HospitalInspections.org

Based on interview and record review, Facility a behavioral health hospital) failed to meet the Condition of Participation for Patients Rights as evidenced by:


(a) Failing to provide care in a safe setting (refer to A144) by not closely monitoring Patient #1 (P1), who was admitted for suicidal ideation (with a plan to commit suicide).


(b) Patient #1 obtained and swallowed a surgical/exacto knife blade. P1 was then transported and admitted to Hospital #3 (H3, acute care hospital) Emergency Department.


(c) Facility staff failed to provide appropriate level of observation to ensure the safety of Patient #1, and further failed to have a system in place to prevent patients from acquiring harmful/dangerous objects which can be used as a weapon and a means for self-harm which can lead to death.


This deficient practice resulted in P1 to be transported from Facility to an Acute Care Hospital Emergency Department for emergency medical care after swallowing a surgical/exacto knife blade. P1 was a direct admission from Hospital 1 (H1, acute care hospital) to Facility and contents of P1's personal belongings were not searched for contraband.

Based on record review and interview, facility failed to provide care in a safe setting by failing to:

(a) closely monitor Patient #1 (P1), who was admitted on 11/15/17 for suicidal ideation (with a plan). Patient #1 obtained and swallowed a surgical / exacto knife blade.

(b) to place appropriate level of monitoring to ensure the safety of Patient #1 after voicing her suicidal intent/plan.

(c) have a system in place to prevent patients from acquiring harmful/dangerous objects which can be used as a weapon, and a means for self-harm which can lead to death.

These deficient practices placed P1 and all patients admitted to facility at risk for acquiring harmful/dangerous objects which can be used for self-harm or to harm others.


The findings are:

A. Record review of Pt #1's medical chart revealed that on 11/13/17, Pt #1 was transported to [H#1] after making suicidal ideations to her school counselor. At [H#1], Pt #1 was evaluated and diagnosed with depression with suicidal ideation (SI) and on 11/15/17 was transferred to facility for further treatment, P#1 was admitted on the date of transfer.


B. Record review of facility's initial treatment plan dated 11/14/17 included complete contraband check, begin 15-minute checks, provide a safe, secure environment, monitor for agitation/anxiety and administer PRN [as needed] medication as indicated, monitor for responses to internal stimuli.


C. Record Review of a Psychiatric Evaluation from facility dated 11/15/17 at 11:05 a.m. written by Medical Doctor (Dr) revealed the following:

1) "13-year-old Navajo female transferred from Hospital #1 (H1) for SI (Suicidal Ideation). She reported SI to school counselor and parents took her to the ER (Emergency Room). Reports SI with a plan to 'swallow something'."

2) Pt #1 has a history of depression, self-harm and inpatient treatment.

3) Review of symptoms: SI with plan (to harm herself by swallowing 'something'), hallucinations, difficulty sleeping, self-harm, poor appetite, binging, weight loss past 2 weeks, flashbacks, nightmares, panic attacks, anxiety and anger outbursts, fair insight and poor judgement.

4) Pt #1 "high suicide risk."

5) Diagnoses (dx): depression, Post Traumatic Stress disorder (PTSD)

6) Treatment plan to include medication management and 5 to 10 days inpatient treatment to address SI psychosis, self-injury, victim-trauma abuse, anxiety, PTSD, depression, and substance use.


D. Review of Nursing Daily Progress Note dated 11/16/17 from the facility revealed the following: "Pt (patient) voiced to staff (RN) at 1902 (7:02 pm) about swallowing razor. Pt gave 1 razor to staff and swallowed 1". Indicating that P#1 had possession of 2 razors at H #2.


E. On 11/17/17 at 3:45 pm during a telephonic interview, complainant stated that P#1 was admitted to H#3 on 11/16/17. P#1 had an X-ray and ultrasound, a foreign object [razor blade] was observed in the results. P#1 was kept for observation to ensure that she "passed" the foreign object. However, no surgery was needed. P#1 was going to be admitted to H#4 in Albuquerque after discharge from H#3


F. During an interview on 11/20/17 at 10:57 am, S#19 (Director of Nursing) stated that there is no policy or procedure in place to conduct metal detection wanding when there are direct admissions to the facility. S#19 also stated that facility staff did not conduct any metal detection wanding on patient #1 [or any of the other patients who were direct admissions on that date] when she was admitted. S#19 stated that typically personnel will check for contraband before giving items to patients but this did not ocur.


G. During an interview on 11/21/17 at 2:30 pm, S#9 (Registered Nurse) stated that because the facility had so many direct admissions to the hospital, patients' belongings were not checked. S#9 also confirmed that all patients admitted to the facility were placed on 15 minute checks. S#9 also confirmed that patients are placed on a higher level of care according to their initial treatment plan.


H. During an interview on 11/21/17 at 3:00 pm, S#5 (Mental Health Tech) stated that P1 asked for her jacket because she was cold, staff #5 (MHT) then took P1's jacket from the contraband area and she did not check the jacket for contents before giving the jacket to P1. S#5 did not follow protocol on checking for contraband prior to giving the jacket to P#1.


I. On 11/21/17 at 9:00 am administrative personnel (Director of Nursing and Risk Manager) provided surveyors with a Plan of Removal for Immediate Jeopardy removal confirming that there was an issue with direct admissions to the behavioral health hospital and not having a system in place for preventing patients from acquiring harmful / dangerous objects.


Plan of Removal included:

- re-training on staff for contraband searches prior to placement on units,

- metal detection wanding and general contraband searches when patients move from one part of the facility to another.

- changes in policies for contraband searches and metal detection wanding as well as training for personnel.


A list of employees who were trained on new policies and procedures was also provided with the Plan of Removal. Surveyors confirmed with administrative personnel and direct support staff regarding training and policy changes during walk-through of the facility before exit on 11/21/17.