HospitalInspections.org

Based on staff interview and review of patient records and PI records, it was determined the hospital failed to ensure the PI program had analyzed all patient adverse events and injuries for 5 of 7 patients (#1, #2, #4, #5 and #6) whose records were reviewed. This resulted in the inability of the hospital to develop and implement processes to improve care. The findings include:

1. Patient #4 was a 34-year-old female who was admitted to the hospital on 8/12/09 for treatment of suicidal ideation and depression.

a. A Psychiatric Progress note, dated 8/26/09 at 10:07 PM, stated Patient #4 was seen individually following an attempted hanging in her room and subsequent transfer to the Adult Special Care Unit where she, again, attempted to tie a ligature around her neck while in the bathroom. An Interdisciplinary Progress Note, dated 9/09/09 at 3:15 PM, written by an RN stated, "Late entry for 8/26/09-approximally 12:40 PM." The note stated the RN opened a door and found the patient hanging from the top of a door. The patient was cared for and transferred to the Adult Special Care Unit. A second Interdisciplinary Progress Note, dated 8/26/09 at 1:25 PM, stated Patient #4 was in the bathroom in the safe area of the Adult Special Care Unit when the patient was found trying to hang herself with her bra.

A Risk Occurrence Report, dated 8/31/09, documented only the first suicide attempt. No Risk Occurrence Report was found for the second suicide attempt. On 1/27/10 starting at 4:10 PM, the Quality Director was interviewed. He could not find a Risk Occurrence Report for the second suicide attempt for Patient #4. On 1/27/10 starting at 4:36 PM, the Executive Director of Risk Management and Physicians' Relations was interviewed. He also could not find a Risk Occurrence Report for the second suicide attempt for Patient #4. He stated that one should have been filled out for the second event.

b. A nursing note, dated 8/27/09 at 5:37 PM, stated Patient #4 was trying to scratch herself with a ring. A Psychiatric Technician Note, dated 8/27/09 at 6:10 PM, stated Patient #4 appeared to be using her rings to cut her arms and when her rings were taken away she began to "bang" her head on the floor. On 1/27/10 starting at 4:10 PM, the Quality Director was interviewed. He could not find a Risk Occurrence Report for the 8/27/09 event for Patient #4. On 1/27/10 starting at 4:36 PM, the Executive Director of Risk Management and Physicians' Relations was interviewed. He also could not find a Risk Occurrence Report for the 8/27/09 event for Patient #4. He stated that one should have been filled out. He stated that reports should be filled out on all self mutilations.

c. A Psychiatric Technician Note, dated 8/31/09 at 4:30 PM, stated Patient #4 was in the lounge area with others when she got up quickly and headed to the bathroom. It stated Patient #4 had her right hand clenched in a fist. Staff had Patient #4 open her hand and they found a pen lid that had been broken into pieces. When staff took away the contraband Patient #4 began to "bang" her head on the floor. A physician's progress note, dated 9/01/09 at 10:50 AM, stated that on 8/31/09, Patient #4 secured an object, a pen cap, to use for self-harm. On 1/27/10 starting at 4:10 PM, the Quality Director was interviewed. He could not find a Risk Occurrence Report for the 8/31/09 event for Patient #4. On 1/27/10 starting at 4:36 PM, the Executive Director of Risk Management and Physicians' Relations was interviewed. He also could not find a Risk Occurrence Report for the 8/31/09 event for Patient #4. He stated that one should have been filled out. He stated that reports should be filled out on all contraband found in the hospital's psychiatric center.

d. A physician's progress note, dated 9/13/09 at 12:39 AM, stated Patient #4 was given a medication that caused the patient to become agitated and thrash around as though she had severe akathisia (a syndrome characterized by unpleasant sensations of "inner" restlessness that manifests itself with an inability to sit still.) Patient #4 was sent to the hospital's Emergency Department for evaluation. On 1/27/10 starting at 4:10 PM, the Quality Director was interviewed. He could not find a Risk Occurrence Report for the 9/13/09 event for Patient #4. On 1/27/10 starting at 4:36 PM, the Executive Director of Risk Management and Physicians Relations was interviewed. He also could not find a Risk Occurrence Report for the 9/13/09 event for Patient #4. He stated that one should have been filled out. He stated that a Risk Occurrence Report for medication adverse reactions should be filled out.

The hospital failed to ensure that all adverse patient events related to Patient #4 were reported to the quality improvement program so they could be analyzed and steps could be taken to prevent further incidents.

2. Patient #1 was a 22-year-old male who was admitted to the hospital on 1/13/10 for treatment of suicidal ideation and depression.

a. A Psychiatric Evaluation, dated 1/14/010 at 10:23 PM, stated Patient #1 was allergic to the medication Geodon, saying it causes his tongue and throat to swell. On 1/15/10 at 10:00 PM, a RN obtained a verbal order for Geodon 20 mg IM (intermuscular) as a onetime dose. The medication order was retracted before it was given at 10:15 PM. On 1/27/10 starting at 4:10 PM, the Quality Director was interviewed. He could not find a Risk Occurrence Report for Patient #1 for the medication event. On 1/27/10 starting at 4:36 PM, the Executive Director of Risk Management and Physicians' Relations was interviewed. He also could not find a Risk Occurrence Report for Patient #1 on 1/15/10. He stated that one should have been filled out. He stated that a Risk Occurrence Report for medication near misses should be filled out.

b. A nursing note, dated 1/16/10 at 3:15 PM, stated Patient #1 attempted to take blood pressure tubing off a blood pressure machine. He attempted to it take them back to his room. During an interview on 1/27/10 starting at 1:40 PM, the Executive Director stated it was his understanding that Patient #1 took the blood pressure tubing in attempt to cause trouble or hurt himself. On 1/27/10 starting at 4:10 PM, the Quality Director was interviewed. He could not find a Risk Occurrence Report for Patient #1 for the 1/16/10 event. On 1/27/10 starting at 4:36 PM, the Executive Director of Risk Management and Physicians' Relations was interviewed. He also could not find a Risk Occurrence Report for Patient #1 on 1/16/10. He stated that one should have been filled out for the event.

The hospital failed to ensure that all adverse events related to Patient #1 were reported to the quality improvement program so they could be analyzed and steps could be taken to prevent further incidents.

3. Patient #6 was a 61-year-old male who was admitted to the hospital on 8/06/09 for treatment of psychosis. A nursing note, dated 8/08/09 at 10:21 PM, stated a Psychiatric Technician found a pocket knife in the patient's room. On 1/27/10 starting at 4:36 PM, the Executive Director of Risk Management and Physicians' Relations was interviewed. He could not find a Risk Occurrence Report for the 8/08/09 pocket knife and stated that one should have been filled out.

The hospital failed to ensure that all adverse events related to Patient #6 were reported to the quality improvement program so they could be analyzed and steps could be taken to prevent further incidents.

4. Patient #5 was a 34-year-old female who was admitted to the hospital on 11/09/09 for depression and a suicide attempt.

a. A physician's discharge summary note, dated 12/15/09 at 9:16 PM, stated that "While in the emergency department (11/09/09), the patient attempted to strangle herself with IV (intervenous) tubing." A Risk Occurrence Report could not be found for this incident. This was confirmed during an interview on 1/27/10 starting at 4:36 PM, with the Executive Director of Risk Management and Physicians' Relations.

b. A nursing note, dated 11/17/09 at 9:45 PM, stated Patient #5 was "touched and propositioned" by another female patient. The Risk Occurrence Report only contained the incident. It did not contain a review, investigation and resolution of the incident. This was confirmed during an interview on 1/27/10 starting at 4:36 PM, with the Executive Director of Risk Management and Physicians' Relations where he stated the Risk Occurrence Report was incomplete.

The hospital failed to ensure that all adverse events related to Patient #5 were reported to the quality improvement program so they could be analyzed and steps could be taken to prevent further incidents.

5. Patient #2 was a 14-year-old male who was admitted to the hospital on 11/06/09 for bipolar disorder. A Psychiatric Technician Note, dated 11/08/09 at 9:15 AM, stated Patient #2 punched a staff member twice. A second Psychiatric Technician Note, dated 11/08/09 at 12:15 AM, stated that Patient #2 punched and kicked another staff member. A nursing note dated 11/08/09 at 5:28 PM, stated Patient #2 had picked up a long wooden piece to a game and hit a staff member with it and when staff took the wood piece from Patient #2, he hit the staff and later hit staff in the chest and kicked them. Patient #2 was restrained on 11/08/09 starting at 11:45 AM. The RN restraint checklist stated that Patient #2 complained that his back hurt because he sustained an injury during the restraint process.

On 1/27/10 starting at 4:36 PM, the Executive Director of Risk Management and Physicians' Relations was interviewed. He could not find the Risk Occurrence Reports for the above incidents with Patient #2. He stated that one should have been filled out for each event.

The hospital failed to ensure that all adverse events related to Patient #2 were reported to the quality improvement program so they could be analyzed and steps could be taken to prevent further incidents.