HospitalInspections.org

Based on observation, interview, and record review, the facility failed to provide a safe setting for patients and staff by failing to:
1. Ensure the Behavioral Health Unit (BHU) was monitored for objects that were a potential ligature risk (anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation i.e. handles, coat hooks, pipes, etc), or that could be used as a weapon against others, were out of reach for patients on the BHU.
2. Ensure a policy was developed and available to facility staff that addressed the safety of medical equipment in a mental health care setting.

These failures had the potential to result in patient self-harm as well as harm to other patients and staff members. And had the potential for staff members to lack knowledge regarding what patient care equipment may place patients, staff, and others at risk for harm.

Findings:

On 9/17/19 at 11:15 a.m., a complaint validation survey was conducted at the facility regarding a complaint by a contracted Centers for Medicare and Medicaid (CMS) survey team that on 9/12/19, a patient ,who was assessed in the Emergency Department (ED) as being high risk for suicide, was not provided 1:1 monitoring as defined by the facility's Suicide Risk Assessment policy. The CMS survey team had also identified a potential ligature risk (anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation).

On 9/17/19 at 12:15 p.m., a tour of the Behavioral Health Unit (BHU) was conducted with the Quality Assurance Director (QAD) and BHU Director.
An observation of Patient 1's (P1), room revealed an oxygen (O2) flow meter (a device that measures the flow of oxygen from an oxygen-dispensing unit to the user of the oxygen) that was connected to the O2 outlet in the wall, next to the bed. An oxygen nasal cannula (plastic tubing that is used to deliver supplemental oxygen to a person that needs oxygen therapy - one end rests inside the nostrils, the opposite end connects to a flowmeter) was draped over the flowmeter.

When questioned if the flowmeter was considered a patient risk, the BHU Director responded that P1 was not suicidal, and that P1 used the O2 once in a while and also received breathing treatments. The BHU Director then unsuccessfully attempted to remove the flow meter from the wall outlet, then stepped outside the room and asked the charge nurse, (RN 1) to come to the room. RN 1 stated the flow meter should not have been left in P1's room, and that all respiratory equipment as well as other types of treatments were kept in the Nurses Station for safety reasons. RN 1 then disconnected the flow meter from the O2 outlet and removed the nasal cannula. When asked if there was a policy that addressed potentially unsafe equipment, RN 1 responded that she did not think there was a policy, but it had been the practice of the BHU since she started working there 22 years ago and was supposed to be done.

During an observation of the Nurses Station immediately following with the BHU Director and QAD, P1 approached the door of the station. P1 stated in an angry voice that someone had made false accusations against her. P1 then threatened to harm the person if she found out who that person was.

A review of P1's Psychiatric Evaluation, dated 9/11/19, indicated P1 was admitted to the BHU on 9/11/19 with diagnoses that included suicidal ideations and history of Schizoeffective Disorder (a mental disorder in which a person experiences a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). The evaluation also indicated that P1 had told the psychiatrist that she intended to hit people who bothered her.

A review of the Physician Orders indicated an order, dated 9/11/19, for respiratory aerosol treatment every six hours for 30 days.

On 9/17/19 at 1:35 p.m., a telephone interview was conducted with the Respiratory Therapy Director (RTD). The RTD stated that for BHU patients, it is the practice of the respiratory therapists (RT) to bring all equipment necessary to administer a respiratory treatment, including nebulizers (a device used for inhaling a medicinal drug), respiratory medications, and O2 tanks, to a patient's room. Following completion of the treatment, the RT will remove the respiratory equipment and medications from the room so no devices remain that can be used as a potential weapon. When questioned if there was a policy that addressed this process, the RTD responded that it was the clinical practice of the RT Department, but there was not a written policy.

A policy titled "Oxygen Therapy Protocol" was provided to the surveyor. However, the policy did not address oxygen precautions on the BHU.