HospitalInspections.org

Based on observation, record review, and interview, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient's rights as evidenced by:
1) failure to ensure 1 (#5) of 3 (#2, #3 and #5) patients on suicide precautions sampled were observed per physician orders (See findings under A0145).
2) failure to ensure contraband was not accessible to patients (See findings under A0144);
3) failure to identify an environmental safety risk as evidenced by allowing an unstable patient in the nurses' station for PRN injection (See findings under A0144);
4) failure to ensure patients with a diagnosis of homicidal ideations received a Violence Risk Assessment per policy in 1 (#5) of 3 (#1, #4, and #5) patients reviewed for Violence Risk Assessment (See findings under A0144);
5) failure to ensure staff criminal background checks did not include convictions that bar employment in 1 (#S4DPA) of 4 (S2MHT, S4DPA, S9MHT, and S10MHT) non-licensed personnel files reviewed (See findings under A0145);
6) failure to ensure nursing staff observed patients' #R11-#R17 every 2 hours as per hospital policy (See findings under A0145);
7) failure to ensure the hospital's direct care staff were educated, trained and demonstrated knowledge on the use of nonphysical intervention skills as evidenced by 1 (#S7LPN) of 9 (S1LPN, S2MHT, S4DPA, S5RN, S6LPN, S7LPN, S8RN, S9MHT, and S10MHT) direct care staff sampled having an expired certification in Management of Aggressive Behavior. (See findings under A0200).

Based on observation, record review and interview the hospital failed to ensure each patient received care in a safe setting as evidenced by:
1) failure to ensure contraband was not accessible to patients;
2) failure to identify an environmental safety risk as evidenced by allowing an unstable patient in the nurses' station for PRN injection;
3) failure to ensure patients with a diagnosis of homicidal ideations received a Violence Risk Assessment per policy in 1 (#5) of 3 (#1, #4, and #5) patients reviewed for Violence Risk Assessment.
Findings:

1) Failure to ensure contraband was not accessible to patients.
Review of hospital policy titled "Rights of All Patients", dated 07/2021, revealed in part: The right to receive care in a safe setting.

Review of hospital policy titled "General Facility Safety and Patient Management", dated 01/2021, revealed in part: Policy, in part: The behavioral Health services environment shall be maintained in a safe, clean and orderly manner at all times. The facility shall be routinely checked to protect patients, visitors, and staff from potential safety hazards.

Review of hospital policy titled "Contraband", dated 12/26/23, revealed, in part: Policy: It is the policy of the hospital to define contraband as those items that could poise potential safety risks to patients or threaten the integrity of the milieu. Purpose: to define items considered contraband and to establish controls for maintaining the safety and security of the milieu. Procedure: In part: 1. Contraband (Harmful Material) is defined as, in part: c. Medication and drugs: prescribed, illicit, and over-the-counter. h.Grooming products... i....plastic bags. f ...cell phones. g....lighters.

Review of hospital policy titled, "Patient Room Safety", dated 01/2021, revealed in part: Policy, in part: Patient rooms will be checked every shift. Contraband will be removed if found and charge nurse is notified.

Review of hospital policy titled. "Admission Process", dated 01/2021, revealed in part: Procedure, in part: 4 ....The patient will be wanded for metal detection and safety before entering the unit. 5. The MHT/nurse will conduct a patient search and complete the patient belongings inventory in the intake room ...Prior to securing patient clothing and valuables, the staff will ensure all items are present and verified by admitting RN. 6. All valuables will be placed in a security envelope labeled with the patient's name. A copy of the inventory form will be attached to the outside of the envelope with the original placed in the chart. The receipt from the security envelope will be attached to the original inventory form in the chart. The original inventory list is signed by the patient, the nurse, and the MHT. The original inventory list is maintained in the medical record.

Observations

Review of hospital census dated 07/15/2024 revealed 10 (#3, #R1, #R3-#R10) patients on suicide precautions.

Observation on 07/15/2024 at 10:00 a.m. revealed plastic garbage bag in trashcan in dayroom c.

In an interview on 07/15/2024 at 10:00 a.m., S3DON confirmed that the plastic garbage bag is considered contraband and should not be in dayroom c where it is accessible to patients.

Observation on 07/15/2024 at 10:04 a.m. revealed room a contained a bottle of deodorant on bedside table. Further observation revealed room b contained a bottle of deodorant on bedside table.

Review of Unit A's census dated 07/15/2024 revealed #R1 was assigned to room a. Further review revealed #R1 was on suicide precautions.

Review of Unit A's census dated 07/15/2024 revealed #R2 was assigned to room b. Further review revealed #R2 was on behavioral precautions.

In an interview on 07/15/2024 at 10:05 a.m., S3DON verified rooms a and b each contained a bottle of deodorant on bedside table.

In an interview on 07/15/2024 at 10:15 a.m., S3DON #R1 was in room a and was on suicide precautions and should not have contraband in her room. S3DON verified #R2 was in room b and was on behavioral precautions and should not have contraband in her room.

In an interview on 07/15/2024 at 1:10 p.m., S3DON and S11RM confirmed all grooming products, including deodorant, are considered contraband. S3DON reported that although the policy for contraband was updated in March, it should be further updated to include "Deodorant" as a grooming product. S3DON stated a contraband search of all rooms should be done and the bottles of deodorant removed immediately.

Patient #4

Review of incident log dated 02/09/2024 at 3:07 p.m. revealed Patient #4 was found smoking drugs in his room. There were no actions listed on the incident log. The log indicated a self-report was not submitted.

Review of incident log dated 02/09/2024 at 9:00 p.m. revealed Patient #4 was found with a lighter. Patient #4 appeared to be fidgety and acting suspicious. It was discovered that Patient #4 was hiding something between the wall and the handrail in the hallway. A search revealed a lighter. Action was to search Patient #4 and everything removed from room to be searched. The log indicated a self-report was not submitted.

Review of incident report dated 02/09/2024 at 3:07 p.m. revealed Patient #4 was found smoking drugs in his room. Further review failed to reveal details of the incident. Continued review failed to reveal a supervisor or a physician was notified.

Review of incident report dated 02/09/2024 at 9:00 p.m. revealed Patient #4 was found with a lighter. The incident report indicates this was the second lighter, the first lighter was found in his room. Measures to put in place were to do better searches during intake process.

In an interview on 07/16/2024 at 11:10 a.m., S11RM confirmed the incidents that occurred on 02/09/2024 at 3:07 p.m. and 9:00 p.m. S11RM reported the hospital observed video and did not see where Patient #4 picked up the lighters or the drugs. The hospital interviewed staff and Patient #4 and could not determine where the lighters came from, what drugs he was smoking or how he obtained the lighters or the drugs. S11RM believed the drugs were flushed after found but could not verify. S3DON and S11RM do not know how or where Patient #4 obtained the contraband. S3DON and S11RM confirmed Patient #4 should not have had lighters or drugs per hospital policy.

Patient #5

Review of incident log dated 04/15/2024 at 11:55 a.m. revealed Patient #5 was found with a cellphone and lighter in his room while cleaning it out upon discharge. Action was to educate staff on the importance of contraband rounds. The log indicated a self-report was not submitted.

Review of incident report dated 04/15/2024 at 11:55 p.m. revealed Patient #5 was found to have a lighter and a cell phone on his person. The report indicated that Patient #5 walked up and asked if he could have a charger for his phone. He had tried charging his phone with the hand dryer. When asked how he had possession of a phone, Patient #5 stated he had the phone since he came in. Patient #5 was also found to have a black lighter when he was smoking with another patient.

A review of Patient #5's medical record revealed admission on 04/08/24 at 10:50 p.m. and discharge on 04/15/2024 at 12:45 p.m.

In an interview on 07/16/2024 at 12:35 p.m., S11RM reported Patient #5 was to be discharged on 04/15/2024. S11RM stated staff had him sign for his belongings and he grabbed the phone and lighter from the belonging bag at that time.

A review of Patient #5's "Personal Items Inventory Form", dated 04/08/2024 at 10:50 p.m. failed to reveal a lighter and a cell phone were included on the list of Patient #5's personal items. Further review revealed Patient #5 signed the form on 04/08/2024 at 10:50 p.m. Continued review revealed the section labeled, "Discharge Signatures and Return of Property", contained Patient #5's signature dated 04/15/2024 at 12:45 p.m., which was 50 minutes after the incident occurred.

In an interview on 07/16/2024 at 12:45 p.m., S11RM confirmed Patient #5's "Personal Items Inventory Form", dated 04/08/2024 at 11:00 p.m. failed to reveal a lighter and a cell phone were included on the list of Patient #5's personal items. S3DON and S11RM verified Patient #5 signed the form on 04/08/2024 at 10:50 p.m. and at discharge on 04/15/2024 at 12:45 p.m., which was 50 minutes after the incident occurred. S11RM did not know why the incident report and the incident log did not correlate. S11RM and S3DON confirmed patient should not have had a lighter or a phone per hospital policy.

2) Failure to identify an environmental safety risk as evidenced by allowing an unstable patient in the nurses' station for a PRN injection.
Review of incident log dated 06/02/2024 at 5:20 p.m., revealed Patient #1 was located in a locked and enclosed nurses' station, yelling and screaming. Patient #1 was in the nurses' station in order to receive a PRN medication. Patient #1 proceeded to pull a nurse's wig from her head and a fight broke out. Actions taken: the patient removed from nurses' station. The incident log indicated the incident was self-reported due to workplace violence.

Review of Incident Report dated 06/02/2024 at 5:20 p.m. revealed Patient #1 was cursing, threatening and yelling at another patient. She was brought into the nurses' station to receive a PRN medication. While administering the injection, Patient #1 jumped up and attacked an employee. She hit her in the back of the head and pulled her hair. Staff intervened. Patient #1 was removed from the nursing station. No injuries noted.

Review of Hospital Abuse/Neglect Initial Report dated 06/04/2024 at 8:30 a.m. revealed that on 06/02/2024, Patient #1 was brought into the Unit A nurses' station to receive a PRN medication. S1LPN was sitting at the nurses' station desk. Patient #1 stood up and pulled S1LPN's wig off head. S1LPN attempted to punch Patient #1 however, ended up hitting S2MHT. Patient #1 was removed from nurses' station and escorted to room c with an MHT to keep her away from other patients. She was on Q 15 minute observations and discharged on 06/04/2024. S2MHT denied pain or injuries. S1LPN was sent to Unit B for the rest of shift. After hospital reviewed video, S1LPN was suspended for 3 shifts and required to complete crisis prevention training and anger management training before returning to work.

In an interview on 07/15/2024 at 10:15 a.m., S3DON stated that PRN injections should be given in the patient rooms unless staff are unable to bring patient to their room.

In an interview on 07/15/2024 at 12:59 p.m., S3DON confirmed patients are not allowed in the nurses' station due to the risk of compromising patient and staff safety. S3DON reported that they are currently revising a policy regarding patient entrance into the nurses' station. Patients are not allowed in nurse's station. Any interaction should be in patient room, or exam room, or other room where a camera is located.

In an interview on 07/16/2024 at 11:17 a.m, S2MHT stated Patient #1 was brought into the nurses' station in order to contain her. S2MHT reported Patient #1 was in a chair in nurses' station to get PRN injection. Two techs and three nurses were also in nurses' station. S1LPN was working on the computer while Patient #1 was getting the injection. Patient #1 started acting out during injection, 3 techs tried to contain her. S1LPN's back was to Patient #1 when Patient #1 reached out and snatched her wig off. S2MHT was hit in the middle of the nose while S1LPN was flailing her arms about. S2MHT stated she did not tell anyone she was hit until 06/04/2024.

3) Failure to ensure patients with diagnosis of homicidal ideation received a Violence Risk Assessment per policy in 1 (#5) of 3 (#1, #4, and #5) patients reviewed for Violence Risk Assessment.
Review of hospital policy titled, "Homicide/Violence Precautions, Serious Threats of Physical Harm Including Tarasoff Warning", revised 01/2024, revealed in part: Level II: Homicidal Precautions, in part: 1. Patient assessed to have a history of homicidal behavior or intent. 2. Patient behavior: a. possibility of the presence of homicidal ideation.

Review of Patient #5's medical record revealed an admission date of 04/08/24 at 10:50 p.m. with diagnosis of homicidal ideation, suicidal ideation, depressive disorder, substance use. Patient was admitted after fighting with his uncle.

Review of Patient #5's Psychiatric Evaluation dated 04/09/2024 at 1:47 p.m. revealed in part: Danger to others/Aggressive behavior. Behaviors that create a risk to self or others: Homicidal Ideations. Criteria for discharge, in part: No homicidal ideations for three days. Problem list for treatment plan: homicidal ideations, mood lability and substance abuse.

Review of Patient #5's Nursing Admission Assessment dated 04/08/2024 at 10:50 p.m. revealed Section VI: Violent Risk Assessment. Further review failed to reveal the assessment had been completed.

In an interview on 07/16/2024 at 12:15 p.m., S11RM verified patient #5 was diagnosed with homicidal ideation and
the level of homicidal/violence precaution could not be determined because the Violent Risk Assessment was not completed.

Based on observation, record review and interview the hospital failed to ensure all patients were free from all forms of abuse, harassment or neglect as evidenced by:
1) failure to ensure 1 (#5) of 3 (#2, #3 and #5) patients on suicide precautions sampled were observed per physician orders.
2) failure to ensure staff criminal background checks did not include convictions that bar employment in 1 (#S4DPA) of 4 (S2MHT, S4DPA, S9MHT, and S10MHT) non-licensed personnel files reviewed;
3) failure to ensure nursing staff observed patients' #R11-#R17 every 2 hours as per hospital policy;

Findings:

1) Failure to ensure 1 (#5) of 3 (#2, #3 and #5) patients on suicide precautions sampled were observed per physician orders.
Review of hospital policy titled "Assessment of the Patient at Risk for Suicide", dated 01/2021, revealed in part: Procedure, in part: 1. Suicide Precautions with appropriate monitoring will be initiated once suicide assessment completed and when a Physician's Order is given to initiate suicide precautions as follows, in part: 7. Ongoing documentation by the nursing staff is required to verify that suicide precautions are maintained during each shift ...9. The charge nurse or nurse designee is responsible for ensuring that the appropriate level of observation is maintained and documented. 12. Employees who monitor a patient placed on Suicide Precautions must be trained in at least the following areas in part: Proper completion of the Observation Sheet.

Review of hospital policy titled, "Observation Precautions", dated 01/2021, revealed in part: Policy, in part: ...Observation of the patient by clinical staff members will be accomplished to maintain patient/employee safety in the least restrictive manner. Procedure, in part: Documentation, in part: ...Charge nurse or designee will make rounds every 2 hours and sign the observation sheet to ensure that MHT's are ...filling the form out correctly ...

Review of Patient #5 electronic medical record, guided by S11RM, revealed an admission date of 04/08/24 at 10:50 p.m. with diagnosis of suicidal ideation, homicidal ideation, and major depressive disorder.

Continued review revealed Patient #5's Psychiatric Evaluation dated 04/09/2024 at 1:47 p.m.. The review revealed in part: 3. Attempt, threat or danger of Suicide. History of suicidal thoughts. Behaviors that create a risk to self or others: Suicidal Ideations ... Criteria for discharge, in part: No suicidal ideations for three days. Problem list for treatment plan: suicidal Ideations, homicidal ideations, mood lability and substance abuse.

Additional review revealed provider orders dated 04/08/2024 at 11:49 p.m. included Suicide Precautions.

Further review of Patient #5's electronic medical record revealed a scanned observation sheet dated 04/09/2024 signed by the day and night nurse but failed to include Patient #5 was on suicide precautions.

In an interview on 07/16/2024 at 12:30 p.m., S11RM verified that the scanned observation sheet in the electronic medical record dated 04/09/2024 failed to reveal Patient #5 was on Suicide Precautions. S11RM presented a paper copy of the observation sheet that was located in the closed chart also dated 04/09/2024, with an upside down check mark next to Suicide Precautions. S11RM indicated she was not sure if the paper version of the observation sheet had been altered.

2) Failure to ensure staff criminal background checks did not include convictions that bar employment in 1 (#S4DPA) of 4 (S2MHT, S4DPA, S9MHT, and S10MHT) non-licensed personnel files reviewed.

Review of hospital policy titled "Patient Abuse and /or Neglect, dated 01/2021, revealed in part: Policy: It is the policy [hospital] to provide for a safe environment free from all forms of abuse or harassment. The intent of this requirement is to prohibit all forms of abuse, neglect (as a form of abuse) and harassment whether from staff, other patients or visitors. Goals, in part: 2. Screening of Employees: persons with a record of abuse or neglect will not be hired or retained employees.

Review of hospital policy titled, "Personnel/New Hire policy", revised, 01/2024, revealed in part: Procedure, in part: 3. The department Program Director does the interviews and when they have decided who to hire, HR submits background check ...4. When background check comes back clear, HR will notify Program Director. HR gives the PA to CEO for approval. HR then contacts the potential employee to come in to complete paperwork, receive identification badge, HR will schedule the new employee to complete mandatory ...trainings/orientations at this time.

Review of incident log dated 05/31/2024 at 9:16 a.m. revealed Patient #1 was yelling and screaming. Patient #1 approached S4DPA and hit her, and S4DPA hit back. Once staff intervened and separated both parties, S4DPA went back and again attacked Patient #1. Action: Patient #1 was discharged per provider order. S4DPA was terminated. The incident log indicated the incident was self-reported.

Review of Incident Report dated 05/31/2024 at 9:16 a.m. revealed Patient #1 was administered a PRN medication prior to incident. Patient yelling and cursing and ran up to staff member and punched her in the face. Staff members intervened and separated both parties. The incident report failed to indicate a follow up assessment was completed for Patient #1.

Review of Hospital Abuse/Neglect Initial Report dated 05/31/2024 at 9:16 a.m. revealed video footage that on 05/31/2024, Patient #1 was walking in hallway when S4DPA walked out of office. Patient #1 appeared to be exchanging word. Patient #1 then swung at S4DPA and S4DPA swung back. Staff intervened immediately. S4DPA attempted to hit Patient #1 again. Patient #1 was brought to her room. Actions: Patient #1 was placed in her room and a discharge order was obtained from provider. Patient #1 unable to be discharged due to group home refusing to accept patient back and family not willing to accept patient back due to psychosis. S4DPA was terminated. The allegation was substantiated due to S4DPA hitting Patient #1.

Review of terminations list revealed #S4DPA was terminated on 05/31/2024.

Review of #S4DPA's personnel file revealed date of hire 12/15/2023.

Review of #S4DPA's criminal background check, updated on 12/12/2023, revealed the following:

02/15/2020-CCRP 202 warrant. Continued review failed to reveal a disposition for the arrest warrant.

In an interview on 07/16/24 at 1:30 p.m., S11RM confirmed the hospital does not have the disposition for #S4DPA's arrest warrant and further stated the exact reason for the warrant was unknown.

3) Failure to ensure nursing staff observed patients' #R11-#R17 every 2 hours as per hospital policy.
Review of hospital policy titled, "Observation Precautions", dated 01/2021, revealed in part: Policy, in part: ...Observation of the patient by clinical staff members will be accomplished to maintain patient/employee safety in the least restrictive manner. Procedure, in part: Documentation, in part: ...Charge nurse or designee will make rounds every 2 hours and sign the observation sheet to ensure that MHT's are observing their assigned patient, filling the form out correctly and not charting ahead.

Review of Job Description titled, "Registered Nurse, Inpatient", N.D. , revealed in part: Essential Job Functions, in part: 1. Responsible for supervision of ...MHTs. 19. Completes and signs ...required documentation within guidelines mandated by law and applicable hospital policies and procedures.

Review of observation sheets dated 07/15/2024 for patients' #R11-#R17 on Unit B failed to reveal the nurse made rounds every 2 hours and signed the observation sheet ensuring that MHT's observed their assigned patients, filled the form out correctly and did not chart ahead.

In an interview on 07/15/2024 at 1:40 p.m., S3DON confirmed nurse did not document rounds per hospital policy.

Based on record review and interview, the hospital failed to ensure the hospital's direct care staff were educated, trained and demonstrated knowledge on the use of nonphysical intervention skills as evidenced by 1 (#S7LPN) of 9 (S1LPN, S2MHT, S4DPA, S5RN, S6LPN, S7LPN, S8RN, S9MHT, and S10MHT) direct care staff sampled having an expired certification in Management of Aggressive Behavior.
Findings:

Review of hospital policy titled, "Workplace Violence Plan", dated 06/15/2021, revealed in part: Purpose: ...to minimize the risk of violence occurring in the workplace, establish and maintain a safe, secure environment and comply with law and regulation. Annual Continuing Education, in part: All employees are required to participate in annual education and training activities related to workplace violence prevention ...

Review of S7LPN's personnel record revealed a certificate titled, "Management of Aggressive Behavior", dated 06/10/2022 with an expiration date of 06/10/2024.

Review of unit assignments dated 07/15/2024 revealed S7LPN was on the schedule for the day shift.

In an interview on 07/15/2024 at 4:02 p.m., S3DON verified S7LPN is currently on the schedule and her crisis prevention training expired 06/10/24.

Based on record review and interview the hospital failed to ensure nursing staff followed the policies and procedures of the hospital. This deficiency is evidenced by failure of the nursing staff to monitor fetal heart tones for Patient #1 per provider order.
Findings:

Review of hospital policy titled, "Fetal Heart Tones, Monitoring", revised 01/2024, revealed in part: purpose: 1. To monitor the status of the fetus. 2. To detect fetal distress and provide appropriate nursing intervention. Policy in part: All pregnant females admitted [to hospital] will be monitored. Procedure in part: 8. Check the fetal heart tones (FHT) every shift. Follow physician orders for perimeters and instructions.

Review of Patient #1's electronic medical record, guided by S11RM, revealed Patient #1 was admitted on 05/24/2024 at 5:30 p.m. and discharged on 06/04/2024 at 5:20 p.m. Continued review revealed Patient #1's History and Physical completed on 05/25/2024 at 5:17 p.m. indicated Patient #1 was 18 weeks pregnant. Further review of Patient #1's History and Physical revealed the provider's Assessment and Plan. The Assessment and Plan revealed in part: 8. Pregnancy (18 weeks)-Fetal heart tones every shift. Monitor.

Review of provider order dated 05/25/2024 at 5:21 p.m. revealed close observation-Staff to monitor Fetal Heat Tones every shift. Call if FHR <110 or >180.

Review of Patient #1's nursing notes revealed the following:
05/26/2024 at 10:00 p.m. Patient #1 refused FHT and was in seclusion. No indication medical provider was notified.
05/27/2024 day shift and night shift with no FHTs recorded. No documentation as to why.
05/28/2024 day shift and night shift with no FHTs recorded. No documentation as to why.
05/30/2024 night shift. Patient #1 refused FHTs and was in seclusion. No indication medical provider was notified.
05/31/2024 day shift or night shift with no FHTs recorded. No documentation as to why.
06/01/2024 day shift or night shift with no FHTs recorded. No documentation as to why.
06/02/2024 day shift or night shift with no FHTs recorded. No documentation as to why.
06/04/2024 day shift with no FHTs recorded. No documentation as to reason why.

In an interview on 07/16/2024 at 11:10 a.m., S11RM verified that the FHTs were not recorded as above and the provider orders were not implemented per policy.