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.

EASTERN STATE HOSPITAL 1350 BULL LEA ROAD LEXINGTON, KY 40511 April 13, 2017
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on interview, record review, and review of facility Policy, it was determined the facility failed to ensure competent nursing care was provided for one (1) of ten (10) sampled patients (Patient #3).

Patient #3 was on close observation for suicidal ideation on 04/09/17 and staff were to keep the patient in visual contact at all times due to moderate risk of self-harm. Although staff had been educated during orientation related to the Patient Supervision Policy and close observation, staff allowed Patient #3 privacy, resulting in Patient #3 removing stitches from his/her left arm.

The findings include:

Review of the facility Policy, titled Patient Supervision, undated, revealed close observation may be used for medical and behavioral purposes when a patient was at moderate risk for injury. The Policy further stated staff assigned to close observation were required to continually have patients in clear view and within twelve (12) feet.

Review of Patient #3's medical record revealed the facility admitted the patient on 04/05/17 with diagnoses to include Substance Induced Mood Disorder and Suicidal Ideation. Further review of the medical record revealed Patient #3 had been admitted from another hospital with self-inflicted lacerations to both wrists which had required sutures. Continued review revealed he/she was admitted on safety level, restricted to unit, on close observation as he/she was suicidal.

Review of the Provider Order for Level of Supervision dated 04/05/17, revealed Patient #3 had made suicidal statements and stated he/she would find something to cut his/her wrist with, and was placed on close observation.

The Progress Note dated 04/06/17, revealed the patient had a diagnoses of Drug -Induced Mood Disorder and made statements that he/she was suicidal. Further review of the Progress Note revealed Patient #3 had bandaging to both wrists covering self-inflicted lacerations which had required sutures on 04/04/17 prior to admission.

Review of the Patient Supervision Record from 04/05/17 until 04/09/17 revealed Patient #3 was on close observation as he/she was high risk for self-harm. Continued review of Patient Supervision Record revealed Patient #3 remained on close observation up until the incident on 04/09/17.

Review of the facility Incident Report Form, dated 04/09/17 at 8:30 PM, revealed Patient #3 was on close observation when MHA #4 entered the patient's bathroom to find the patient had pulled out the sutures on his/her left wrist and exposed a deep wound with bleeding. A second Incident Report Form, dated 04/09/17 at 10:15 PM, regarding the same incident, revealed when MHA #4 arrived to replace MHA #3, Patient #3 was not visible as he/she was in the bathroom and MHA #3 was standing by the door.

Interview with MHA #3 on 04/12/17 at 2:30 PM revealed Patient #3 had reported to her he/she needed to defecate at 7:20 PM on 04/09/17, and she allowed him/her to do so with the door closed. She revealed she asked through the door if Patient #3 was alright, and received the reply that he/she was alright. MHA #3 further stated she was aware Patient #3 was on close observation, which meant he/she was to be within twelve (12) feet and in view at all times, but she wanted to provide privacy for patient to toilet. She stated her shift ended at 7:30 PM, at which time MHA #4 was present to replace her.

Interview with MHA #4, on 04/12/17 at 2:45 PM, revealed he came in to relieve MHA #3 at 7:30 PM on 04/09/17, at which time Patient #3 was in his/her bathroom with the door ajar. MHA #4 stated MHA #3 reported to him the patient was having a bowel movement and apparently having some difficulty. MHA #4 stated he asked Patient #3 if he/she was alright through the door, and Patient #3 responded that he/she was alright. MHA #4 further stated he was distracted for a couple of minutes by Patient #3's roommate, who wanted to talk, but at approximately 7:33 PM he asked Patient #3 if he could open the door, and Patient #3 stated "yes". MHA #4 stated Patient #3 was seated on the floor of his/her bathroom with his/her back to the wall. Per interview, the patient's left wrist was open where sutures had been removed, and he/she was picking at the wound with his/her right hand. MHA #4 stated he rushed over to help Patient #3, and Patient #3's roommate went to get help, which arrived quickly. Further interview revealed Patient #3 was sent out to the emergency room . When questioned about policy, MHA #4 revealed he was aware he had to be within twelve (12) feet of a patient on close observation, but at the time of the incident was not certain about having to keep eyes on the patient while in the bathroom.

Review of Mental Health Associate (MHA) #3's orientation packet, initiated 12/01/16 and completed on 12/07/16, revealed on 12/05/17 MHA #3 was educated on Patient Supervision, to include keeping patients in sight at all times when on close observation or one-on-one.

Review of MHA #4's orientation packet, initiated on 11/20/16 and completed on 11/30/16, revealed on 11/20/16 MHA #4 was educated on Patient Supervision, to include keeping patients in sight at all times when on close observation or one-on-one.

Interview with MHA #1 on 04/11/17 at 2:22 PM, revealed she was on day two (2) of her orientation, and had already been trained on patient supervision. Per interview the different levels of supervision included close observation, which required patients to be within twelve (12) feet and within eyesight at all times.

Interview with MHA #5 on 04/13/17 at 7:57 AM revealed close observation required staff to be within twelve (12) feet of patients with eyes on them at all times. He revealed, since Patient #3's return from the hospital, he/she has been moved up to one-on-one supervision, requiring staff to be within arms reach with eyes on the patient at all times. He revealed, due to Patient #3's incident, the patient also had to always have one (1) hand visible and could not keep both hands under blankets while sleeping.

Interview with the Director of Quality, Safety, and Risk Management on 04/12/17 at 8:35 AM, revealed although the policy on Patient Supervision was not dated, it was not new, having last been revised approximately three to four years ago, and it was reviewed at least yearly. She further stated staff who failed to follow the policy had been suspended, and re-education on the supervision policy began the morning of 04/10/17.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interview, record review, and review of facility Policy, it was determined the facility failed to ensure patients received care in a safe setting for one (1) of ten (10) sampled patients (Patient #3).

Patient #3 was on close observation for suicidal ideation on 04/09/17 when staff allowed him/her privacy, resulting in Patient #3 removing stitches from his/her left arm in a suicide attempt.

The findings include:

Review of the facility Policy, titled "Patient Supervision" undated, revealed close observation may be used for medical and behavioral purposes when a patient is at moderate risk for injury. The Policy further stated, staff assigned to close observation were required to continually have patients in clear view and within twelve (12) feet.

Review of Patient #3's medical record revealed the facility admitted the patient on 04/05/17.
with a diagnosis of Substance Abuse Mood Disorder. Further review of the medical record revealed Patient #2 had been admitted from another hospital with self-inflicted lacerations to both wrists which had required sutures. Continued review revealed the patient was admitted on safety level, restricted to unit, on close observation as he/she was suicidal.

Review of the Provider Order for Level of Supervision dated 04/05/17, revealed Patient #3 had made suicidal statements and stated he/she would find something to cut his/her wrist with, and was placed on close observation.

The Progress Note dated 04/06/17, revealed the patient had a diagnoses of Drug -Induced Mood Disorder and made statements that he/she was suicidal. Further review of the Progress Note revealed Patient #3 had bandaging to both wrists covering self-inflicted lacerations which had required sutures on 04/04/17 prior to admission.

Review of the Patient Supervision Record from 04/05/17 until 04/09/17 revealed Patient #3 was on close observation as he/she was high risk for self-harm. Continued review of Patient Supervision Record revealed Patient #3 remained on close observation up until the incident on 04/09/17.

Review of the facility Incident Report Form, dated 04/09/17 at 8:30 PM, completed by the Risk Management Department, revealed Patient #3 was on close observation when Mental Health Associate (MHA) #4 entered the patients bathroom to find the patient had pulled out the sutures on his/her left wrist and exposed a deep wound with bleeding.

A second Incident Report Form, dated 04/09/17 at 10:15 PM, completed by the Risk Management Department, regarding the same incident revealed when MHA #4 arrived to replace MHA #3, Patient #3 was not visible as he/she was in the bathroom and MHA #3 was standing by the door.

Interview with MHA #3 on 04/12/17 at 2:30 PM, revealed Patient #3 had reported to her he/she needed to defecate at 7:20 PM on 04/09/17, and she allowed him/her to do so with the door closed. She stated she asked through the door if Patient #3 was alright, and received the reply that he/she was alright. MHA #3 further stated she was aware Patient #3 was on close observation, which meant he/she was to be within twelve (12) feet and in view at all times, but she wanted to provide privacy for the patient to toilet. She further stated her shift ended at 7:30 PM, at which time MHA #4 was present to replace her. Per interview, MHA #3 then clocked out as it was the end of her shift.

Interview with MHA #4 on 04/12/17 at 2:45 PM, revealed he came in to relieve MHA #3 at 7:30 PM on 04/09/17, at which time Patient #3 was in his/her bathroom with the door ajar. MHS #4 stated MHA #3 reported to him the patient was having a bowel movement and apparrently having some difficulty. MHA #4 revealed he asked Patient #3 if he/she was alright through the door, and Patient #3 responded that he/she was alright. MHA #4 further stated, he was distracted for a couple of minutes by Patient #3's roommate, who wanted to talk, but at approximately 7:33 PM he asked Patient #3 if he could open the door, and Patient #3 stated "yes". Continued interview, revealed Patient #3 was seated on the floor of his/her bathroom with his/her back to the wall. MHA #4 stated the patient's left wrist was open where sutures had been removed and the patient was picking at the wound with the right hand. MHA #4 stated he rushed over to help Patient #3, and Patient #3's roommate went to get help, which arrived quickly. Further interview revealed Patient #3 was sent out to the emergency room . When questioned about policy, MHA #4 revealed he was aware he had to be within twelve (12) feet of a patient on close observation, but at the time of the incidnet was not certain about having to keep eyes on the patient while in the bathroom.

Interview with MHA #5, on 04/13/17 at 7:57 AM, revealed he observed MHA #4 while on tour with Registered Nurse (RN) #5 at shift change, at which point MHA #4 was standing outside Patient #3's bathroom door with the door open a crack just prior to 7:30 PM. He revealed less than ten (10) minutes later, Patient #3's roommate came running up to the nurse's station stating Patient #3 had ripped out his/her sutures. MHA #5 stated he went to the bathroom, saw MHA #4 holding Patient #3's hands to discourage picking at the wound, and he [MHA #5] grabbed a clean towel and began applying pressure to the wound. He revealed RN #5 came in, saw the damage, and called the on call doctor who arrived shortly thereafter. MHA #5 stated following Physician's assessment, orders were received to send the patient sent out to the emergency room .

Interview with the Director of Quality/Safety/Risk Management, on 04/12/17 at 8:35 AM, revealed although the Policy on Patient Supervision was not dated, it was not new. She stated the Policy had last been revised approximately three (3) to four (4) years ago and was reviewed at least yearly. She further stated the staff who failed to follow the policy related to Patient #2 had been suspended, and re-eductaion on the "Patient Supervision" Policy began the morning of 04/10/17.