HospitalInspections.org

Based on record review and interview, the facility failed to ensure specific patient rights were protected and promoted; and their written policy and procedures that protect and promote each patient's rights were implemented for 2 of 3 patients (P#1, P#2) reviewed with a patient rights violation complaint regarding the facility not providing a safe environment by not ensuring contraband items were on patient units and not ensuring full body searches were conducted on all admissions for adolescent patients sneaking in pencil sharpener blades; which violated the patient rights and patient safety for all patients admitted in the facility.

Specifically,

1.) The facility failed to maintain a safe and therapeutic enviromenet per their policy, titled Provision of Care, Treatment and Services PC-49A. The policy states in part....the facilty prohibits contraband on the units, Contraband is defined as any items that could be considered physically, emotionally, or pyschologically dangerous....the facility policy further defines contraband to include....razors and pencil sharpeners.

2.) the facility failed to conduct full body searches per their policy, titled, Provision of Care, Treatment and Services PC-49, last reviewed on January 2015...which states in part....Full body searches shall require removal of clothes with a full visual inspection of the patient's body including the inspection of clothing and property carried by the patient. Full body searches shall be conducted on all admissions.



Refer to A144 and A145 for evidence of specific findings.


The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.

Based on Record Review and Interviews, the facility failed to ensure patients received care in a safe setting. Specifically, the facility failed to conduct full body searches, per their policy, allowing Patient #1 and Patient #2 to bring contraband items (pencil sharpener blades) onto the patient units, violating the safety and rights of all patients. Patient #3 swallowed golf pencils on the unit was not placed on special precautions for her safety.


The finds were:


Patient #1:

Record review of Patient #1's medical record revealed she was admitted on 7/23/18 due to suicidal ideations. Patientt #1 also reported a history a self injurous behaviors by cutting herself.

Record review of Patient #1's discharge summary revealed Patient #1 reported to staff that "she swallowed a razor blade that she hid in her shoe prior to her admission.

Record review of Patient #1's admission medical screening, dated 7/23/18, revealed the facility used a safety wand to search for contraband items. There was no documentation that patient #1 had a full body search.


Patient #2:

Record review of Patient #2's medical record revealed she was admitted on 6/12/18 due to suicide attempts and discharged on 7/2/18.

Further review of the medical record revealed, as of 8/15/18, there was no discharge summary available for review.

Record review of Patient #2's admission medical screening, dated 6/12/18, revealed the facility used a safety wand to search for contraband items. There was no documentation that patient #1 had a full body search.

Record review of Patient #2's medical record revealed the patient had eloped from the faiclity on approximately 6/30/18 and returned to the facility on 7/1/18. Further review revealed the patient had snuck in a pencil sharpener blade, which she swallowed at the facility.

There were no documentation that full body searches were completed.


Patient #3:

Record review of Patient #3's medical record revealed:

6/30/18- Patient #3 was admitted to the hospital due to swallowing a short wooden pencil while at the facility.
7/03/18- Patient #3 was admitted to the hospital due to swallowing a short wooden pencil while at the facility.
7/15/18- Patient #3 was admitted to the hospital due to swallowing a small wooden pencil while at the facility.

Record review of Patient #3's phyiscian orders and nurses orders revealed there was no documentation of Patient #3 having been placed on special precautions orders for wearing facility scrubs, finger foods, or being placed on the opposite side of the room so she couldn't grab contraband or plastic eating utensils or pemcils.

Interview on 08/15/2018 at 12:08 PM with the facility Director of Clinical Services for Adolescents and Children
confirmed there was no documentation in the medical record for Patient #3 to be placed on special precautions.

She further revealed there is no written policy on being placed on special precautions.



Interview on 8/14/18 at 2:30 PM with the facility Director of Intake revealed the facility does not conduct full body searches as they feel it is intrusive to the clients. Instead the facility will wave a wand around the body. She further stated, shoes are only removed from the patients if they are admitted due to Emergency Detention, as they are deemed a higher risk. She did reveal she feels it is a good idea to remove shoes from all patients.

Interview on 8/14/18 at 2:00 PM with the facility Risk Manager, revealed the facility did not have a policy in regards to Full Body searches versus using a Body Wand.

She further confirmed there is policy for Pica, or what to do if patient's ingest objects.

Interview on 8/15/18 at 10:48 AM with the facility's Psychiatrist revealed, clothes are inspected on the unit when a kid elopes and then put on a number of precautions including for Suicidal Ideation, Assault, and Elopement.
He stated he can't answer regarding inspection during admission process. He stated once there was knowledge of ingestion behavior, they usually are placed on a number of precautions including but not limited to blue scrubs, finger foods (no plastic utensils).
He said treatment team would determine if there is a need or scrubs, finger foods, other precautions. Treatment team is MD, nurse, and therapist.


Record review of the facility policy, titled Provision of Care, Treatment and Services PC-49A. The policy states in part....the facilty prohibits contraband on the units, Contraband is defined as any items that could be considered physically, emotionally, or pyschologically dangerous....the facility policy further defines contraband to include....razors and pencil sharpeners.


Record review of the facility policy, titled, Provision of Care, Treatment and Services PC-49, last reviewed on January 2015...which states in part....Full body searches shall require removal of clothes with a full visual inspection of the patient's body including the inspection of clothing and property carried by the patient. Full body searches shall be conducted on all admissions.


Record review of the facility's policys revealed the facility did not have a PICA policy.

Based on Record Review and Interviews, the facility failed to ensure patients received care in a safe setting and a failed to protect the rights of all patients. Specifically, the facility failed to conduct full body searches, per their policy, allowing Patient #1 and Patient #2 to bring contraband items (pencil sharpener blades) onto the patient units, violating the safety and rights of all patients. Patient #3 swallowed golf pencils on the unit was not placed on special precautions for her safety.


The finds were:


Patient #1:

Record review of Patient #1's medical record revealed she was admitted on 7/23/18 due to suicidal ideations. Patientt #1 also reported a history a self injurous behaviors by cutting herself.

Record review of Patient #1's discharge summary revealed Patient #1 reported to staff that "she swallowed a razor blade that she hid in her shoe prior to her admission.

Record review of Patient #1's admission medical screening, dated 7/23/18, revealed the facility used a safety wand to search for contraband items. There was no documentation that patient #1 had a full body search.


Patient #2:

Record review of Patient #2's medical record revealed she was admitted on 6/12/18 due to suicide attempts and discharged on 7/2/18.

Further review of the medical record revealed, as of 8/15/18, there was no discharge summary available for review.

Record review of Patient #2's admission medical screening, dated 6/12/18, revealed the facility used a safety wand to search for contraband items. There was no documentation that patient #1 had a full body search.

Record review of Patient #2's medical record revealed the patient had eloped from the faiclity on approximately 6/30/18 and returned to the facility on 7/1/18. Further review revealed the patient had snuck in a pencil sharpener blade, which she swallowed at the facility.

There were no documentation that full body searches were completed.


Patient #3:

Record review of Patient #3's medical record revealed:

6/30/18- Patient #3 was admitted to the hospital due to swallowing a short wooden pencil while at the facility.
7/03/18- Patient #3 was admitted to the hospital due to swallowing a short wooden pencil while at the facility.
7/15/18- Patient #3 was admitted to the hospital due to swallowing a small wooden pencil while at the facility.

Record review of Patient #3's phyiscian orders and nurses orders revealed there was no documentation of Patient #3 having been placed on special precautions orders for wearing facility scrubs, finger foods, or being placed on the opposite side of the room so she couldn't grab contraband or plastic eating utensils or pemcils.

Interview on 08/15/2018 at 12:08 PM with the facility Director of Clinical Services for Adolescents and Children
confirmed there was no documentation in the medical record for Patient #3 to be placed on special precautions.

She further revealed there is no written policy on being placed on special precautions.



Interview on 8/14/18 at 2:30 PM with the facility Director of Intake revealed the facility does not conduct full body searches as they feel it is intrusive to the clients. Instead the facility will wave a wand around the body. She further stated, shoes are only removed from the patients if they are admitted due to Emergency Detention, as they are deemed a higher risk. She did reveal she feels it is a good idea to remove shoes from all patients.

Interview on 8/14/18 at 2:00 PM with the facility Risk Manager, revealed the facility did not have a policy in regards to Full Body searches versus using a Body Wand.

She further confirmed there is policy for Pica, or what to do if patient's ingest objects.

Interview on 8/15/18 at 10:48 AM with the facility's Psychiatrist revealed, clothes are inspected on the unit when a kid elopes and then put on a number of precautions including for Suicidal Ideation, Assault, and Elopement.
He stated he can't answer regarding inspection during admission process. He stated once there was knowledge of ingestion behavior, they usually are placed on a number of precautions including but not limited to blue scrubs, finger foods (no plastic utensils).
He said treatment team would determine if there is a need or scrubs, finger foods, other precautions. Treatment team is MD, nurse, and therapist.


Record review of the facility policy, titled Provision of Care, Treatment and Services PC-49A. The policy states in part....the facilty prohibits contraband on the units, Contraband is defined as any items that could be considered physically, emotionally, or pyschologically dangerous....the facility policy further defines contraband to include....razors and pencil sharpeners.


Record review of the facility policy, titled, Provision of Care, Treatment and Services PC-49, last reviewed on January 2015...which states in part....Full body searches shall require removal of clothes with a full visual inspection of the patient's body including the inspection of clothing and property carried by the patient. Full body searches shall be conducted on all admissions.


Record review of the facility's policys revealed the facility did not have a PICA policy.