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.

ST LUKES HOSPITAL 915 EAST 1ST STREET DULUTH, MN 55805 March 14, 2012
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, record review, interview and policy review, the facility failed to ensure patients received adequate supervision in order to provide care in a safe environment for 1 of 10 (#1) patient records reviewed. Findings include:

During a tour of the mental health unit at 2:45 p.m. on 3/7/12, each patient room had an approximate two to three foot square panel in the ceiling that was secured in place with 6 screws and a hidden hinge. The rest of the ceiling was a solid surface.

Review of Patient #1's record revealed the patient was admitted to the mental health unit of the facility on 1/17/12, with diagnoses of post traumatic stress disorder, psychotic disorder with paranoia, polysubstance abuse, depression and a history of suicidal ideation.

Interview with Individual (E) at 10:35 a.m. on 3/13/12, revealed at approximately 3:00 p.m. on 1/19/12, Individual (E) went to visit Patient #1. Patient #1's door to the room was closed and upon entering the room Individual (E) observed the patient standing on the third step of a ladder with the upper half of her body in an open panel in the ceiling. In addition, Individual (E) indicated electrical cords were laying on the floor and Patient #1 was alone in the room. Individual (E) raised her voice to Patient #1 and instructed and assisted her to come off the ladder. Facility staff immediately responded to her raised voice. According to Individual (E), Patient #1 was not injured during the incident.

Interview with Individual (F) at 3:04 p.m. on 3/13/12, revealed she was visiting Patient #1 with Individual (E) on 1/19/12. Individual (F) said Patient #1's door to the room was mostly closed and upon entering the room the patient was observed on a ladder with her upper torso in the ceiling panel. The ladder was under the open ceiling panel and an extension cord and hose that looked like a garden hose were laying on the floor of Patient #1's room. Patient #1 was alone in the room. Facility staff that were in the hallway immediately intervened and were informed of the incident.

Individual (E) and Individual (F) said after visiting Patient #1, the facility staff informed the patient she could be in the open seclusion room or the lounge until the duct work was completed in her room.

Review of Patient #1's record revealed no documentation of the incident.

Interview with the manager of the mental health unit at 2:10 p.m. on 3/7/12, established the hallway where Patient #1 resided was monitored by the physical presence of a staff person 24/7 and every fifteen minute checks were completed for patient safety.

Interview with the manager at 2:45 p.m. on 3/7/12, revealed contracted work was being completed with the ducts on the unit. According to the manager that type of contracted work was rarely done on the unit. When the duct work was being completed on the unit, supervision of patients and close monitoring of the contracted workers was completed. Patients were allowed access to their rooms. In order to complete the duct work, the contracted staff had to open a panel in the ceiling and use a ladder in each patient's room to access the ducts. The manager indicated staff had reported Patient #1 was up 2 to 3 steps on the ladder but was not alone in her room. Staff did not report Patient #1 had been able to access the ceiling panel therefore the occurrence was not documented as an incident.

Review of the facility's policy and procedure titled...Vulnerable Adult Maltreatment..." with an effective date of 7/10, stated, "...Neglect is the failure or omission...to supply the vulnerable adult with care or services, including...supervision which is reasonable and necessary to...maintain the vulnerable adult's physical or mental health and safely..."