The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

NORWOOD HOSPITAL 800 WASHINGTON STREET NORWOOD, MA 02062 July 18, 2012
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on documentation review, interviews and observations of Emergency Department (ED) patients, Immediate Jeopardy was determined because the Hospital failed to ensure that:
1.) items posing potential danger to a suicidal patient were removed from 1 of 8 ED behavioral health patients deemed suicidal in accordance with the Hospital's policy/procedure titled "Homicidal/Suicide Precautions in a Non-Psychiatric Setting" resulting in a drug overdose.
2.) 6 of 8 ED behavioral health patients deemed suicidal were supervised in accordance with the Hospital's policy/procedure titled "Homicidal/Suicide Precautions in a Non-Psychiatric Setting".
3.) a physician or other licensed independent practitioner's order was obtained for the application of 1 of 3 ED behavioral health emergency physical restraint applications.
4.) a patient in simultaneous restraint and seclusion (Patient #1) was continually monitored face-to-face or by both video and audio equipment.

Please refer to Tags A-0144, A-0168 and A-0183 for details.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on documentation review, interviews and observations of Emergency Department (ED) patients, it was determined that the Hospital failed to ensure that:
1.) items posing potential danger to a suicidal patient were removed from 1 of 8 ED behavioral health patients deemed suicidal (Patient #2) in accordance with the Hospital's policy/procedure titled "Homicidal/Suicide Precautions in a Non-Psychiatric Setting" resulting in a drug overdose.
2.) 6 of 8 ED behavioral health patients deemed suicidal (Patient's #1, #2, #5, #6, #7 and #8) were not supervised in accordance with the Hospital's policy/procedure titled "Homicidal/Suicide Precautions in a Non-Psychiatric Setting".

Findings include:

The Hospital's policy/procedure titled "Homicidal/Suicide Precautions in a Non-Psychiatric Setting" indicated that patients expressing suicidal ideation are to be placed on constant visual observation, within arm's length of a staff member, at all times (including when the patient is in the bathroom). The physician is to order the observation and a psychiatric consultation. The policy/procedure also indicated that items posing a potential danger to the patient were to be removed from the patient and environment.

PATIENT #1:

An Ambulance Trip Report dated 6/23/12 indicated that Emergency Medical Service (EMS) personnel were summoned at 2:30 A.M. because Patient #1 was found intoxicated and with facial trauma by police. Patient #1 was combative and stated that he/she was going to kill himself/herself. Patient #1 was transported to the Hospital's ED.

ED Triage documentation dated 6/23/12 at 3:14 A.M. indicated that Patient #1 was agitated and anxious. Patient #1 answered no when asked if he/she had tried to hurt himself/herself and denied doing so in the past.

A Confidential Patient Observation/Restraint Form dated 6/23/12 indicated that Patient #1 was placed on Observation at 3:15 A.M. by ED Registered Nurse (RN) #1 because Patient #1 exhibited serious suicidal ideation and/or behavior. Documentation on the Form indicated that the observation was to be provided by Security staff and the security officer was to remain outside the room. Patient #1 could use the bathroom but if he/she attempted to leave the ED, he/she was to be physically restrained and ED staff were to be notified. The documentation also indicated that the room was cleared of all possible hazards, Patient #1 was searched and placed in a hospital gown, and Patient #1's belongings were removed from the room and secured.

ED Physician documentation dated 6/23/12 indicated that Patient #1 was evaluated by ED Physician #1 at 3:20 A.M. Patient #1 was awake and angry and indicated that he/she wanted to die. Patient #1 had bruising on the nose and forehead and a small laceration through the right eyebrow. ED Physician #1 ordered diagnostic and treatment interventions and completed an Application for and Authorization of Temporary Involuntary hospitalization (commonly known as a Section 12a; a form that when properly completed mandates an involuntary hospitalization until a formal psychiatric evaluation is completed). The Section 12a Form indicated that Patient #1 was at substantial risk of physical harm secondary to suicidal ideation and impaired judgement.

A review of Patient #1's ED Physician Orders did not evidence an order for a specific type or level of Patient Observation.

ED Physician documentation dated 6/23/12 indicated that Patient #1 was diagnosed with alcohol intoxication, facial fractures and suicidal ideation. Patient #1 was medically cleared for a psychiatric evaluation at 7:00 A.M.

ED Nursing documentation dated 6/23/12 indicated that a clinician from the Contracted Psychiatric Service tried to evaluate Patient #1 sometime prior to 10:30 A.M., but Patient #1 was too sleepy. At 10:30 A.M., Patient #1 asked for his/her underwear and a security officer provided his/her belongings bag. Patient #1 put on underwear and a pair of shorts and proceeded to leave the ED. Patient #1 was ordered to stop, but took flight. Patient #1 was apprehended by a security officer and put in 4-point leather restraints. Patient #1 was evaluated by ED Physician #2 and administered intramuscular Ativan (an anti-anxiety/sedative medication).

Patient #1's 6/23/12 Confidential Patient Observation/Restraint Form was not updated to indicate that he/she was a significant flight risk.

ED Nursing documentation dated 6/23/12 indicated that all of Patient #1's restraints were removed by 11:20 A.M.

A Psychiatric assessment dated [DATE] indicated that Patient #1 was evaluated by the Contracted Psychiatric Service at 12:20 P.M. Patient #1 was cooperative and indicated that he/she wanted to go home. The psychiatric clinician assessed Patient #1 to be at a low risk for suicide and discussed discharge planning with an (un-named) ED physician. The ED physician indicated that he wanted Patient #1 admitted for safety and containment. The Section 12a was continued and an inpatient psychiatric bed search was initiated.

ED Nursing documentation dated 6/23/12 indicated that Patient #1 eloped from the ED at 6:24 P.M. The documentation also indicated that security staff were busy with another behavioral health patient at the time of Patient #1's elopement.

ED Nursing documentation dated 6/23/12 indicated that Patient #1 was located by local police and returned to the ED under a Section 12a at 8:43 P.M. Patient #1 was unharmed.

The Hospital's Risk Manager was interviewed in person on 7/17/12 at 8:20 A.M. The Risk Manager said a Hospital Internal Investigation was conducted regarding Patient #1's 6/23/12 ED care/elopement.

A review of the Hospital Internal Investigation revealed it determined that ED security staff/behavioral health patient ratios were often high and that this made effective constant observation impossible. The Investigation also determined that there were hand-off communication issues related to Patient #1's flight risk. A Corrective Action Plan was not developed/implemented.

The Hospital Internal Investigation did not determine that: a.) Patient #1 was not supervised in accordance with the Hospital's policy/procedure titled "Homicidal/Suicide Precautions in a Non-Psychiatric Setting", b.) ED Physician #1 did not order a specific type or level of observation for Patient #1 and c.) the security officer did not consult with Patient #1's nurse regarding giving Patient #1 his/her belongings bag.


PATIENT #2:

ED Triage documentation dated 6/21/12 indicated that Patient #2 was brought to the ED by EMS personnel and police at 10:59 P.M. because he/she had been drinking alcohol and fell sustaining an ankle injury. The police indicated that Patient #2 may have also been using cocaine and that he/she had texted suicidal messages to a family member. Patient #2 answered no when asked if he/she had tried to hurt himself/herself and denied doing so in the past.

An ED Nursing assessment dated [DATE] indicated that Patient #2 had a history of anxiety and depression.

The ED RN assigned to Patient #2 (ED RN #1) was interviewed in person on 7/17/12 at 3:00 P.M. ED RN #1 said that she questioned Patient #2 about being suicidal and Patient #2 denied suicidal ideation. ED RN #1 said that Patient #2 indicated that he/she was having marital problems and following an altercation with his/her spouse, he/she texted a family member and said something like he/she was ready to kill himself/herself. ED RN #1 said that Patient #2 indicated that he/she was not serious about killing himself/herself and that he/she would never do such a thing as he/she had 3 young children.

ED RN #1 reported getting Patient #2 settled and giving a verbal report regarding Patient #2 to ED RN #2.

Documentation completed by ED Physician #3 on 6/21/12 (time not indicated) indicated that Patient #2's spouse and sibling said that Patient #2 had been exhibiting self-injurious behaviors. ED Physician #3 ordered diagnostic procedures and completed a Section 12a. The Section 12a was timed 11:35 P.M. and indicated that Patient #2 was at substantial risk of physical harm secondary to suicidal ideation.

A review of Patient #2's ED Physician Orders did not evidence an order for a specific type or level of Patient Observation.

Laboratory testing dated 6/22/12 indicated Patient #2 tested positive for cocaine (a narcotic) and benzodiazepines (a class of anti-anxiety/sedative medications).

ED RN #2 was interviewed in person on 7/18/12 at 8:00 A.M. ED RN #2 said that she received a verbal report regarding Patient #2 from ED RN #1 around 11:00 P.M. ED RN #2 said that ED RN #1 indicated Patient #2 arrived in the ED under a Section 12a, in police custody with an ankle injury and possible drug overdose.

ED RN #2 said that shortly after getting report from ED RN #1, she observed Patient #2 standing at the end of his/her stretcher in the Behavioral Health Treatment Area (BHTA), looking like he/she might be getting ready to leave. ED RN #2 reported asking the security officer covering the BHTA (Security Officer #1) if he was watching Patient #2. ED RN #2 said that Security Officer #1 indicated that Patient #2 was not on a Security Watch. ED RN #2 reported informing Security Officer #1 that Patient #2 needed to be on a Security Watch and filling out a Confidential Patient Observation/Restraint Form.

A Confidential Patient Observation/Restraint Form dated 6/22/12 indicated that Patient #2 was placed on Observation at 12:45 A.M. by ED RN #2 because Patient #2 was a significant flight risk. Documentation on the Form indicated that the observation was to be provided by Security staff and the security officer was to remain outside the room. Patient #2 could use the bathroom and was not to be restrained if he/she attempted to leave. The documentation also indicated that the room was cleared of all possible hazards, Patient #2 was searched and placed in a hospital gown, and Patient #2's belongings were removed and secured.

ED RN #2 said that Patient #2 was wearing his/her clothes when she filled out the Confidential Patient Observation/Restraint Form. ED RN #2 said that Security Officer #1 told Patient #2 that he/she needed to change into hospital scrubs. ED RN #2 said that Patient #2 indicated that he/she did not want to change into the scrubs and wanted to talk with his/her spouse. ED RN #2 said the Spouse was in the ED Waiting Room and she summoned him/her for Patient #2.

ED RN #2 said that she completed the 6/22/12 Confidential Patient Observation/Restraint Form without verifying that Patient #2's belongings were removed and secured. ED RN #2 said that she did this because she thought Patient #2 had arrived on a Section 12a and ED RN #1 had secured the belongings and forgot to document. ED RN #2 also said that she knew Patient #2 was thought to be suicidal and she should have indicated this on the Confidential Patient Observation/Restraint Form.

ED RN #2 said that Patient #2 spoke with his/her spouse twice and then went into the BHTA bathroom to put on scrubs.

Documentation completed by ED RN #2 on 6/22/12 indicated that at 2:15 A.M., a security officer reported that Patient #2 went into the bathroom with a personal bag and shortly after emerging, had slurred speech.

Documentation completed by ED Physician #3 on 6/22/12 indicated that Patient #2's slurred speech was evaluated and determined to be secondary to the ingestion of multiple tablets of Xanax (a benzodiazepine medication) in the bathroom. Emergency treatment interventions were provided. Patient #2 required intubation (the insertion of a tube into the airway to facilitate breathing) and mechanical ventilation (a breathing machine) for respiratory depression. Patient #2 was transferred to the Intensive Care Unit (ICU).

ICU documentation dated 6/23/12 indicated that Patient #2 was extubated (the breathing tube and mechanical ventilation were discontinued) on 6/22/12 and transferred to a General Medical Unit in stable condition on 6/23/12. A Psychiatric Unit transfer was planned.

The Hospital's Risk Manager said a Hospital Internal Investigation was conducted regarding Patient #2's 6/21/12-6/22/12 ED care/overdose.

A review of the Hospital Internal Investigation revealed that it determined that items posing potential danger to a suicidal patient were not removed from Patient #2 and that there were several hand-off communication issues related to Patient #2's care. A Corrective Action Plan was not developed/implemented.

The Hospital Internal Investigation did not determine that Patient #2 was not supervised in accordance with the Hospital's policy/procedure titled "Homicidal/Suicide Precautions in a Non-Psychiatric Setting" and/or that ED Physician #3 did not order a specific type or level of observation for Patient #2.


PATIENTS #5, #6, #7 and #8:

A Tour of the ED conducted on 7/16/12 at 8:15 A.M. revealed a large Department with 25+ treatment areas including a 4-room BHTA along a hallway off the Main ED. BHTA rooms #2 and #4 and the BHTA bathroom were on the left side of the hallway and BHTA rooms #1 and #3 were on the right side. All of the BHTA rooms had doors and were "safe rooms" (rooms without equipment that could be hazardous to impaired or suicidal patients). BHTA rooms #2 and #4 had observation windows. Security Officer #2 was posted in the BHTA. Security Officer #2 was sitting between BHTA rooms #2 and #4, near the BHTA bathroom, facing the Main ED.

Continued tour of the ED revealed there were 5 patients in the BHTA (Patients #3, #4, #5 and #6) and 1 behavioral health patient in the Main ED (Patient #8). One of the patients in the BHTA was on a stretcher in the hallway and the other 4 patients were in BHTA rooms #1-#4.

During the tour of the BHTA, the ED Nurse Manager asked Security Officer #2 if someone was in the bathroom and Security Officer #2 indicated that he did not know.


PATIENT #5:

A Section 12a Form completed on 7/14/12 (not timed) indicated that Patient #5 was at substantial risk of physical harm secondary to suicidal ideation.

A Psychiatric assessment dated [DATE] at 2:30 P.M. indicated that Patient #5 was at high risk for suicide.

During the 7/16/12 ED tour, Patient #5 was observed to be in BHTA room #1. The door to the room was open approximately 2 inches and the room was dark. Patient #5 was not on constant visual observation within arm's length of a staff member. Security Officer #2 could not see Patient #5 from where he was sitting.


PATIENT #6:

A Section 12a Form completed on 7/15/12 at 1:00 P.M. indicated that Patient #6 was at substantial risk of physical harm secondary to suicidal ideation.

A Psychiatric assessment dated [DATE] at 7:21 P.M. indicated that Patient #6 was at high risk for suicide.

During the 7/16/12 ED tour, Patient #6 was observed to be in BHTA room #4. Patient #5 was not on constant visual observation within arm's length of a staff member.


PATIENT #7:

A Section 12a Form completed on 7/15/12 at 4:15 P.M. indicated that Patient #7 was at substantial risk of physical harm secondary to suicidal ideation.

A Psychiatric assessment dated [DATE] at 5:23 P.M. indicated that Patient #7 was at moderate risk for suicide.

During the 7/16/12 ED tour, Patient #7 was observed to be in BHTA room #3. The door to the room was partially closed. Patient #7 was not on constant visual observation within arm's length of a staff member. Security Officer #2 could not see Patient #7 from where he was sitting.


PATIENT #8:

A Section 12a Form completed on 7/16/12 at 1:25 A.M. indicated that Patient #8 was at substantial risk of physical harm secondary to suicidal ideation.

ED physician documentation dated 7/16/12 indicated that a Psychiatric Assessment was ordered for Patient #8.

During the 7/16/12 ED tour, Patient #8 was observed to be in Main ED treatment room #3. The large glass door to the room was closed and the room was darkened. A mental health counselor was sitting in a chair outside of the room and across the hallway. Patient #8 was not on constant visual observation within arm's length of a staff member.

Following the 7/16/12 ED tour, the Surveyors informed the Hospital System's Regional Director of Quality & Patient Safety and the Hospital's Director of Quality of concerns regarding the Hospital Internal Investigations related to Patients #1 and #2 and the monitoring of suicidal patients in the ED. Within a short period of time, all patients deemed suicidal in all non-psychiatric Hospital settings were placed on one-to-one observation within arm's length of the staff member.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on documentation review, it was determined that the Hospital failed to ensure that a physician or other licensed independent practitioner's order was obtained for the application of 1 of 3 Emergency Department (ED) behavioral health emergency physical restraint applications (related to Patient #1).

Findings include:

Please see Tag A-0144 for information regarding Patient #1.

An Application for and Authorization of Temporary Involuntary hospitalization (commonly known as a Section 12a; a form that when properly completed mandates an involuntary hospitalization until a formal psychiatric evaluation is completed) completed by ED Physician #1 on 6/23/12 at 3:30 A.M. indicated that Patient #1 was at substantial risk of physical harm secondary to suicidal ideation and impaired judgement.

ED Nursing documentation dated 6/23/12 indicated that at 10:30 A.M., Patient #1 asked for his/her underwear and a security officer provided his/her belongings bag. Patient #1 put on underwear and a pair of shorts and proceeded to leave the ED. Patient #1 was ordered to stop, but took flight. Patient #1 was apprehended by a security officer and put in 4-point leather restraints.

A review of Patient #1's ED Physician Orders did not evidence an order for the 4-point leather restraints.

ED Nursing documentation dated 6/23/12 indicated that Patient #1 was evaluated by ED Physician #2 almost immediately after being placed in the 4-point leather restraints.

A review of the Hospital Internal Investigation related to Patient #1's 6/23/12 ED care/elopement revealed that it identified that there was no written physician or other licensed independent practitioner's order for the emergency behavioral health restraints applied to Patient #1 shortly after 10:30 A.M. on 6/23/12. A Corrective Action Plan was not developed/implemented.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0183
Based on documentation review, it was determined that the Hospital failed to ensure that a patient in simultaneous restraint and seclusion (Patient #1) was continually monitored face-to-face or by both video and audio equipment.

Findings include:

Please see Tags A-0144 and A-0168 for information regarding Patient #1.

An Application for and Authorization of Temporary Involuntary hospitalization (commonly known as a Section 12a; a form that when properly completed mandates an involuntary hospitalization until a formal psychiatric evaluation is completed) completed by ED Physician #1 on 6/23/12 at 3:30 A.M. indicated that Patient #1 was at substantial risk of physical harm secondary to suicidal ideation and impaired judgement.

Emergency Department (ED) Nursing and Physician Notes, ED Physician Orders, a Restraint Documentation Flow Sheet and a Confidential Patient Observation/Restraint Form dated 6/23/12 indicated that Patient #1 was simultaneously restrained and secluded for 3 periods of time on 6/23/12. The restraint episodes commenced at 3:30 A.M., shortly after 10:30 A.M. and at 8:50 P.M.

ED documentation did not indicate that Patient #1 was on face-to-face (one-to-one) monitoring at any time on 6/23/12.