HospitalInspections.org

Based on record review and interview the hospital failed to preserve the rights of three of three patients (Patient #2, #19, #20) to receive care in a safe setting.

1) On 09/29/15 at approximately 02:00, Patient #2 was able to walk past the glass-encased nurses station, left the patient unit through an unlocked door to the kitchen which had multiple objects potentially useable in self-harm or to harm others. Patient #2 left the hospital through a back door. Patient #2 spent two and one-half early morning hours outside and required emergency care evaluation upon discovery.
2) At the time of survey, Patients #19 and #20's rooms were equipped with metal beds which posed a safety hazard and /or ligature risk to the patients who had been assessed to be depressed.


Findings included:

1) Patient #2's Record of Admission reflected a patient admission date of 09/24/15 at 15:40 and a discharge dated of 09/29/15 at 04:30.

Patient #2's Psychiatric Evaluation dated 09/25/15 at 09:14 noted the patient thought that he was in prison. The patient was noted to have poor insight and judgment. Admission diagnoses included Psychosis, Impulse Control Disorder, and Cognitive Impairment.

Multi-Disciplinary Note dated 09/29/15 at 02:00 reflected nursing staff was unable to locate Patient #2. The patient had last been seen at 01:45 "wandering in hallway..." and "...door leading to kitchen found unlocked. " At 04:30 Patient #2 was found outside and transported to the acute care hospital Emergency Department.

Physician Discharge Summary dated 10/09/15 at 16:42 by Employee Physician #15 reflected Patient #2 was "confused and disoriented and memory impaired." The document noted that "...one of our mental health technician failed to properly monitor the patient, and he inadvertently eloped through an unlocked door..was found on or near hospital property and was taken to a nearby hospital to determine this status...not going to return."

Hospital Employee #3 agreed on 12/30/15 at 14:45 that the kitchen environment was very unsafe, had chemicals, and was "like a maze."

On 12/30/15 at 15:50 Hospital Employee #9 was asked by the surveyor whether he was aware of the fact that the Patient #2 was documented to have been gone for 2 ½ hours before found and stated he had no answer to that.

Observational rounds were conducted on 12/30/15 between 11:45 and 12:20 in the hospital's kitchen, dining room, and patient room. The kitchen had a four-burner gas stove, walk-in refrigerator and freezer, staff lockers, chemicals, and a fire extinguisher. The distance between the room where Patient #2 had resided and the kitchen door was more than 150 feet (65 steps) and included passing by the glass-enclosed nurses' station through the patient dining area. The kitchen door was locked.

2) Observations on 12/30/15 at 11:45 reflected a metal bed in one occupied patient room. The metal bar underneath the bed extended the length of the bed and provided for a sheet and/or object to be tied to the bar for self-harm and ligature risk.

Employee #9 stated on 12/30/15 at 11:45 that four wood-framed beds had been ordered to replace the metal beds in the four rooms closest to the nurses' station. The new beds had not arrived yet. Employee #9 confirmed that forty-four metal beds were scheduled to stay and be used by inpatients.

Review of the daily census report dated 12/29/15 reflected that Patient #19 and #20 slept in rooms with metal beds.

Patient #19's History and Physical Examination dated 11/21/15 at 08:00 reflected the patient was "depressed."

Patient #19's Psychiatric Evaluation dated 11/21/15 reflected the patient was "presumably psychotic and may be attending to internal stimuli." The Treatment plan noted, "Should...[Patient #19] get so severe as to present danger to herself or others, we will begin involuntary medication."

Patient #20's History and Physical Examination dated 12/24/15 at 15:40 reflected the patient was "depressed."

Patient #20's Daily Nurses' Notes dated 12/30/15 at 13:45 reflected the patient was on suicide precautions.

Based on record review and interview the hospital failed to ensure that the RN completed an initial comprehensive nursing assessment for one of one patient (Patient #1) whose initial skin assessment did not reflect any skin issues. During his hospitalization, Patient #1 was noted to have multiple skin problems including a stapled wound, a stage two pressure ulcer, and bruises.
Findings included:

Patient #1's Record of Admission reflected an admission date of 11/18/15 at 13:20 and a discharge date of 12/07/15 at "02:30 [not specified AM or PM]."

Admission Orders dated 11/18/15 at 13:20 reflected admitting diagnoses that included Acute Exacerbation of Schizoaffective Disorder with Depression.

The Comprehensive Integrated Nursing Assessment dated 11/18/15 at 12:40 did not address any skin problems.

Physician Progress Notes dated 11/21/15 reflected the patient had "steri-strips to his right lateral eyebrow, not evident to me previously."

Multi-Disciplinary Notes dated 11/25/15 at 10:45 reflected "...present, but not new, was a dime-sized wound at the end of the sacrum [lower back] that was a stage two wound."

The Skin and Braden Reassessment documentation dated 12/06/15 reflected multiple skin problems including staples above the patient's right eye, at least three bruises on the patient's right lower leg and two on his left lower leg, and a "scab" around the patient's right knee cap.

Hospital Employee #9 was asked about the initial comprehensive nursing skin assessment on 12/30/15 at 16:35 and stated, "It was not done."