HospitalInspections.org

Based on observation, review of clinical records, interviews and review of hospital policies and procedures for two of ten patients (Patients # 11 and 16) admitted with suicidal ideation, the hospital failed to ensure that the environment was safe for patients who had self-injurious behaviors of cutting themselves with utensils.

Immediate Jeopardy was identified under the Condition of Participation of Patient Rights at 42 CFR 482.13.


Refer to A-144.

Based on observation, review of clinical records, interviews and review of hospital policies and procedures for two of ten patients (Patients # 11 and 16) admitted with suicidal ideation, the hospital failed to ensure that the environment was safe for patients that had self-injurious behaviors of cutting themselves with utensils and as a result, Immediate Jeopardy was identified. The findings include:

a. Patient #11 was admitted on 6/20/14 with suicidal ideation and urges to self-injure by cutting self, and a diagnostic history that included bipolar disorder and personality disorder.

Review of MD #1's note (Chair of Psychiatry) contained in the clinical record indicated that during the several day course of the patient's previous admission on 5/27/14, the patient acted upon urges to self-injure on two occasions utilizing plastic implements to create superficial abrasions or cuts to his/her forearms.

Review of Patient #11's master treatment plan, dated 6/21/14, identified a problem of suicidal ideation, cuts to the left wrist with interventions that included fifteen-minute checks for safety because of the patient's history, scan the patient care areas and consider the need to remove any unusual items to provide a safe environment.

Review of Psychiatric Technician (PT) #3's progress note dated 6/25/14 at 11:09 A.M. identified that Patient # 11 continues to have intermittent suicidal thoughts and did contact staff and handed in his/her knife to staff. The patient was advised by PT #3 to stay in the lounge area and continue to check in with staff about his/her thoughts. Review of the clinical record failed to identify that PT #3 reported to the nurse that the patient had intermittent suicidal thoughts or that the patient had a knife, and interview with PT#3 confirmed this fact.

Review of RN #6's progress note dated 6/25/14 at 5:23 P.M. identified that after dinner Patient #11 was found with superficial scratches on the left inner arm from cutting self with a plastic knife. The patient reported s/he had to cut "for release" and that s/he had been struggling with urges. Patient #11 gave the knife to staff, MD #3 was notified of the incident, and directed staff to maintain fifteen-minute checks.

Review of the Multidisciplinary Team Treatment Plan (MTP) dated 6/26/14 failed to identify and/or address that Patient #11 was found with superficial scratches on the left inner arm from cutting self with a plastic knife on 6/25/14.

Review of the fifteen-minute observation checks, dated 6/26/14 during the period of 7:15 A.M. to 8:45 A.M., identified that Patient #11 was in the lounge/kitchen and/or hallway. According to the observation checks, PT #4 confirmed that these areas were scanned for potentially dangerous items. Interviews with PT #4, on 6/26/14 at 10:16 A.M. and 10:40 A.M., identified that s/he scanned the common areas during the aforementioned time period and the only safety concern at that time was a coffee spill which s/he cleaned immediately.

During a tour of the unit with Nurse Director #1 and the Assistant Director of Performance Improvement, on 6/26/14 at 9:16 A.M., the surveyor observed plastic utensils including spoons, two forks and a knife in one of the two unlocked drawers (with the capability of locking) in the open kitchenette/lounge area that all patients had free access to. Staff could not explain the presence of forks and a knife in the drawer labeled "spoons".

PT #4 failed to identify that plastic utensils were stored in unsecured drawers in the open kitchen area that all patients had free access to during the fifteen-minute environmental checks documented on Patient #11's observation check sheet.
Observation on 6/26/14 at 10:05 AM with Nurse Director #1, the Assistant Director of Performance Improvement, and RN #1, on 6/26/14 at 10:05 A.M., it was identified that the plastic spoons, two forks and a knife remained in the unlocked drawer continuing to pose an immediate threat to patients on that unit. Subsequent to the surveyor's second inquiry, the plastic cutlery was discarded by the surveyor in the presence of Nurse Director #1, the Assistant Director of Performance Improvement, and RN #1, due to lack of staff response.

Interviews with Nurse Director #1, RN #1, RN #2, RN #3, PT #1, PT #3 and Patient Care Assistant #1, on 6/26/14 from 2:15 P.M. to 2:50 P.M., identified that staff keep extra plastic utensils in one of the two drawers in the open kitchenette/lounge area and the drawers are never locked/secured.

On 6/26/14 at 2:15 P.M., Patient #11 was being observed every five minutes by PT #2. Interview with PT #2, on 6/26/14 at 2:15 P.M., identified that s/he had been observing the patient since 1:00 P.M. to ensure the patient did not harm him/herself. PT #2 further stated that s/he was unsure why the patient was placed on five-minute checks, as a report from RN #3 was not provided.

Interview with RN #3, on 6/26/14 at 2:15 P.M., identified that five-minute observations were initiated at 11:00 A.M. due to the patient's self-injurious behavior, cutting him/herself with a plastic knife from his/her dinner tray on 6/25/14 (at approximately 5:23 P.M.). RN #3 stated that s/he had not provided PT #2 with a specific report as to why Patient #11 required five-minute observations.

The facility failed to update Patient #11's Master Treatment Plan for 17 hours and 37 minutes to ensure the safety of the patient.

b. Patient #16 was admitted on 6/25/14 with acute psychosis with a history of suicide attempts and self-injurious behaviors. Review of the MTP dated 6/25/14 identified a problem related to psychological impairment with worsening psychosis and attempting to stab self with a fork with interventions that included fifteen-minute checks and provide a "safe and supportive environment by monitoring mood and mental status".

The MTP identified a problem of suicidal ideation, hearing a voice telling his/her to harm-self and was attempting to stab self with a fork upon arrival to the emergency room with interventions that included fifteen-minute checks for safety because of the patient's history to harm self, scan the patient care areas and consider the need to remove any objects patient may use to harm self to provide a safe environment.

Review of the fifteen-minute observation check dated 6/26/14 at 8:00 A.M., documented that the patient was in the hall and the environment was scanned for potentially dangerous items.

During tour of the unit on 6/26/14 at 9:16 A.M, it was identified that the plastic spoons, two forks and a knife were observed in an unlocked drawer in the open kitchen area adjacent to the hallway posing an immediate threat to Patient #16's safety.

Review of the hospital policy and procedure, titled "Patient Interventions", identified that during the fifteen minute checks, staff ensures each patient and the environment is safe and staff provides patient care under the direction of a Registered Nurse.

Review of the hospital policy and procedure, titled "Multidisciplinary Team Treatment Plan" identified that each patient's individualized treatment is documented in the plan by members of the multidisciplinary teams members, based on assessment/changes, and is reviewed and updated by the team.

On 6/26/14 the Connecticut Department of Public Health directed the hospital to submit an immediate action plan to address safety in the Behavioral Health units. The Hospital's immediate action plan included reassessment of each patient for suicidal ideation, safety review of the environment, plastic utensils were removed from the unit, alteration in the dinner and breakfast menus (to all finger foods), review and update of the MTP to include any identified changes in conditions, re-educate the RN's regarding communication to assigned staff members regarding changes in patients condition, notification to the units physician leaders and immediate staff education.

Based on a review of clinical records, hospital policies and interviews for two of two patients (Patients #3 and 4) that received psychotropic medication, the hospital administered psychotropic medication absent physician rationale/clinical justification for the use of chemical restraints and/or the specific behavior that warranted the use of restraints. The findings include:

a. Patient #3 presented to the ED on 6/4/14 at 11:50 PM with agitation, impulsiveness and irritability after illegal drug use. Review of a physician's order dated 6/5/14 at 12:05 AM directed Ativan 2 mg IM "now", absent physician rationale/clinical justification for the use of chemical restraints. Although the clinical record indicated that the patient "was a danger to self and others" and the patient was placed in four-point restraints on 6/5/14 at 12:08 AM, the record failed to note the specific behaviors that determined this designation. Record review and interview with the VP of Nursing on 6/26/14 at 10:25 AM stated the physician's are expected to document the rationale for chemical restraints in a progress note, however, this was not done.

b. Patient #4 presented to the ED on 6/3/14 at 11:56 AM with an overdose. The note indicated that the patient was aggressive and hitting the technician. A physician's order dated 6/3/14 directed Ativan 1 mg IV push and the patient was placed in four-point soft locked restraints at 1:34 PM. The physician's orders further directed administration of Ativan 2 mg IV push now at 2:09 PM, 4:37 PM and 1 mg IV push at 4:17 PM, absent physician rationale/clinical justification. Record review and interview with the VP of Nursing on 6/26/14 at 10:25 AM stated the physicians are expected to document the rationale for chemical restraints in a progress note, however, this was not done.

Review of the policy and procedure, titled "Restraint and Seclusion", identified in part, documentation of clinical justification for use, clinical oversight, circumstances/behavior leading up to each use, alternatives tried or considered, and rationale for type.

Based on a review of clinical records, hospital policies, and interviews, the hospital failed to ensure physician orders for restraints were followed for one of two patients (Patient #3) restrained. The finding includes:

Patient #3 presented to the ED on 6/4/14 at 11:50 PM with agitation, impulsiveness and irritability after illegal drug use. Review of the physician's orders dated 6/5/14 at 12:08 AM directed the use of soft locked bilateral wrist restraints. The clinical record indicated that the patient "was a danger to self and others", however lacked specific behaviors. Review of the nursing restraint application documentation identified that the patient was placed in four-point restraints on 6/5/14 at 12:08 AM absent a physician's order for the four-point restraints. Record review and interview with the VP of Nursing on 6/26/14 at 10:25 AM confirmed that four-point restraints were applied although the physician directed two restraints be utilized.

Review of the policy and procedure, titled "Restraint and Seclusion", identified that behavioral restraints are used for the management of violent or self-destructive behaviors that jeopardizes the immediate physical safety of the patient staff member or others, and all restraints are in accordance with physician/providers orders.