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A. Based on medical record review, review of hospital documents, and staff interview it was determined the hospital failed to maintain a safe setting for one (1) of one (1) patients reviewed who was treated for swallowing razor blades (patient #1). The hospital failed to ensure staff were inserviced on the patient's Adaptive Behavior Support Plan. This failure creates the potential for the care of all patients who engage in self-injurious behaviors to be adversely impacted.

Findings include:

1. Review of the medical record for patient #1 revealed the patient reported swallowing razor blades on 3/19/13. The record reflected the patient was sent out for emergency treatment and then transferred to a medical center where she was hospitalized for treatment. The patient returned from medical leave on 3/28/13. The record reflected a nursing safety plan, an adaptive behavior support plan and an increased level of staff were among the steps implemented to keep the patient safe upon her return.

2. Staff training records related to the Adaptive Behavior Support Plan for patient #1 were requested and reviewed. The document provided included a notation that all E2 staff must attend the training provided by psychology staff for this Behavior Plan. A review of the training record provided revealed thirty-seven (37) active E2 staff were listed and fourteen (14) of these staff had not completed the training on the Adaptive Behavior Support Plan as required. The Interim Nurse Manager confirmed this training had not been completed by all staff.

3. Interview was conduced with the Interim Nurse Manager of Unit E2 at 1000 on 5/14/13. She confirmed the hospital had implemented multiple interventions, as noted above, as a direct result of this incident in order to keep the patient safe from further self-injurious behaviors. She confirmed the patient was currently on two to one (2 : 1) staffing. She stated that nursing staff has been trained as to the patient's programs and rotates every half hour for this assignment.

4. An interview was conducted with the Psychologist who is the Treatment Team member for patient #1 at 1215 on 5/14/13. She confirmed the Adaptive Behavior Support Plan was implemented with patient #1 on 4/15/13 in order to reduce self-injurious behavioral incidents. She acknowledged the training had not been completed by all E2 staff as required.

B. Based on observation, review of medical records, observations and staff interview it was determined the hospital failed to ensure care was provided in a safe setting in Unit E2. The hospital failed to ensure items which can pose a danger to patients, such as batteries and electrical cords were secured and utilized under supervision. This failure creates a potential risk to all patients.

Findings include:

1. Review of the medical record for patient #1 revealed the patient has ingested foreign bodies on multiple occasions during her hospitalization. These incidents of foreign body ingestion include multiple ingestions of batteries (12/17/12, 1/16/13, 1/28/13, 2/16/13), screws, clips, tabs, pipe cleaners and razor blades (3/19/13). Review of documentation revealed many of these ingestions of foreign bodies occurred when the patient was on one on one (1 : 1) staffing.

2. Observation of the patient rooms on the E2 Unit was conducted at approximately 1700 on 4/13/13. The surveyor was accompanied on this observation by the Bar Code Medication Administration (BCMA) Coordinator, who was working as a staff nurse on the E 2 Unit.

3. During this tour and observation electronic equipment containing batteries, such as clocks, radios and personal music players/devices were observed in rooms 122, 116, 115, 113 and 112. The personal music players all had cords attached with headphones for listening to music. One device was plugged into an outlet for charging with an electrical cord.

4. Observation in room 109 revealed a continuous positive airway pressure (CPAP) machine. This machine was observed to have tubing which was approximately five (5) feet long in addition to a three (3) foot electrical cord with an additional two (2) foot cord on back of the machine. The approximate length of these cords were reviewed and confirmed with Health Service Worker (HSW) #2 who was present in this room.

5. Batteries and electric cords pose a risk to the safety of psychiatric patients. These findings were discussed with the BCMA Coordinator, who acknowledged the risk these items can pose to patients.

6. Interview was conducted with the Attending Psychiatrist for patient #1 at 0940 on 5/14/13. These findings related to the observation of electronic devices with batteries and equipment with electrical cords and hoses were shared. He stated he was not aware batteries were allowed in patient rooms. He agreed both batteries and electrical cords pose a safety risk to patients.

7. Interview was conducted with the Psychologist for patient #1 at 1215 on 4/14/13. These findings related to the observations of electronic devices with batteries and equipment with electrical cords and hoses were shared. She agreed both batteries and electrical cords pose a safety risk to patients.

Based on review of medical records and staff interview it was determined the medical staff failed to be accountable for the quality and continuity of medical care for one (1) of one (1) patients reviewed who swallowed razor blades (patient #1). The physician failed to ensure the outcome of the patient's outside treatment and hospitalization was included in the medical record for continuity of care. This failure creates the potential for the care and condition of all patients who are sent for outside treatment and hospitalization to be adversely impacted.

Findings include:

1. Review of the medical record for patient #1 revealed the patient reported swallowing razors on 3/19/13. The record reflects the patient was sent to the local hospital for emergency care. The patient was then transferred to a large medical center where she was hospitalized for treatment. Nine (9) days later the patient returned to Sharpe Hospital.

Review of the medical record revealed copies of records from both hospitals (both local and medical center) with x-ray results reflecting metallic foreign bodies. No documentation was noted from the medical center related to the course of treatment or the outcome of any surgical procedures performed.

Review of both physician and social work progress notes during the patient's hospitalization 3/19/13 through 3/28/13 revealed conflicting information related to what treatment was provided by the medical center or how many razors were ingested and whether the razors were removed

2. This record was reviewed and discussed with the Interim Nurse Manager of Unit E2 at 1345. She acknowledged the record lacked information related to the outcome of treatment at the medical center including, how many razor blades were identified and/or whether razor blades were removed.

3. Interview was conducted with the Attending Psychiatrist for patient #1 at 1115 on 5/14/13. He stated he was not aware if the medical center had removed the razor blades. He also confirmed no discharge summary and/or operative reports had been received from the medical center related to the patient's course of treatment.

Based on medical record review, review of documents and staff interview it was determined the medical staff failed to enforce bylaws/rules and regulations which require an examination of patients returning from Temporary Medical Leave (TML). This failed practice impacted one (1) of one (1) patients reviewed who returned from TML (patient #1). This failed practice has the potential to negatively impact the care and condition of all patients who return from TML.

Findings include:

1. Review of the medical record for patient #1 revealed the patient reported swallowing razor blades on 3/19/13. The record reflects the patient was sent out to a local hospital for emergency evaluation.. The patient was then transferred to a medical center for admission and treatment. The patient was hospitalized at the medical center until 3/28/13 when the patient discharged and returned to Sharpe Hospital from the TML.

2. Review of the medical record reveals no physician progress note or examination note until 4/1/13, which was four (4) days after patient's return to the hospital.

3. This record was reviewed and discussed with the Bar Code Medication Administration (BCMA) Coordinator who was reviewing this record for the Quality/Compliance department. She agreed with this finding.

4. The Medical Staff Rules and Regulations, reviewed 1/13, were provided for review. The Rules and Regulations governing patient management state in part: "Sharpe Patient returning from Temporary Medical Leave (TML): Does not require new History and Physical or Psychiatric Evaluation but does require an adequate progress note or dictation including an updated mental status exam. All treatment orders should be reviewed and if the patient has been on TML overnight, all medications need to either be renewed or discontinued, as appropriate."

Based on observation, review of policy and staff interview it was determined the registered nurse (RN) failed to supervise the process for the use of safety razors on the E2 Unit per policy. This failure creates the potential for the care and condition of all patients to be adversely impacted.

Findings include:

1. Interview with the Dayshift Acting Charge RN on Unit E2 was conducted at 1155 on 5/13/13. She stated the unlicensed staff (Health Service Workers (HSW)) supervise the use of disposable razors by patients.

2. Observation of the patient shaving/razor tracking process was conducted on 5/13/13 at 1645 with Evening shift HSW #2. She was observed with a disposable wash basin containing nine (9) disposable razors. HSW #2 stated that HSW #1 had previously removed ten (10) razors from the clean utility room and already disposed of one (1) razor which was used by a male patient. She stated he then provided her with nine (9) razors for which she was now responsible. She stated staff supervises patients as razors are used and the patient's name and number of razors used is recorded along with any unused razors which are returned.

HSW #2 supervised shaving by three (3) female patients. She was observed to hold the used razors in her hand while the clean unused razors were maintained in the basin under her arm. After the shaving was completed, HSW #2 disposed of three (3) used razors in the soiled utility room and returned (6) six razors to the clean utility room.

3. Review of the documentation completed by both HSW #1 and 2 revealed each completed a Patient Shaving/Razor Tracking form.

Review of the 5/13/13 form completed by HSW #1 at 1630 revealed he documented nine (9) razors were removed, one (1) razor was used and eight (8) razors were returned.

Review of the 5/13/13 form completed by HSW #2 at 1630 revealed she documented nine (9) razors were removed, three (3) razors were used and six (6) razors were returned.

4. This observation and documentation was reviewed and discussed at 1700 on 5/13/13 with the Bar Code Administration Coordinator who was working as a staff nurse on E2. She agreed the documentation regarding the number of razors removed by HSW #1 conflicted with the documentation of the number of razors removed (received) by HSW #2.

5. The policy "Safety Razors, " revised 4/13, revealed the policy states in part: "The use of safety razors will be monitored and supervised by nursing staff...After shave time is over, staff will subtract the used razors from the unused razors and document the total razors to be returned to the utility room."

6. These findings were reviewed and discussed with the Interim Nurse Manger at 0930 on 5/14/13. The 5/13/13 Patient Shaving/Razor Tracking documentation, and a count of the razors in the clean utility room was conducted. The Interim Nurse Manager acknowledged the process for monitoring and supervision of the use of safety razors by nursing staff was not completed correctly. It was noted during this discussion that one (1) of the "clean" razors in the basin was soiled and had been previously used. The Interim Nurse Manager threw all razors away and acknowledged that nursing staff needed more training and supervision related to the policy/expected process for supervision of the use of razors by patients.

Based on review of medical records, hospital documents and staff interview it was determined the hospital quality program failed to identify serious/adverse events accurately and document the status of on-going efforts to reduce these events. This failure has the potential to adversely affect the quality of care and treatment provided to all patients.

Findings include:

1. Review of the medical record for patient #1 revealed fifteen (15) serious events involving self-injurious behaviors (SIB) between January 2013 and April 2013. The record revealed two (2) of these events resulted in the patient's hospitalization in January and March 2013.

2. Review of monthly Continuous Quality Improvement (CQI) meeting minutes from November 2012 through April 2013 revealed patient incidents are reported quarterly by the Safety Department. No data related to these complaints was found in the CQI minutes. Review of the Safety reports for 3rd and 4th Quarters of 2012 revealed only a statement that a review of incidents for the quarter occurred.

3. Review of incident data which is presented to the Safety Committee revealed it was inaccurate. A review of this data for February through April 2013 revealed the
Patient Incident data which was reported, dated 2/19/13 and 4/16/13, indicated there were no incidents resulting in patient hospitalizations in January and March.

4. Interview with the Compliance Officer at 1340 on 5/15/13 revealed that incidents are monitored monthly at the Safety Committee and confirmed that no data related to these incidents is provided to the CQI Committee with the quarterly reports.

5. When this information was reviewed and discussed with the Compliance Officer she acknowledged this was not correct. She confirmed patient #1 was hospitalized in both January and March as a result of SIB incidents.

6. Further review and interview with the Compliance Officer revealed incidents are not being followed up by the Compliance/Quality department unless they are deemed Adverse or Sentinel Events. A review of the 2013 incident log revealed a 4/7/13 report of "attempted hanging." The Compliance Officer acknowledged this had not been identified as a serious or adverse event and had not been assigned for investigation/followup.