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.

Based on interview and document review, the hospital failed to protect the right of a patient to receive care in a safe setting for one of eleven patients reviewed, P1. The hospital did not ensure that the patient was adequately supervised and monitored prior to the patient ingesting foreign objects on three separate occasions while hospitalized on the Behavioral Health Unit. The hospital was found not in substantial compliance with the Condition of Participation of Patient Rights at 42 CFR 482.13.

Findings include:

The hospital failed to protect and promote the right to receive care in a safe setting for 1 of 11 patients reviewed. Staff failed to implement adequate monitoring and supervision measures for P1, who had an extensive history of self-injurious behavior and ingestion of foreign objects. P1's physician's order indicated P1 was to be on independent observation status (IOS), meaning 1:1 staff monitoring. The physician's order initially stated staff were to provide 1:1 supervision of P1 at a distance of five feet but following a 10/1/18 ingestion incident the distance was changed to one foot. P1's additional ingestion incidents on 10/7/18 and 10/20/18 indicated the 1:1 staff monitoring of P1 at a distance of one foot was not adequate and effective. P1 was eventually changed to 2:1 staff monitoring on 10/28/18. Refer to the deficiency issued at A144.
Based on interview and document review, the hospital failed to provide adequate monitoring and supervision to prevent 1 of 11 patients reviewed (P1) from self injurious behavior and ingesting foreign objects.

Findings include:

P1's hospital record indicated patient #1's diagnoses include schizoaffective disorder, bipolar disorder, borderline personality disorder, borderline intellectual functioning and self injurious behavior. The patient presented to the Emergency Department (ED) on 9/22/18 with a complaint of suicidal ideation and was placed on every fifteen minute checks. The record indicated P1 had a history of many hospital admissions at various hospitals related to psychiatric problems. P1 was transferred from the ED to the Behavioral Health Unit and was placed on status individual observation (SIO), which included 1:1 staff observation at a distance of five feet following admission to the unit.

P1's progress note dated 10/1/18 and written at 10:09 p.m. indicated P1 removed four AA batteries from the sound machine that was in her room and swallowed the batteries at about 5:00 p.m. on 10/1/18. An x-ray of P1's stomach confirmed that the batteries were in P1's stomach and that an upper endoscopy would be needed if the batteries were still present in her stomach on 10/2/18. A progress note dated 10/2/18 indicated an upper endoscopy was performed on 10/2/18, and the four batteries were removed from P1's stomach.

A physician's order dated 10/2/18 and written by nurse practitioner (C) at 9:27 a.m. indicated P1's 1:1 staff observation status was changed from five feet to a distance of one foot.

A progress notes dated 10/7/18 and 10/8/18 indicated P1 reported to staff that she swallowed two plastic marker caps that she took without staff knowledge and placed in her underwear before ingesting them. X-ray did not reveal any radiopaque objects in her stomach.

A progress note dated 10/20/18 indicated P1 reported to staff that she ingested a piece of metal that she had removed from a face mask. Staff had given the face mask to P1 when she had a cough, and staff forgot to remove the face mask from P1's room. An abdominal x-ray was ordered and on 10/21/18 a combined esophagostomy, gastroscopy and duodenoscopy were performed under general anesthesia for removal of the metal piece. A 10/21/18 progress note indicated a coil of wire and two marker caps were removed from P1's stomach during the procedure.

A physician's order dated 10/26/18 was reviewed and indicated P1's staff observation status was changed from 1:1 to 2:1 at a distance of one foot and without any exceptions due to P1's history of ingesting objects.

When interviewed in person on 11/6/18, at 11:00 a.m., nurse practitioner (NP-C) stated P1 has a history of self- injurious behavior and ingestion of foreign objects. (NP-C) stated she determined that staff were not consistently supervising and monitoring P1 in accordance with (C's) status individual observation (SIO) orders. P1's ingestion incidents were the result of inconsistent monitoring and supervision. P1 has not had any additional ingestion incidents since the status individual observation was changed to 2:1.

The hospital policy titled Level of Observation and Patient Care Alerts on Inpatient Units, dated June 1990, and revised in October 2018, identified foreign body ingestion precautions and included the following: 1) Status individual observation 2) Evaluate for mitts 3) Finger foods 4) No silverware or plastic utensils on patient's food tray 5) Remove items which may be ingested (in whole or in pieces) including: remote controls, batteries, cell phones, pens, pencils, ID badges, toothbrush, toothpaste, etc.