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.

DANVILLE STATE HOSPITAL 50 KIRKBRIDE DRIVE DANVILLE, PA 17821 Dec. 28, 2011
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined that the facility failed to ensure a safe environment was provided for one of 11 applicable medical record reviewed (MR1).

Findings include:

Review on December 28, 2011, of the facility's "Information Booklet for Consumers and Families Danville State Hospital," last revised September 2011, revealed "... Visitors ... To help ensure a safe and therapeutic visitation process, the following guidelines have been put into effect. Your attention and cooperation is appreciated. ... All items brought into the hospital for consumers shall be reviewed by hospital Safety and Security Staff prior to the actual visit. ... Any items considered to be contraband, or are contraindicated for the consumer you wish to visit, are not permitted. ... Failure to cooperate with these guidelines may result in the visit being denied. Your full cooperation is anticipated. ..."

Review on December 28, 2011, of the facility's "Search of Consumers and Disposition of Contraband" policy, last reviewed April 20, 2011, revealed "Definition: Contraband is defined by the Office of Mental Health and Substance Abuse Services (OMHSAS) as anything that would be illegal or dangerous in the possession of a consumer, and/or is prohibited by the hospital. Contraband includes: but is not limited to: plastic bags, knives, firearms, weapons of any design, matches/cigarette lighters, tobacco, tobacco products, glass containers/items containing glass, sharps of any type (e.g. scissors, nail files, nail clippers), any type of hand tool, rope, cord, twine, chain or other items that may be used to choke or harm, razors, electrical devices, alcoholic beverages of any liquids/substances containing alcohol, any type of solvent, paint, glue, aerosols, controlled substances/medications and drugs (including over-the-counter) not prescribed by the hospital physicians, cameras, audio and /or video recording devices, , [sic] cell phones, computers, any potentially dangerous items, and/or any other items addressed in the individualized treatment plan as contraband. ... Policy: A search of consumers, their belongings, assigned sleeping quarters and storage areas shall only be conducted if there is reasonable cause to suspect contraband or conditions that may constitute a threat to health and safety. ..."

Review on December 28, 2011, of the facility's "Letting Persons on/off Unit Areas" policy, last revised October 27, 2011, revealed "Policy: It is the policy of Danville State Hospital to insure that all persons entering or leaving consumer areas are authorized to do so. Procedure: ... 2. Visitors: ... Items brought into the facility for a person currently receiving treatment within the hospital, shall be reviewed by Safety / Security staff. ... Unit staff shall escort the visitor from the Communication Center to the designated visitor location; ensuring items brought by the visitor are accurately recorded, labeled, and stored. ..."

Review on December 28, 2011, of the facility's "Search of Visitors" policy, last reviewed April 20, 2011, revealed "Policy: Random or routine searches are prohibited. It is required for staff to establish "reasonable cause" to suspect contraband before a search. ... Procedure: 1. Visitors may only be subject to a personal search with their permission, and only when there is reasonable cause to suspect contraband ... 4. If a visitor refuses to be searched, he or she shall be prohibited access to the facility during that visit and the consumer to be visited shall be notified of the cancelled visit. ..."

Review on December 28, 2011, revealed MR1 was admitted to the facility on on [DATE], for the treatment of major depression, anxiety disorder, personality disorder and attempted suicide on several occasions prior to admission to this hospital. Further review of MR1 revealed that during the course of MR1's stay at Danville State Hospital, MR1 swallowed a quarter thinking that it would block the airway; drank a bottle of lotion in an attempt to kill self; and drank a bottle of nail polish while on leave of absence with family.

Review on December 28, 2011, revealed on July 20, 2011, MR1 swallowed approximately 50 milliliters (ml) of hair color containing isopropyl alcohol, oleic acid, propylene glycol and other chemicals with the intention to kill self. Shortly following the ingestion of the hair color, MR1 experienced a generalized seizure and was transported to a local hospital for further evaluation and treatment. MR1 was admitted to the local hospital. MR1 experienced difficulty breathing and was placed on a ventilator (a breathing machine). MR1 died 11 days after ingesting the hair color.

Review on December 28, 2011, of the facility's investigation revealed a family member brought in hair color for MR1 the previous day; that the family member did not make facility staff aware of the hair color; and that the family member gave the bottle of hair color to MR1.

Interview with EMP1, EMP2, EMP3 and EMP4 on December 28, 2011, at approximately 11:00 AM confirmed that MR1 swallowed approximately 50 ml of hair color; that MR1 experienced a generalized seizure and was transported to a local hospital for further evaluation and treatment; that MR1 experienced difficulty breathing; was placed on a ventilator and that MR1 died 11 days after ingesting the hair color. Further interview with EMP1, EMP2, EMP3 and EMP4 confirmed the facility's investigation revealed a family member brought in hair color for MR1 the previous day; that the family member did not make facility staff aware of the hair color; and that the family member gave the bottle of hair color to MR1.