HospitalInspections.org

Based on interview and record review, the Hospital failed to ensure 1 of 1 patient (Patient #1) was provided a safe environment while seeking psychiatric intervention. Hospital personnel did not secure and/or remove a hazardous object (cigarette lighter) from (Patient #1) upon admission to the Psychiatric ED (Emergency Department). (Patient #1) removed a cigarette lighter from her pants and lit her shirt on fire while in seclusion.

Findings included:

Patient #1 was admitted to the Psychiatric ED with mood disorder, suicidal ideation, unspecified psychosis and episodic mood disorder.

The physician note dated 10/08/11 timed at 15:32 PM, reflected, "While in the dayroom patient became increasingly agitated, despite this writer's efforts to calm her down...patient quickly escalated, yelling profanities at this writer and other staff, throwing her cup of ice water at the window and banging on the window with her hands...patient was escorted to the seclusion at 15:30 PM, a personal hold was not needed, emergency medication given at 15:31 PM. Will continue to monitor patient..."

The nursing note dated 10/08/11 timed at 14:12 PM reflected, "Patient admits to police officer that she is depressed and wants to hurt herself. Patient attempted to kill herself by jumping out of a moving vehicle. Noted patient has multiple bruises on her arms and legs. Dr...aware...patient stated she is going through a lot...told Dr...she has been drinking...everyday. Patient with rapid pressured speech, paranoid, hyper verbal...search and scanned by...tech (technician)."

The Flow sheet data record dated 10/08/11 timed at 14:14 PM reflected, "Belongings checked, body checked, clothing checked..."

The Social Worker note dated 10/08/11 timed at 16:27 PM reflected, "After being placed in seclusion, pt (Patient) started a fire. Her shirt was fully enflamed before seclusion room staff entered the room. From the rooms TV (television) it showed that pt was not near the fire, removed before the room filled with smoke. Pt was not hurt and did not show any signs of stress over the fire..."

The nurse note dated 10/08/11 timed at 16:10 PM reflected, "Reported by...while watching the camera that this patient has started a fire in seclusion room...writer went to seclusion room right away and patient was already removed by...psych tech from seclusion room, fire is already extinguished. Per tech patients shirt is not on her person but lighted the shirt with lighter. Patient was examined and assessed, no visible injury, burns or signs and symptoms of smoke inhalation observed on the patient...Dr. was made aware...patient seclusion was discontinued..."

On 11/04/11 at 10:20 AM Personnel #2 was interviewed. Personnel #2 stated the technician did not search and/or scan the patient when she arrived. Personnel #2 stated the technician who was asssigned to monitor the patient one to one while Patient #1 was in seclusion turned his back away from the patient and did not conduct one to one supervision.

On 11/04/11 at 2:05 PM, Personnel #13 was interviewed. Personnel #13 was asked to review her nursing note entry for Patient #1 where she documented the patient was searched and scanned. Personnel #13 stated she did not physically see the technician search the patient. Personnel #13 said she assumed the technician did the search and scan as it was their job.

The Hospital Video Clip dated 10/08/11 timed at 14:31 PM to 16:05 PM reflected, "14:32...technician verifying patient, plastic bag for valuables nurse present...ended 14:36 PM...no search/scan completed...seclusion room 03:26 PM placed in seclusion...received a shot at 03:30 PM...at 16:02;46 patient took lighter out of left lower pajama bottom pocket...16:03;31 lit a white tee shirt she had removed from her upper...16:04;34 smoke started filling the seclusion room...16:05 door opened, patient removed...shirt on floor of seclusion room on fire. Technician put out fire with his hands and removed the shirt still burning out of the seclusion room...returned and cleaned up the room from the burned shirt..."

The Hospital Property and Valuables Record dated 10/08/11 reflected, "Technician signed and dated 10/08/11 at 14:00 PM patient's valuables were obtained and secured...shoes, medications...lap..." No documentation was found which indicated a lighter was found.

The Patient Search and Scan Policy with a revision date of June 2011 reflected, "To provide a safe environment for patients in the Psychiatric Emergency Services Department (PESD), patients are searched and scanned to assure they are free of harmful items...Scan: a systematic search by the Psychiatric Technician utilizing a hand-held metal detector (wand). The patient is searched for items posing a danger to themselves or other...potentially dangerous items...removed from patients, including, but not limited to...shoes or shoelaces, jewelry, cigarettes and lighters/matches...the search and scan is documented in the Registered Nurse admission note including the identification of the staff member conducting the search and gathering/securing patient belongings..."

The Psychiatric Services Contraband policy with a revision date of June 2011 reflected, "A pat search and hand held metal detector sweep are done on all patients prior to being escorted to a secured patient area and all contraband is removed from the patient..."

The Patients Rights and Responsibilities policy Admin. 6-09 with a revision date of June 2011 reflected, "Patients have the right to...receive considerate and respectful care in a safe setting..."