HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital failed to:
- Follow their policy and ensure patients were free from restraint and seclusion; (A-0162)
- Ensure that bed cords were under 18 inches in length to prevent a ligature (anything which could be used for the purpose of hanging or strangulation) risk; (A-0144)
- Provide a call light system or adequate alternative communication devices for patients on the Behavioral Health Unit (BHU); (A-0144) and
- Remove a two foot long piece of rubber baseboard that hung onto the floor on the Adult BHU. (A-0144)

These failures created an unsafe environment and had the potential to place all patients admitted to the hospital at risk for their safety. The hospital census was 38.

The severity and cumulative effect of these systemic practices resulted in the overall noncompliance with 42 CFR 482.13 Condition of Participation: Patient's Rights.

Based on observation, interview, record review and policy review, the hospital failed to provide care in a safe setting when the hospital failed to:
- Ensure that bed cords were under 18 inches in length to prevent a ligature (anything which could be used for the purpose of hanging or strangulation) risk.
- Provide a call light system or adequate alternative communication devices for patients on the Behavioral Health Unit (BHU).
- Remove a two foot long piece of rubber baseboard that hung onto the floor on the Adult BHU.

These failed practices had the potential to affect all patients admitted to the hospital and placed them at risk for harm from ligatures, the inability for patients or staff to call for assistance in an emergency situation and had environmental hazards that could have been used as weapons that placed all patients and staff at risk of harm and injury. The hospital census was 38.

Findings included:

Review of the hospital's policy titled, "Patient Care, Suicide Precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm)," revised 12/2022, showed that a safe, therapeutic environment must be provided for patients at risk for suicide by implementing safety measures to reduce the risk of suicide while in the hospital. Interventions showed that a safe environment must be maintained.

Observation on 07/18/23 at 10:30 AM, on the BHU, geriatric psychiatry unit (Geropsych, a unit that focuses on treating mental health and psychiatric disorders in older adults), showed there were four hospital beds with a cord that were over 18 inches in length, approximately six feet long that was attached to the control board at the foot of the hospital beds. The bed cords had not been secured and hanging under the hospital bed. Staff W, BHU Interim Nurse Manager (INM) immediately called maintenance and the cords were removed from all beds.

During an interview on 07/18/23 at 10:45 AM, Staff W, BHU INM, stated that the cords should not have been on the beds and were not safe for behavioral health patients. She stated that was an immediate danger and a patient could use them as a self-harm method. Cords were normally removed or secured to keep the patient safe. Before a patient is placed into a room, a safety check should be performed as well as daily safety checks. She did not know why these cords were on the beds and stated there was no auditing tool that was currently being used to ensure that daily visualization was being done.

During an interview on 07/18/23 at 11:20 AM, Staff M, Patient Care Technician (PCT), stated that 15 minute rounding checks were performed on all Geropsych patients to ensure their safety and all rooms should be visualized at that time for potential safety problems.

Review of the hospital's policy titled, "Fall Prevention," reviewed 06/2023, showed that all adult patients (18 and over) were at universal risk for falls. Universal fall risk guideline interventions included maintaining the call light within reach, and return demonstration with the patient.

Review of the hospital's document titled, "South City Hospital 3rd Floor Psych," dated 07/17/23, showed that 10 patients were present on the Geropsych Unit, all were at an increased risk for falls and required universal fall risk interventions.

Review of the hospital's document titled, "South City Hospital 3rd Floor Psych," dated 07/17/23, showed that 15 patients were present on the Adult BHU, all were to have universal fall risk interventions in place.

Observation on 07/17/23 at 2:45 PM, on the BHU, showed there were no call lights located in 31 patient rooms or bathrooms, on the Geropsych Unit and the Adult BHU.

During an interview on 07/18/23 at 9:45 AM, Staff W, BHU INM, stated that all patients were identified as a fall risk due to medication and potential side effects from medications like dizziness. Patients on the Geropsych unit often had multiple medical problems and utilized wheelchairs, walkers, or were on oxygen therapy, therefore made them a higher fall risk category. Geropsych patients often had the diagnosis of Dementia (a loss of thinking abilities and memory) or Alzheimer's disease (a chronic brain disorder characterized by gradual loss of memory, decline in intellectual ability and deterioration in personality) that made those patients a higher fall risk category. There were no call lights in any of the behavioral health rooms and she thought staff had been given whistles to blow if there was an emergency. She was unsure that all staff had a whistle because of frequent staffing changes or if they left it at home.

During an interview on 07/18/23 at 11:00 AM, Staff X, PCT, stated that there was no call light system on the floor or any way to notify other staff if there was an emergency. In an emergency situation she would have to yell for help if someone was found to be on the floor or non-responsive. This was not safe for the patients or staff. There were times that patients became violent and the only way to alert other staff members that they needed assistance was to yell for help.

During an interview on 07/18/23 at 11:15 AM, Staff Y, Licensed Practical Nurse (LPN), stated that there were no call lights in patient rooms. If someone needed help they were expected to yell for help. If there was a code blue, she would have had to yell for help and then another staff member would have to go to the phone in the nurse's station to call the operator to tell them to do an overhead page for a code blue. She felt this was not the safest situation for the patients.

During an interview on 07/18/23 at 11:20 AM, Staff M, PCT, stated that there were no call lights in patient room's and that if a patient fell in between rounds the patient would have no way to notify staff but to yell for help. If she found a patient that was unresponsive she would have to yell for help and if no one responded she would have to run to the nurse's desk and call the operator. She had concerns for the safety of the patients but there had not been any call light system in place for a long time. She stated she could not remember how long but probably years.

The nurse's stations located on the Geropsych Unit and the Adult BHU were enclosed by glass where patients could easily be seen, but unable to be heard clearly, placing all staff and patients at risk for not being heard in an emergency situation.

Review of an undated document titled, "Daily Safe Room Set-up Checklist," showed all items that were sharp or could be used as a weapon if thrown or swung when not in use should be removed by staff.

Observation with concurrent interview on 07/17/23 at 3:10 PM showed in a male, adult psychiatric room, two foot of rubber baseboard was hanging off the wall. Staff D, RN, stated that a patient could have hurt themselves or someone else with the rubber baseboard if it was ripped off the wall.

During a telephone interview on 07/25/23 at 9:30 AM, Staff B, Risk Manager, stated that Plant Operations were to secure all loose cords and wires so that there was not a risk to patients. She stated a cord that was over 18" long was a safety hazard and should have been eliminated. She added that if a patient was in a hospital bed on the BHU and were suicidal, the patient was to have a one to one (1:1, continuous visual contact with close physical proximity) sitter. She stated that there were no call lights in the BHU and that there were not many options for a call light system for patients that have a fall risk. If there was a rubber baseboard that was falling off, it was considered a risk for all patients. Plant operations were to check every unit on a daily basis to ensure there were not any risks to patients. Charge nurses had a safe room checklist that was to have been completed each shift and then turned into their unit manager. Staff were to have communicated any unsafe findings in hand off report at every shift change.

During a telephone interview on 07/25/23 at 10:35 AM, Staff A, Chief Nursing Officer (CNO), stated that room checks were to have been completed by the RN with a Daily Safe Room Checklist, each shift for anything that would cause harm to a patient. This included the bed cords and any contraband. She stated that the bed cords that were identified as over 18 inches in length was a safety hazard and should have been removed from the bed prior to placing a behavioral health patient into the room. There should be a call light system for any patient or staff that had a need, but at that time, staff would yell out for assistance. She added that call lights were a work in progress. It was a concern of hers that a patient could need assistance and they would be laying there for another 15 minutes until the patient rounding was performed. Baseboards, not fully on the wall, was a potential event and a safety issue for all patients. Rounding observations that were completed every 15 minutes should also include observation of the patient room for any potential safety hazards.





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Based on interview, record review and policy review, the hospital staff failed to follow their policy for the use of restraints and seclusion, when one discharged Patient (#10), was placed in a padded room for her protection, and leadership staff left written instructions, without the direction or knowledge of a physician, at the nursing station to place the patient in restraints if she attempted to leave the room.

Direction of leadership staff to keep a patient in her room and place her in restraints if she attempted to leave the room, put all behavioral health patients with self-harm intentions at risk of losing the freedom from restraint or seclusion. The hospital census was 38.

Findings included:

ASReview of the hospital's policy titled, "Patient Rights and Responsibilities," revised 06/2022, showed that every patient has the right to the following:
- Receive care that is considerate, respectful and compassionate.
- Receive care in a safe environment that is free from abuse neglect, and exploitation.
- Be free from restraint and seclusion unless needed for safety.

Review of the hospital's policy titled, "Restraints or Seclusion," revised 09/2022, showed the following directives for staff:
- Restraints were defined as any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to freely move his or her arms, legs, body or head.
- Seclusion was defined as the involuntary confinement of a patient alone in a room or an area from which the patient is physically prevented from leaving.
- Patients have the right to be free from restraints.
- When necessary to protect a patient, staff members, or others from harm, restraints or seclusion may be employed, but the least restrictive intervention that will be effective is utilized.
- Restraint or seclusion should not be a standard practice.
- Through the establishment of guidelines this organization will limit the use of restraint or seclusion only to those situation when other less restrictive alternatives are ineffective to protect the safety of the patient or others.
- Restraint or seclusion is NOT allowed for punishment or convenience.
- Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.
- State law permits only physicians (M.D. or D.O.) to order restraints or seclusion.
- A physician who is responsible for the care of the patient must order the restraint or seclusion. "PRN" or "Standing" restraint or seclusion was not permitted.
- There must be documented authorization for restraint application.
- Clinical leadership (nursing supervisor/manager) shall be informed of any instance of restraint or seclusion.
- The use of restraints must meet the requirements in any area it is occurring. Further, the decision to use a restraint is driven not by diagnosis, but by comprehensive individual assessment that concludes that for this patient, at this time, the use of less intrusive measures poses a greater risk than the risk of using a restraint or seclusion.

Review of the hospital's document titled, "Behavioral Plan for Pt. #10", dated 07/06/23, showed that Patient #10, continued to be a safety risk due to removing her helmet and banging her head that caused the reopening of a head wound. For her safety she was escorted to the padded seclusion room on the Geriatric Psychiatry (Geropsych, a unit that focuses on treating mental health and psychiatric disorders in older adults) Unit with a sitter. The door was to remain unlocked unless she attempted to leave or harm herself. If either of those situations occurred, it would turn into a restraint event and documentation should follow accordingly. The document was not signed.

Review of Patient #10's medical record showed the following:
- She was a 24-year-old female that was admitted on 06/26/2023 with the diagnosis of Schizoaffective Disorder (mental health disorder where speech and thought are disorganized, and a person may find it hard to function socially and at work, and may experience hearing voices that are not real) and depression (extreme sadness that doesn't go away). She had broke a glass and cut her neck and was banging her head, had suicidal ideations when she was admitted for inpatient psychiatric care.
- Past medical history included self-harm (behavior that is harmful or potentially harmful to one self) that included banging her head against the wall.
- Patient #10 received medical care on 06/26/23 and 7/01/23, she received sutures (a strand or thread used to sew skin and other body tissues together to close up a surgical incision or a tear) to the top of the head as a result of banging her head on the wall.
- She was placed in a padded room near the Geropsych unit on 07/06/23 and remained in that room until 07/14/23.
- There was no documentation of Patient #10 being placed into restraints while she was in the padded seclusion room, and no physicians orders for seclusion, or to place Patient #10 in restraints if she attempted to leave the room.

During an interview on 07/19/23 at 3:00 PM, Staff W, Behavioral Health Unit Interim Nurse Manager (BHU INM), stated that she had typed up that behavioral plan. Administration had made the decision to implement the behavioral plan. The administration team involved in the development of that plan included the Risk Manager, Chief Nursing Officer (CNO), and other management members.

During an interview on 07/18/23 at 11:00 AM, Staff X, Patient Care Technician (PCT), stated that she felt Patient #10 needed to have a 2:1 sitter (person assigned to continuously observe a patient within close proximity, to ensure their safety.) while the patient was in the padded seclusion room. The door of the seclusion room had been open at all times. She had safety concerns because Patient #10 would get upset and take off running past the assigned 1:1 sitter. She would take her helmet off and bang her head on the corner of a wall. There was a plan that was taped on the nurse's station stating not to let the patient out of the seclusion room, and to restrain her if she attempted to leave the padded seclusion room. She had extensive restraint training and felt that what they were told to do to Patient #10 was not right.

During an interview on 07/19/23 at 10:34 AM, Staff H, Registered Nurse (RN), stated that she had been directed to place Patient #10 into the seclusion room on the Geropsych unit and the door was to remain unlocked. If the patient tried to leave the room they were to proceed with a restraint event. She considered that to be seclusion, which was a type of restraint and there were no physician orders directing them to do that. She stated that behavioral plan for Patient #10 was posted at the nurses stations.

During an interview on 07/20/23 at 1:30 PM, Staff OO, Medical Doctor (MD), BHU, stated that he had not given direction for Patient #10 to be placed into seclusion and that he had no knowledge of the behavioral health plan that staff had been directed to follow.

During an interview on 07/20/23 at 4:15 PM, Staff LL, RN, stated that Patient #10, had been a patient on the Adult BHU prior to being placed in the padded seclusion room on the Geropsych Unit. Patient #10, wore a helmet and had random impulses to take off her helmet and bang her head on the wall. She had to be treated in the Emergency Department several times, and had sutures and glue to close the incision on top of her head that was sustained after banging her head on the wall. Staff W, BHU INM, told staff that the patient had a behavioral plan that forced Patient #10 to stay in the seclusion room. Although the door was unlocked, it was still considered seclusion due to the fact that the staff had been instructed to follow the behavioral plan. The behavioral plan directed staff to restrain Patient #10 if she attempted to leave the room. Patient #10 should have been considered a secluded patient, which would have been a type of restraint because she was not allowed to leave the room. The BHU INM, told him that Administration, which included the Medical Director, CNO, and Risk Manager, directed staff to follow the behavioral plan. Staff LL, RN, stated that he was told by Staff W, Patient #10 had to be restrained if she got out of the padded seclusion room and not to let her out.

During a telephone interview on 07/24/23 at 09:30 AM, Staff NN, RN, stated that there was a behavioral plan posted at the nurse's station that directed Patient #10 to be placed in a padded seclusion room with the door unlocked, if the patient attempted to leave the seclusion room she was to be restrained. There were no physician orders to keep Patient #10 in the padded seclusion room and management stated that the door was unlocked so they did not need a physician's order.

During a telephone interview on 07/24/23 at 11:30 AM, Staff PP, House Supervisor, stated that when she was made aware of the behavioral plan for Patient #10, that was placed in all the BHU nursing stations, she went to discuss the behavioral plan with Staff W, BHU INM. Staff PP stated that she went to Staff W's office and asked her, "if this was a seclusion room and you were the patient, are you directing me to hold my hand out and say no, if you attempted to leave this padded seclusion room." Staff W replied "yes, she was not to leave the seclusion room and that restraints were to be used if she attempted to leave." She felt that was considered seclusion, a type of restraint and there were no medical orders for that. Staff W told her it was the direction of Administration including the CNO and Risk Manager, and that was what staff were to do.

During a telephone interview on 07/24/23 at 9:30 AM, Staff B, Risk Manager, stated that she was not aware of the behavioral plan that had been placed at the nurse's station for Patient #10. There were discussions about Patient #10's self-harm behaviors and they had discussed placing her into a padded room, but that the door was to remain open. She had not given any directive to restrain the patient if she attempted to leave, that would have required a physician's order.

During a telephone interview on 07/25/23 at 10:30 AM, Staff A, CNO, stated that she had been aware of Patient #10 being placed in a safe room. It was not considered a seclusion room and the patient could come and go as she wanted. The door was always open and she had been assigned a 1:1 sitter. She was not aware of the behavioral plan that had been placed at the nurse's station directing staff to restrain Patient #10 if she attempted to leave the room. She did not give direction for Staff W, BHU, INM, to direct staff to keep the patient secluded in the room and did not direct them to restrain her if she attempted to leave. All behavioral health plans should have a physician's order and all nursing staff were to follow the medical orders.





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