on (1:1) enhanced supervision due to danger to self and danger/threat to others. However, there were no updates to the care plan that documented any further updates or individualized interventions to decrease the risk of violence directed at self.

On 9/11/17 at approximately 1530 during an interview Staff G Cottage 16 Assistant Nurse Executive Manager was unable to explain how patient #4 who was at risk for self-harm was able to secure a paper medication cup and choke on it while on 1:1 observation.

On 9/11/17 at approximately 1640 a phone interview was conducted with RCA Staff E. When queried regarding the patient choking on a paper medication cup he (Staff E) said he relieved another staff member approximately 2-3 hours before the incident. When asked to explain how or when the patient got the paper medication cup and choked on it he stated, "I don't know. I asked her (#4) and she said she got the cup hours ago."

On 9/11/17 at 1500 a review of the medical record for patient #1 was conducted.
Per record review patient (#1) was a 19 year old female admitted to the facility on 3/9/2017 with diagnoses that included major depressive disorder. Further review of the patients medical record (psych evaluation dated 3/10/17) revealed the patient had a history of cutting herself, bitting herself and swallowing non-edible objects that had to be subsequently removed per endoscopy resulting in the patient requiring (1:1) supervision to minimize the risk of her further swallowing non edible objects.

A review of the patient's (#1's) Incident/Accident (I/A) reports dated 5/17/17 through 8/12/17 revealed the patient while on enhanced supervision (1:1) had made 3 successful attempts for the ingestion non-edible objects. Including transfer to an acute care hospital for evaluation following ingestion of a foreign body on 8/12/2017.
A review of the patient's (#1's) "At risk for violence directed towards self" dated 3/9/2017 documented the patient would not inflict self harm on herself and would learn alternative coping methods. Nursing interventions included the patient would be placed on close observation and maintained on close proximity of staff and staff would conduct initial and periodical search of the patients belongings and environment for items that could be used to harm herself.
Additionally, a review of a "Freedom of Movement" (physicians order for enhanced 1:1 supervision) documented the following:
On 5/17/2017 at 1152, On 5/18/2017 at 1302, On 5/18/17 at 1402, On 5/22/2017 at 1349, On 5/22/17 at 1352, On 8/12/14 at 0732, and On 8/22/2017:
(1:1) AM and PM Shifts Female staff only, hands, neck and face visible to staff at all times due to danger to self supervised bathroom at all times ingests foreign objects
On 8/22/17 at 1517 the patient's enhanced supervision increased to (2:1).
However, there were no updates or individualized interventions documented on the patient's (#1's) "at risk for violence directed towards self" care plan between 4/21/17 and 8/3/17 or thereafter to give staff direction on meeting the patient's care needs.

On 9/12/17 at approximately 1030 Staff B explained nursing staff would be expected to adhere to following the "Freedom of Movement" orders for supervision interventions versus the nursing care plan. However, a review of the facility's Nursing Process/ Nursing Care Plan policy #NS-160 dated 7/1/16 documented:
"...Development of the Nursing Care Plan...#7 d. The Nursing Intervention column is designed to give staff direction to best assist the patient in meeting the identified goals. The RN will describe interventions that are staff oriented: they delineate staff action (i.e., they are to monitor encourage, they are to document, report, assist, etc.)..."