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HORSHAM CLINIC 722 EAST BUTLER PIKE AMBLER, PA Feb. 12, 2015
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, review of facility documents, review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to provide appropriate interventions and adequate supervision to maintain a safe environment for a patient identified with suicidal ideation and a history of drug abuse for one of twelve medical records reviewed (MR1).
Findings include:
Review of the facility's policy "Patient Visitors," dated January 2015, revealed "Procedure: ... 10. staff must monitor their patients closely during and after visiting hours observing for any reactions related to their visiting and document in the medical record." .
Review of the facility's policy "Detoxification Protocols," dated January 2014, revealed "Procedure: ... 3. The patient will be directly observed by staff at least once every fifteen minutes...".
Review of the facility's policy "Personal Search," dated August 2011, revealed " Policy: The Horsham Clinic will conduct personal searches to maintain the safety of all patients, staff and visitors. Purpose: To define a mechanism to: 1. Insure the safety of all patients and staff by preventing the introduction of harmful material to the treatment units. ... Procedure: 1. A personal search should be conducted on all patients: a. Upon admission to the program ... c. Demonstrating signs of drug or alcohol abuse ... g. Upon order of SIP status 2. Staff will conduct the personal search as follows: ... b. Families and friends will be engaged in the process of identifying contraband prior to the start of a personal search. ... d. ... Note: If the patient is admitted on , or is placed, on elopement or SIP precautions, additional precautions are taken ..."
Review of the facility's policy "Suicide Assessment / Self-Injury Precautions," approved August 2013, revealed "Policy: Staff have the responsibility to recognize suicidal feelings and observe for suicidal behaviors in patients. Patients will be assessed and evaluated to determine dangerousness to self and presence of suicidal ideation. If an individual is determined to present danger to self, staff will supervise him, until potential for self-injury is determined, per evaluation of attending physician. Purpose: To maintain patient safety, Definitions: SIP: Suicidal ideation is present. The patient's ability to maintain control is questionable. Patient does not demonstrate an imminent risk. The patient will be observed minimally every fifteen (15) minutes. In addition to observation, standards of professional care require behavioral assessment, the provision of necessary intervention, and insuring patient safety.".
Review of MR1's "Attending Psychiatrist Evaluation /Admission History and Examination," dated January 19, 2015, revealed that the patient was "... alert, oriented, intellectual, able to concentrate, but very, very depressed. Patient stated on admission ... was addicted to Oxycodone because ... back issues. "
Review of MR1's "Clinical Group Note," dated January 21, 2015, at 1300, revealed "Behavior ...Withdrawn ...Negative peer interaction ...Affect ...Sedated ...Cognition Sedated ... "
Review of MR1's "Psychiatry Progress Note," dated January 22, 2015, revealed "The patient remains calm withdrawn, but cooperative. SI (Suicidal Ideation) no plan. Mood ok. Thought Process Linear... Cognition is intact."
Review of MR1's "Clinical Group Note," dated January 22, 2015, at 1300, revealed " ...Affect ...Sedated ...Cognition Impaired Memory ...Confused ...Impaired Judgment ... " .
Review of MR1's "Code White/ Medical Emergency Documentation Form,"dated January 22, 2015, at 7:23 PM, revealed "... a Code White was called and patient was found to be pulseless and unresponsive. Facility staff administered CPR only and a carotid pulse was found. AED pads were placed on the patient's chest and the AED directed not to shock the patient. EMT arrived at 7:38 PM and inserted an IV and administered Narcan 1 mg. at 7:42 PM patient started to respond with moaning sounds and started to mumble. At 7:45 PM patient was being transported off the unit.".
Interview on February 11, 2015, at 12:30 PM, with OTH1, revealed that when OTH1 left for the day that the patient was in "high spirits." OTH1 indicated that MR1 used a visitor to bring contraband drugs into the facility. MR1 refused to tell the facility who the visitor was that brought the drugs into the facility.

Interview on February 12, 2015, at 1:30 PM , with EMP1 confirmed that visitations occur in specific areas of the facility, the Kitchen and in Group Rooms. Observation revealed that there are cameras in these areas. Interview with EMP1 revealed that the cameras are not always monitored because staff may need to tend to other patients. Visits are supposed to be closely monitored, but staff may need to leave the visitation areas in order to tend to other patient needs.

The facility failed to provide appropriate interventions and adequate supervision of patients and visitors in order to maintain a safe environment and ensure this patient's safety.