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Based on surveyor observation, record review, and staff interview, it has been determined that the hospital failed to maintain and provide care in a safe environment by ensuring adequate supervision of a patient at risk for self-injurious behaviors. The hospital failed to prevent a patient who was on constant observation (ID #1), from obtaining a restricted item (a toothbrush) which she/he swallowed (refer to A-144).

As a result of these findings, and further review with Center for Medicare and Medicaid (CMS) Immediate Jeopardy was identified on April 1, 2022, and removed on April 2, 2022, after the State Survey Agency verified that the hospital had implemented interventions to remove the immediate risk to the health and safety of patients.

Findings include:

Record review for Patient ID# 1 revealed an ongoing physician's order for constant observation due to his/her potential for self-injurious behaviors.

On 3/10/2022 Patient ID#1 swallowed a toothbrush, which was a restricted item for this patient, while under the constant observation of a Mental Health Worker (MHW).

On 4/1/2022 after review of this case with CMS, the hospital was informed of the Immediate Jeopardy.

The hospital provided a resolution plan which indicated all direct care staff will be re-educated on the observation policy and protocols including expectations for staff to keep patients out of restricted areas. Staff were also re-educated to immediately utilize the duress (alarm) button that each staff member has in their possession during their shift.
Additional actions included:

-A risk assessment of all hospital units was completed to identify potential risks to patients, signs were also deployed on all restricted areas.
-Security officers will open doors to restricted areas, and only allow staff to enter.
-Supply rooms were emptied and reorganized to remove items which could be a safety risk.
-A staff member, other than the staff member performing the 1:1 observation, will obtain hygiene bins and review contents before items are given to a patient.
-Patient supply boxes will be stocked only with the items a patient can have and this will be checked by nursing staff.
-Nurse will advise all mental health care workers as to what a patient can or cannot have and will monitor the activities and compliance of unit staff that perform 1:1 observation. Nursing must approve items dispensed to patients.

During a visit on 4/2/2022 it was confirmed that the removal plan had been implemented.

Staff had completed the re-training process including use of the duress button, storage/supply room entry, and patient supply box dispensing protocols. It was also confirmed that re-structuring the content in the supply rooms and hygiene kits had been implemented. Review of the education provided to the employees revealed re-training in resident observation policy/protocols, storage/supply closet contents removed, dispensing of patient supplies, and appropriate use of the duress button.

Based on surveyor observation, record review and staff interview, it has been determined that the hospital failed to ensure the safety of 1 of 7 patients (Patient ID#1). The patient was on constant observation and was allowed to enter a locked, restricted area with the assigned Mental Health Worker and was then allowed access to a toothbrush which he/she was restricted from having due to safety concerns.

Findings are as follows:

Review of the hospitals "Patient Observation" policy, which was last approved on 2/24/2020, reveals:
"POLICY:

It is the policy of Eleanor Slater Hospital to provide safe and supportive care and treatment for all patients throughout their hospital stay. Levels of observation must be assigned and ordered for all patients on admission and when there are patient behavioral changes that increase or decrease harm/potential injury to self or other patients. ESH strives to create the safest environment and assign staff to monitor patients while allowing patients the least restrictive environment that is clinically appropriate.

DEFINITIONS:

Definition of nursing staff includes Registered Nurses, Certified Nursing Assistants, Institutional Attendants Psychiatric, Mental Health Workers, and Psychiatric Technicians.
1. Continuous Observation: The most intensive standard level of observation, which is either 2:1 or 1:1 staff to patient ratio. It assigns staff member(s) to constantly observe the patient; 2:1 staffing may involve one security staff plus one clinical staff. It is used for patients that inflict self-harm, and/or for violent behavior toward others thought to be imminent without observation and/or for patients experiencing suicidal thoughts and urges to act on those thoughts. Continuous observation can be ordered with or without "Special Precautions" (see below).
Requirements for Continuous Observation:
a. An assigned staff member must always be with the patient, including in the bathroom ...
b. The staff member must always be able to physically observe the patient and be able to quickly intercede should it be necessary ...

Further review of the Patient Observation policy failed to reveal how staff should intercede should it be necessary.

During an interview regarding the above policy on 3/15/2022 at approximately, 12:00 PM, the Nurse Manager, Staff F, stated all staff are trained on observations and it is the hospitals protocol to immediately inform the unit nurse of any concerns or issues which occur with a patient on any observation status.

Review of the medical record for Patient ID #1 revealed she/he was admitted to the Benton Forensic Unit in April 2021 with diagnoses including, but not limited to, schizoaffective disorder, depressed mood, and polysubstance dependence. The patient has a history of aggression and self-injurious behavior.

Review of Patient ID# 1's record on 3/15/2022 reveals at the time of the incident on 3/10/2022, the patient was on constant observation due to his/her potential and history of self-injurious behaviors.

Record review revealed the patient is housed on the Intensive Treatment Unit and is integrated into the general population for group activities and socialization daily. Further review of the patient record revealed a form titled "Sharps, Contraband, and Flammables" which identifies what items a patient can and cannot have in their possession while in the hospital. Patient ID# 1's document did not indicate the patient could have a toothbrush. In addition, the record contained a typed document updated on 2/9/2022 which indicates "No Toothbrush." This document is also kept at the nurse's station in a binder for immediate access by all staff to review prior to their shift.

Record review of nursing notes reveal on 3/10/2022, Patient ID#1 swallowed a toothbrush which s/he accessed while under the constant observation of a Mental Health Worker (MHW), Staff A.

During a review of the surveillance video dated 3/10/2022 from 11:40 AM through 12:00 PM, it was observed that Staff A allowed the patient on 2 occasions to follow him into the locked supply closet which had a sign posted on the door indicating "no patients allowed in this closet." Both were noted to be in the closet for a very brief period. Upon vacating the closet on the first entry, it was viewed that Staff A had retrieved a box from the closet. Staff A was observed in the hallway outside of the closet to hold the box out to Patient ID# 1 and allow him/her to pick items from the box. On the second entry to the closet, the patient was noted to stand in the threshold of the doorway as the Staff A was out of view for a brief time. Upon leaving the supply closet, the patient walked around for several minutes as Staff A and the Security Guard followed. The patient was observed to enter a bedroom approximately 40-50 feet from the closet and goes off the video. Staff A followed the patient, and the Security Officer stood in the patient's room doorway. Then all are noted to come out and go to the nurse's station and speak to the nurse at the window.

During an interview on 3/16/2022 at approximately 8:30 AM with MHW, Staff A, who was the employee assigned to complete the 1:1 observation of Patient ID# 1 stated that on 3/10/2022 the patient had requested to complete his/her hygiene. Staff A stated he proceeded to enter the locked supply closet to obtain the patients personal hygiene supply box. He acknowledged this box contained a toothbrush and other hygiene items. He noted he handed the box to the patient and observed the patient take the 3-inch round handle toothbrush from the box. He stated he was aware the patient should not have the toothbrush and repeatedly asked the patient to return the toothbrush, but the patient refused to do so. After several minutes with Staff A requesting Patient ID# 1 to return the toothbrush, the patient proceeded to walk into his/her bedroom, and was observed by Staff A, to wrap the toothbrush in a paper towel and swallow it. The Security Officer, Staff A and Patient ID# 1 then walked to the nurse's station to inform the nurse. When Staff A was asked if he was aware of the hospital policy/protocol to follow when a patient accesses an item they should not have, Staff A stated that nursing should be notified. He stated he did not immediately notify nursing because he thought that he had a good rapport with the patient and could get him/her to return the item without incident. He stated from the time the patient accessed the toothbrush to swallowing it may have been 5 minutes.

During an interview on 3/16/2022 at approximately 8:15 AM, Staff B, the Security officer (SO) who was present on 3/10/2022, stated that the patient took the toothbrush from the personal hygiene box which Staff A held out for the patient to pick from. The patient grabbed the toothbrush and when asked to put it back the patient refused. He stated both Staff A and he followed the patient as Staff A requested the item back. Refusing, the patient walked around for several minutes and then into his/her room where he/she swallowed the toothbrush. The SO indicated it may have been 15 minutes from the time the patient accessed the toothbrush to swallowing it.

During an interview with the Charge Nurse on 3/16/2022 at approximately 9:30 AM, Staff I, stated all constant observation staff are aware to check the "patient binder" which is located at the nurse station before their shift. This is always updated with any restrictions for a patient including items they can and cannot have. Additionally, she stated this information is also reported off to the incoming shift when handing off your shift to the next person. The MHW also has a copy located on the patient clipboard which has the observation sign off sheets for staff to initial.

During an interview on 3/15/2022 at approximately 12:40 PM, the Nurse Manager, Staff F, stated staff are aware that all patients are never allowed in the supply closet nor are they given access to pick their own personal items if they are on constant observation. She also stated all direct care staff are re-trained and aware of the protocol not to allow patients in the supply room and not to give patients on safety precautions access to any items which are restricted for that patient.

During an interview on 3/15/2022 at approximately 12:00 PM, with the Nurse Managers, Staff E and F, both stated the MHW staff should have immediately informed the nurse of the patient accessing the toothbrush for an immediate intervention.

Following the incident, the patient was examined by Medical Services and identified as clinically stable and transported via ambulance to an acute care emergency department for further evaluation. Hospital findings indicated a foreign body was present. The patient was given an order for Miralax as well as to repeat the X-Ray in 2 days. The repeat Xray verified the foreign body had passed.