HospitalInspections.org

Based on observation, interview and record review, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. This is evidenced by failure to ensure patient safety by failing to prevent a patient with a loaded firearm from being admitted into the hospital.
(See findings under tag A0144)

An Immediate Jeopardy was identified on 11/15/2023 at 3:06 p.m. and reported to S11Admin, S6QA, S10Sup and S12ADON, S13DON, and S14CD. The Immediate Jeopardy situation was the result of the hospital failing to ensure direct care staff were correctly trained in the protocol and procedure for pre-admit contraband searches and failing to implement corrective actions to ensure that this break in procedure would not reoccur.

On 11/16/2023 at 10:25 a.m., S6QA and S11Admin presented the plan for lifting the immediacy of the IJ which included the assurance that all direct care staff working with patients on this day were trained in the new protocol and procedure for pre-admit contraband searches. The hospital conducted trainings related to contraband searches beginning 11/15/2023 at 4:00 p.m. and throughout the day on 11/16/2023 until 2:00 p.m. Interviews and record review verified the MHT and nursing competencies were completed on all of the direct care staff present during 11/15/2023 at 4:00 p.m. and 11/16/2023 until 2:00 p.m.

On 11/16/2023 at 2:06 p.m. the IJ was removed; however, there was not enough evidence to determine sustainability of compliance for the Condition of Patient Rights to be cleared. Therefore, noncompliance remains at the Condition Level.

Based on observation and interview, the hospital failed to ensure patients received care in a safe setting as evidenced by:
1) failure to detect a loaded firearm on Patient #1 prior to hospital admittance;
2) failure to complete safety rounds every shift as per hospital policy;
3) failure to implement effective policies and procedures addressing the detection of a loaded firearm on a patient prior to hospital admittance;
4) failure to educate staff on policies and procedures to detect and disarm a patient with a loaded firearm prior to hospital admittance;
5) failure to replace a damaged hand-held weapons detector.
Findings:

1) Failure to detect a loaded firearm on Patient #1 prior to hospital admittance.
Review of hospital policy titled "Patient Rights", revised 11/11/2021, revealed, in part: Policy: it is the policy of the hospital to maintain, protect, and respect the fundamental human, civil, constitutional, and statutory rights in accordance with Federal and State laws of all patients. Patient Rights, in part: The right to an environment that assures the patient's safety, health and wellbeing ...

Review of hospital policy titled "Rights of Involuntary Patients", revised 11/11/2021, revealed, in part: Purpose: The purpose of this policy is to ensure that rights of involuntary patients are upheld in accordance with federal and state laws and the philosophy of the hospital. Rights of the Involuntary Patients, in part: 4. A humane treatment environment that affords reasonable protection from harm ...

Review of hospital document titled "Hospital Occurrence Report-HOR", dated 11/06/2023 at 6:25 a.m., revealed, in part: Patient #1, located on hall 'a' in room 'b'. During the morning MHT safety rounds, S9MHT found a gun in Patient #1's bed. The gun was in a pillowcase, under a pillow. The gun was placed in a patient belonging bag with a patient label and placed in the administration office.

In an interview on 11/15/2023 at 9:28 a.m., S6QA reported the video revealed Patient #1 was not wanded, he was left alone behind the privacy screen for an extended time and that he did not remove all of his clothes but still had his pants and shoes on when exiting room 'c' to be brought to his room.

2) Failure to complete safety rounds every shift as per hospital policy.
Review of hospital document titled "Safety Rounds" revealed, in part: Safety Rounds are completed by one or more off going MHT's on every shift. Not completing the rounds or documenting them will result in disciplinary action. The purpose of these rounds is to ensure the safety and security of the patients and staff.

Review of hospital document titled "Mandatory Shift Change Environmental Safety Rounds Checklist Education", revealed, in part: Outgoing MHT and incoming MHT should perform together whenever possible. Findings should (i.e. incomplete tasks) should be documented in the comments. The assigned MHT is responsible for ensuring all items are complete. If the checklist is not found or there are incomplete assignments, the assigned MHT will be held accountable.

Review of hospital log titled "MHT Safety Rounds Log Book" failed to reveal evidence that safety rounds were completed every shift as per psychiatric hospital policy. The only completed safety round sheets in the MHT Safety Rounds Log Book for October and November of 2023 were dated 10/28/2023 and 11/04/2023.

In an interview on 11/15/2023 at 11:25 a.m., S6QA reported a loaded 22-caliber pistol was discovered in Patient #1's room on the morning of 11/06/2023 during safety rounds. S6QA stated that the policy is for safety rounds to occur every shift. S6QA continued by stating that Patient #1 was always in his bed in room 'c' during safety rounds, but on the morning of the 6th, the patient was not in his bed and the MHT preceded to search the bed and found the 22-caliber pistol under the pillow. S6QA confirmed that the patient had been admitted to the hospital for over a week before the loaded 22-caliber pistol was found during safety rounds.

In an interview on 11/16/2023 at 1:20 p.m., S6QA reported that she could not locate the safety rounding sheets for most of October and November 2023 for hall 'a' that houses room 'b'.

3) Failure to implement effective policies and procedures addressing the detection of a loaded firearm on a patient prior to hospital admittance.

Review of hospital policy titled "Hand Held Metal Detector", reviewed 10/05/2021, revealed, in part: Purpose: The purpose of this policy is to improve security and safety of patients and staff. Policy: It is the policy of the hospital to use a hand-held weapons detector to improve security of patients and staff. Procedure, in part: 1. the hand-held weapons detector will be used on screening of patients for potential weapons or contraband upon arrival to the facility prior to the initiation of the assessment screening.

Review of hospital policy titled "Contraband" last revised 11/11/2023, revealed, in part: Purpose: To define contraband and outline policies regarding the control of contraband. Policy: It is the policy of the hospital that staff shall ensure the strict control of contraband and unauthorized use of permitted items in order to provide a secure and safe environment for patients, staff, and visitors. Procedure, in part: 1. Contraband shall be defined and controlled according to applicable state laws, rules, regulations, and hospital policies and procedures. The most restrictive definition shall prevail. 5. Contraband list, in part: a. the following is a list of items but is not limited to that are considered contraband. They are prohibited from being brought hospital by staff or patients. iii., part: Firearm.

Review of document titled "Admit Protocol for All Patients for Searches", failed to reveal the use of a hand-held metal detector as part of the admission search protocol.

In an interview on 11/15/2023 at 9:28 a.m., S6QA verified that the procedure for admissions did not include the use of the metal detector in the lobby before entering the facility. S6QA further stated that staff did not use the hand-held metal detector on Patient #1 in the lobby.
S6QA stated the procedure was to have the patient in room 'c' behind a privacy screen where the patient is to completely disrobe and put on two green gowns. The MHT is responsible for being behind the privacy screen while patient is changing; using the hand-held metal detector to wand the patient and placing all of their clothes in a bag to be brought to the laundry room.
S6QA interviewed S5MHT who reported that he wanded the patient and it never went off. When asked if it was on, he said he thought so. S6QA verified that there was no evidence of metal detector use noted in the video while patient #1 was in room 'c' on 10/30/2023.
S6QA reported the video revealed Patient #1 was not wanded, he was left alone behind the privacy screen for an extended time and that he did not remove all of his clothes but still had his pants and shoes on when exiting room 'c' to be brought to his room on 10/30/2023.

4) Failure to educate staff on policies and procedures to detect and disarm a patient with a loaded firearm prior to hospital admittance.
Review of document titled "Admit Protocol for All Patients for Searches and Inventory Competency-Old Process", undated, failed to reveal that the patient is scanned with the metal detector in the lobby and a second time in room 'c'.

Review of unapproved document titled "Admission Security Competency-New Process", revealed, in part: 3. the MHT is to successfully use the metal detector wand to scan each patient in the lobby. 7. The patient will be scanned with the metal detector again. All contraband will be removed at this time.

In an interview on 11/15/2023 at 10:20 a.m., S6QA and S10Sup reported that all of the MHTs and nurses had not been educated on the new procedure for admit and contraband search. S6QA further stated the new procedure had not been approved by the governing board, but some of the staff had been verbally educated on the procedure. S6QA verified there was no sign-in sheet confirming which staff had been educated.

In an interview on 11/15/23 at 11:00 a.m., S7MHT, who was scheduled to conduct the next new admission, was unaware of the new admit process for contraband search. S6QA confirmed S7MHT failed to describe the new admit process for contraband search.

In an interview on 11/15/23 at 11:05 a.m., S8MHT who was scheduled to conduct the next new admission after S7MHT, was unaware of the new admit process for contraband search. S6QA confirmed S7MHT failed to describe the new admit process for contraband search.

In an interview on 11/16/2023 at 10:42 a.m., S8MHT stated discomfort in handling a potential discovery of a firearm that requires disarming. S8MHT reported being less uncomfortable if the hospital had a more specific procedure detailing what is required of the MHT during the discovery of a firearm.

5) Failure to replace a damaged hand-held weapons detector.
Observation of hand-held metal detector on 11/15/23 at 11:17 a.m located on unit'd', revealed the hand-held metal detector was held together by clear tape.

In an interview, S6QA reported that the tape was holding the batteries in place. That the hand-held metal detector had been dropped causing the damage requiring the batteries to be taped. S6QA stated she was not sure if a new hand-held metal detector was ordered. S6QA further stated that a nurse had verbalized that the facility needed a better hand-held metal detector, she said "it is more than the battery".

Based on record reviews and interview, the hospital failed to meet the requirements of the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) as evidenced by failing to ensure the Quality Assurance/Performance Improvement program measured, analyzed and tracked qulaity indicators to monitor the safety and effectiveness of services and quality of care. This deficient practice is evidenced by:

1. the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) Program specified the method and frequency of data collection for indicators as evidenced by failure to have documented evidence of current data on quality indicators (see findings in A-0273),

2. the hospital's Quality Assurance and Performance Improvement (QAPI) program failed to identify opportunities for improvement, implement effective action, measure success and track performance related to an identified damaged hand-held metal detector (see findings in A-0283),

3. the hospital failed to track and analyze all dangerous patient events. The deficient practice is evidenced by failure to complete an incident report for a documented dangerous event regarding the discovery of a loaded 22-caliber pistol under the pillow of Patient #1 (see findings in A-0263),

4. the hospital's governing body, medical staff and administrative officials failed to be responsible and accountable for ensuring that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained as evidenced by failing to have a current written, approved and implemented Quality Assurance/Performance Improvement (QAPI) plan and program (see findings in A-0309) and

5. the governing body failed to provide adequate resources for measuring, assessing, improving, and sustaining the hospital's performance by having insufficient staff designated to conduct the Quality Assurance/Performance Improvement (QAPI) functions of the hospital. This deficient practice is evidenced by assigning this responsibility to S6QA who is also assigned the duties of Risk Manager; Infection Control Director; Compliance Officer and Treatment Team Nurse. (see findings in A-0315).

Based on record review and interview, the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) Program specified the method and frequency of data collection for indicators as evidenced by failure to have documented evidence of current data on quality indicators.
Findings:

Review of hospital policy titled "Committee Structure" last reviewed 11/11/2021, revealed in part: Policy, in part: It is the policy ...to promote ongoing performance improvement. Procedure. in part: 5. Quality Council. a, in part: The purpose of the Quality Assurance Committee is to improve the safety and quality of health services. c. The committee shall convene a minimum of 10 times per year.

Review of hospital document titled "Quality Improvement Plan 2023", revealed, in part: Continuous Quality Improvement Departmental Monitoring, in part: ...indicators will be tracked and monitored by the QI department. B. The QI Director will track clinical indicators selected by the hospital's leadership team. The clinical indicators will be discussed monthly and used to identify trends, establish possible corrective action plans, and then to show sustained improvements.

Review of the hospital's QAPI records revealed no documented evidence of current data collection for quality indicators.

In an interview on 11/16/2023 at 2:05 p.m., S6QA confirmed "Incident Reports" and "Outliers Action Plan" revealed June 2023 as the date of the last tracked clinical indicators. S6QA verified the most recent Governing Council-Quality Assurance and Patient Safety and clinical Practice meeting was held July 11, 2023. S6QA reported the QAPI meetings should be 10 times a year per policy and the last meeting was held in July.

Based on record review and interview, the hospital's Quality Assurance and Performance Improvement (QAPI) program failed to identify opportunities for improvement, implement effective action, measure success and track performance related to an identified damaged hand-held metal detector.
Findings:

Observation on 11/15/2023 at 11:17 a.m. of hand-held metal detector located at the nurses' station on Hall 'a', revealed the hand-held metal detector was held together by clear tape.

Review of most recent Governing Council-Quality Assurance and Patient Safety and clinical Practice Minutes dated July 11, 2023 failed to reveal Equipment Maintenance listed. Further review failed to reveal discussion, recommendations and actions regarding the damaged hand-held metal detector.

In an interview, S6QA reported that the tape was holding the batteries in place. S6QA stated the wand had been dropped causing damage requiring the batteries to be taped into place. S6QA further reported she was not sure if a new hand-held metal detector was ordered. S6QA stated that a nurse had verbalized that the facility needed a better hand-held metal detector, "it is more than the battery".

In an interview on 11/15/2023 at 2:30 p.m., S6QA confirmed there was no evidence that the issue regarding the damaged hand-held metal detector was discussed as a QAPI issue.

Based on record review and interview, the hospital failed to track and analyze all dangerous patient events. The deficient practice is evidenced by failure to complete an incident report for a documented dangerous event regarding the discovery of a loaded 22-caliber pistol under the pillow of Patient #1.
Findings:

Review of hospital document titled "Hospital Occurrence Report-HOR", dated 11/06/2023 at 6:25 a.m., revealed, in part: Patient #1, located on Hall 'a' in Room 'b'. During the morning MHT safety rounds, S9MHT found a gun in Patient #1's bed. The gun was in a pillowcase, under a pillow. The gun was placed in a patient belonging bag with a patient label and placed in the administration office. Further review of the HOR failed to reveal corrective measures, analysis, or the signature of the risk manager.

Review of hospital document titled "Framework for Root Cause Analysis and Corrective Actions" (RCA), undated. The 19-page report included video footage dated 10/30/2023 from 10:31 p.m.-11:34 p.m. It was noted that Patient #1 was left by himself behind the privacy screen of room 'c' at 10:34 p.m. Patient #1 came from behind the screen at 10:38 p.m. with a green gown and dark colored pants on his body. Patient #1 exited room 'c' at 11:34 p.m. wearing shoes, pants, beige jacket. It was noted that Patient #1 was favoring left side upon entry and exit from the room 'c'. The left arm did not rise. The video footage failed to reveal staff use the hand-held metal detector per policy. The RCA reported the patient's medications and past medical/psychiatric history. On Page 7 of 19 pages Analysis question #1, "What was the intended process flow?", revealed Analysis findings "See document Security 'Admission Old Process' Sheet. Also on page 7 was Analysis question #2, "Were there any steps in the process that did not occur as intended?" "Analysis Findings" revealed "See document Security Admission 'Process Performed' Sheet. Pages 8-19 were not completed.

Review of the list of incident reports provided failed to reveal the above incident.

In an interview on 11/15/2023 at 12:15 p.m., S6QA confirmed that the hospital did not submit a self-report to LDH because they did not know what category to place the incident. S6QA also verified the RCA was not completed.

Based on record review and interview, the hospital's governing body, medical staff and administrative officials failed to be responsible and accountable for ensuring that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained as evidenced by failing to have a current written, approved and implemented Quality Assurance/Performance Improvement (QAPI) plan and program.
Findings:

Review of all QAPI information presented to the survey team as current revealed it only included the following:
1) Review of hospital document titled "Incident Reports" and "Outliers Action Plan" revealed June 2023 as the date of the last tracked clinical indicators. The "Incident Reports" and "Outliers Action Plan" for the months of July, August, September, and October, 2023 were blank.

2) Review of most recent Governing Council-Quality Assurance and Patient Safety and clinical Practice Minutes dated July 11, 2023. These meeting minutes stated that incidents were not addressed because the incidents document was not completed for the month of June.

3) Review of hospital document titled "Quality Improvement Plan 2023" provided by the hospital staff failed to reveal the Quality improvement Plan 2023 was approved and signed by the governing board.

In an interview on 11/16/2023 at 2:05 p.m., S6QA verified that the QAPI documents provided did not indicate an ongoing program for quality improvement and patient safety because the committee meetings and indicators were not current. S6QA did not know why the Quality Improvement Plan for 2023 was not signed.

Based on record review and interview, the governing body failed to provide adequate resources for measuring, assessing, improving, and sustaining the hospital's performance by having insufficient staff designated to conduct the Quality Assurance/Performance Improvement (QAPI) functions of the hospital. This deficient practice is evidenced by assigning this responsibility to S6QA who is also assigned the duties of Risk Manager; Infection Control Director; Compliance Officer and Treatment Team Nurse.
Findings:

Review of hospital document titled "Quality Improvement Plan 2023", revealed, in part: Continuous Quality Improvement Departmental Monitoring, in part: ...The ...indicators will be tracked and monitored by the QI department. B. The QI Director will track clinical indicators selected by the hospital's leadership team. The clinical indicators will be discussed monthly and used to identify trends, establish possible corrective action plans, and then be used to show sustained improvements.

Review of Organizational Chart provided by hospital staff, dated 01/21/2022, revealed, in part: S6QA listed as QA/Risk Manager; Infection Control; Compliance; and Treatment Team Nurse.

Review of hospital document titled "Incident Reports" and "Outliers Action Plan" revealed June 2023 as the date of the last tracked clinical indicators.

Review of most recent Governing Council-Quality Assurance and Patient Safety and clinical Practice Minutes revealed the the last meeting was held on July 11, 2023.

In an interview on 11/16/2023 at 2:05 p.m., S6QA reported that duties as QA/Risk Manager, Infection Control Director; Compliance Officer and Treatment Team Nurse has made it difficult to track the clinical indicators monthly as per policy.