HospitalInspections.org

Based on document review and interviews, the hospital failed to follow policies and procedures (the Advance Directives/Health Care Proxy Policy) regarding the invocation of a health care proxy of an incapacitated patient, for one (Patient #8) of ten patients sampled.

Findings include:

The policy titled Advanced Directives/Health Care Proxy, last revised 05/2014, states that "A health care proxy is invoked only when a physician determines a patient is unable to make or communicate their own health care decisions. A physician must record in the medical record the cause and nature of a patient's incapacity as well as its extent and probable duration. Using the Health Care Proxy Activation/Revocation form, the attending physician must sign, date and time that the Health Care Proxy has been activated and that notice has been given to the health care agent and, if appropriate, the patient."

The surveyor interviewed the Senior Director of Administration and the Director of Regulatory Readiness on 03/21/2022 at 3:00 P.M. Patient #8 was in an intubated and sedated state on 03/21/2022 and had been in an intubated and sedated state since Patient #8's day of arrival to the hospital on 03/18/2022. Patient #8 did not have an "Activation/Revocation Documentation Form" on file, in accordance with the aforementioned policy stated above, despite Patient #8 having an appointed health care proxy on file.

Based on document review and interviews, the hospital failed to develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program, for two (Patient #1, Patient #6) of ten patients sampled.


See tag A-0286.

Based on document review and interviews, the hospital failed to develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program, for two (Patient #1 and Patient #6) of ten patients sampled, that would ensure the safety of patients who may pose a high risk for self-harm, harm to others, etc.

Findings include:

The hospital reported that Patient #1, a pediatric patient with an extensive history of behavioral health issues, including multiple suicidal attempts, completed a self-harm event. Although Patient #1 was under 1:1 constant observation, Patient #1 managed to obtain a small piece of a razor, and used that small razor to perform a self-harm event (found bleeding from forearms) while taking a shower in the bathroom of Patient #1's room. It was also noted that the patient belongings were searched prior to giving them back to Patient #1 and nothing was detected.

The surveyor interviewed PCSA #1 (a Patient Care Safety Aide who was the constant observer observing Patient #1 at the time of Patient #1's June 2021 incident) on 03/18/2022 at 12:00 P.M. PCSA #1 said that PCSA #1 could only see the feet of Patient #1. PCSA #1 said that the shower curtain was not a see-through curtain.

The policy titled, Suicide Risk Assessment, Prevention, and Precautions, with an effective date of 12/10/2019, states under the Constant Observation section, page 9, Number 5: "Have eyes on the patient and be within a distance that allows immediate intervention at all times, including toileting."

The Solutions Plan, a corrective action document created in response to the June 2021 Patient #1 event, identified an issue with compliance of the observation policy. Under interventions the solutions plan indicated that: "Sitter training provided to Mental Health Specialists (MHS) responsible for constant observation of pediatric patient with suicidal ideation."

The surveyor interviewed the associate Chief Medical Officer (CMO) for Quality on 03/17/2022 at 1:00 P.M. The associated CMO for Quality confirmed that one of the long-term corrective actions in response to Patient #1's event was a training program for the MHSs. However, the associate CMO for Quality did not believe there was any re-training or re-education provided to other staff positions who, as part of their job may still perform the constant observation role, including Patient Care Safety Aides (PCSA) and Clinical Care Technicians (CCT).

The surveyor interviewed PCSA #1 (the constant observer who was observing Patient #1 at the time of Patient #1's June 2021 incident) on 03/18/2022 at 12:00 P.M. PCSA #1 said that besides a conversation with a clinical nurse director, no other corrective actions were implemented after Patient #1's June 2021 event, from PCSA #1's perspective.

The surveyor interviewed the Senior Director of Administration (SDA) on 03/17/2022 at 3:15 P.M. The SDA stated that nurses, as part of their job, may also potentially perform the constant observation role.

The surveyor, during the investigation of Patient #1, identified a similar second self-harm event regarding another pediatric patient (Patient #6) on the same pediatric unit, approximately 2.5 months after Patient #1's self-harm event. Patient #6 was also on a 1:1 constant observer, also observed by a PCSA (PCSA #2). Patient #6 ran into the bathroom and into the shower stall area behind the shower curtain where at this point, PCSA #2 loses visualization of Patient #6. Although PCSA #2 pulled an emergency cord/call bell in the bathroom, PCSA #2 leaves Patient #6 and leaves the bathroom area to go to the threshold between the hallway and the room door to request additional assistance. PCSA #2 finds a Critical Care Technician (CCT) and the CCT and PCSA #2 walk back into the bathroom where the CCT draws the shower curtain, to find Patient #6 kneeling on the ground, using one pant leg around Patient #6's neck and the other pant leg tied to a handicap rail, in what appeared to be a strangulation attempt. The details above were reported to the surveyor by Senior Risk Manager #2 on 03/21/2022.

The aforementioned policy titled, Suicide Risk Assessment, Prevention, and Precautions, with an effective date of 12/10/2019, states under the Constant Observation section, page 9, Number 3: "Stay with the patient at all times except when relieved by nursing staff."

Although the hospital implemented a hiring/training program for a subset group of employees, MHSs, (as indicated in the Solutions Plan) the hospital failed to perform similar re-education and/or re-training to all pertinent staff who may potentially work in the constant observer role. This failure increases the risk that similar, self-harm events could occur again in the future.