Bringing transparency to federal inspections
Tag No.: A0144
Based on a review of facility documentation, facility policies and procedures and staff interviews, the facility failed to consistently and effectively ensure a patient's right to care in a safe setting.
Findings included:
Review of facility incident reports from December 2018 through March 28th 2019 revealed in part the following:
1. 12/02/2018 at 2200: Patient #1 was found with contraband of two blades in the day area of the female adolescent unit that were "brought from home".
2. 12/11/2018 at 1800: Patient #2 on female adolescent unit cut her wrist with metal ceiling tile during discharge.
3. 12/13/2018 at 2230: Patient #3 on adolescent male unit tried to take off ankle monitor with paperclip that he told staff he brought from home.
4. 01/02/2019 at 2330: Patient #4 on adolescent female unit used a pencil to scratch her left forearm.
5. 01/05/2019 at 0628: Patient #5 on adolescent male unit found with vape with charger and refill. Patient refused to tell how he got it. It was believed that he got it during visitation with family.
6. 01/20/2019: Patient #6 on adolescent female was given a cell phone with a cord/charger by Staff #1.
7. 01/20/2019 at 1100: Patient #6 was given a pair of pajamas belonging to Staff #1 with the string left in them by Staff #1.
8. 01/28/2019 at 1029: Patient #6 refused to give contraband to staff that was hidden in her bra. The contraband included colored pencils and broken toothbrushes.
9. 02/03/2019: Patient #6 was refusing to hand over contraband. She was using markers and comb to attempt to scratch underneath her blanket.
10. 02/21/2019: Patient #7 was found with needle from previous hospital. Patient's roommate "told" on her. Patient also had metal hair clip on her body.
11. 02/27/2019 at 2130: Patient #8 on male adolescent unit was found with contraband consisting of nail and rock in his room.
12. 03/04/2019: Patient # 9 on male adolescent unit made a suicide gesture by sticking a nail in outlet and stated he wanted to die. He said " I am not safe".
13. 03/03/2019 at 2100: Patient #10 on female adolescent unit obtained a loose screw from the cabin of the nursing station and swallowed it. All attempts to stop her from swallowing the screw proved unsuccessful. Doctor was notified and Patient #10 was sent to the emergency room for further evaluation.
14. 03/04/2019 at 1958: Patient #6 attempted to cut self from piece of wood obtained from under plastic windows. Nurse #1 attempted to process with Patient #6 but was unable to do so.
15. 03/05/2019 at 0900: Patient #6 had a broken fork and a paper clip that she was using as a nose piercing. Patient was cooperative and gave staff the contraband without resistance. Patient told staff she got paperclip from homework packet.
16. 03/05/2019 at 1930: Patient #10 reports she took a razor from a pencil sharpener and cut herself multiple times on the breast, abdomen and upper thigh, then swallowed it. Patient won't disclose disclose which 1:1 staff member had a pencil sharpener out instead of behind nurse's station because she doesn't want the staff to get into trouble.
17. 03/20/2019 at 2030: Patient #11 on the adult Detox/Rehab unit was noted by staff to have something in her pocket that resembled a vape pen. When asked, patient #11 initially denied having it then stated it was in her room. Staff escorting her to her room, pulling it out from under her clothing that was on the shelves. Patient declined to tell staff where she obtained it from. Vape pen was metal with glass tubing and brown liquid.
Review of Patient Rights and Responsibilities of the Individual, last revised 01/25/2017, revealed but was not limited to the following: "You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity.
Review of Provision of Care, Treatment and Services, last revised 01/25/2017, revealed but was not limited to the following: "1. Staff shall maintain therapeutic boundaries with patients at all times. Fraternization with patients or patient's family is not permitted, including after the patient is discharged. 2. Patients are informed and provided with a sense of safety based on a. Positive staff interaction b. Patient observation rounds that are explained to each patient on admission and throughout the stay. c. Provision of behavioral guidelines and expectations. d. Maintenance of a safe physical environment.
Review of Adult Admissions Department Process, dated 11/11/2018, revealed but was not limited to the following: " Admissions staff removes all belongings and wands patient/family member. If the patient is a violent/aggressive/psychotic patient, prioritize the patient to get the patient to the unit. Includes Complete Safety Search.
Review of Adolescent Admissions Department Process, dated 11/12/2018, revealed but was not limited to the following: "Admissions Staff: MHT (Mental Health Technician) removes all belongings and wands patient/family members. Patient must wait in the lobby area and be supervised by the MHT at all times. The patient will be assessed by the RN and the therapist in the consult rooms, then will return the patient to the patient lobby area. Patients are not to be left in the consult rooms unsupervised. If the patient is a violent/aggressive/psychotic patient, prioritize the patient to get the patient to the unit. Includes Complete Safety Search.
Interview on 03/25/2019 with the facility Director of Admissions revealed but was not limited to the following: "During the admissions process, we take all belongings and wand the patient and/or the family member with them. We wand the patient and/or the family for anything metal. During the safety check, the patient is undressed and a paper gown is placed on the patient. During the admissions process, the admissions nurse completes a skin assessment by touching the patient.
Interview on 03/25/2019 with Staff #1 revealed that she has worked in most of the units. She stated that she sees a lot of contraband including bobby pins found in weave hair styles, ear buds and money. She stated the patients also use staples, paper clips and loose screws to harm themselves. She stated that she has worked in the admissions area in the past. She stated that she observed that nursing staff did not always do a complete skin assessment by touching the patient.
Interview on 03/25/2019 with Staff #2 revealed that she has worked on all units during her tenure at the facility. She stated that she may be responsible for monitoring 15 to 23 patients at one time. She stated the "patients can find a way to sneak in contraband from admissions and/or visitation time". She stated patients have brought in money, blades and candy. She stated the patients are able to get pencils for journaling . She state that she attempts to remember who has a pencil and who has returned their pencil but due to the large number of patients, it is not always possible to remember who has a pencil. In addition, one patient may give their pencil to another patient. Other staff may give them pencils and she is not aware of the patient having a pencil because she didn't give them the pencil. She described the adolescent females as "needy" and always asking for pencils/markers and hygiene items.
Interview on 03/25/2019 with Staff #3 revealed that he worked at the facility on as needed basis (PRN). He stated the facility is "always perpetually understaffed". He stated that he primarily works on the adolescent male unit. He has not personally discovered contraband but has heard that other staff have discovered contraband.
Review of Performance Improvement/Risk Management Committee Meeting Minutes, dated 01/29/2019, revealed contraband increased by 61 percent to a rate of 2.34.
Review of Performance Improvement/Risk Management Committee Meeting Minutes, dated 03/05/2019, revealed but was not limited to the following: " Sense of dignity and respect/safety both fell below goal. Committee concluded that patient's perception of dignity and respect/safety may be attributed to the communication on the unit. The acuity of the patients may be also be a contributing factor in the sense of safety. Contraband decreased by 50%. However, the team discussed analyzing the type of contraband and how the patients obtain them. The next patient Performance Improvement/Risk Management Committee Meeting will analyze the type of contraband brought into the facility." It is noted that the 03/05/2019 meeting was originally scheduled for February but the meeting was late due to facility monthly orientation and competency week.
Interview on 03/28/2019 with facility Chief Executive Officer (CEO) revealed the next Performance Improvement/Risk Management Meeting to discuss the contraband issue is scheduled for tomorrow (03/29/2019). The CEO stated this was the first time the committee would be able to get together to discuss the contraband after the 03/05/2019 meeting.
The above findings were confirmed in an exit interview with the CEO, Chief Nursing Officer (CNO), Director of Clinical Services (DCS), Director of Quality and Risk Management (DQRM) and Director of Admissions (DOA) in the afternoon of 03/28/2019.