HospitalInspections.org

Based on record review, interview, and observation, the governing body failed to discharge its oversight responsibility in ensuring the provision of a safe patient environment. It failed to ensure staff:

1) supervised a patient with active psychosis and at high risk to commit suicide. The patient was found with a sheet around his neck, unresponsive, and not breathing. He died.

2) kept an actively suicidal patient in direct visualization as ordered by the physician. The patient asked for a bed sheet and asked to have his door closed which the staff complied with.

3) prevented suicidal patients to have access to contraband such as a plastic bag and elastics in scrub pants.

4) assured treatment progress for a female patient with a history of intellectual disability and extensive sexual abuse who was closely observed by male staff during the night hours.

5) prevented a child to get kicked by a staff member in retaliatory fashion.

Cross Refer to A144


The governing body further failed to prevent that escalation of incidence of patient altercations, it quadrupled between 08/2018 and 09/2018. The incidence of aggressive and combative nature on patient units doubled during the same time.

Cross Refer to A273


The governing body further failed to ensure that staff maintained current treatment care plans for patients' mental health and/or medical needs.

Cross Refer to A396

Based on record review, observation, and interview, the hospital failed to ensure that 7 of 7 patients (Patient #8, #19, #15, #14, #13, #24, #25) receive care in a safe environment.


1) Although Patient #8 was admitted with active psychosis and experienced severe stressors that put the patient at high risk to commit suicide, staff failed to monitor the patient effectively. Approximately 28 hours into Patient #8's hospital stay, a nurse found the patient not breathing with a sheet tied around his neck. Patient #8 died.


2) Patient #19 was admitted to the hospital with suicidal ideation and severe depression. Three days into Patient #19's hospitalization, he received disturbing family news. Actively suicidal, Patient #19 was placed on special staff observation that required direct patient visualization. During the survey, staff in charge of monitoring Patient #19 supervised nine other patients and did not keep the patient in direct eye sight. The patient had asked for a bed sheet and his door closed, which the staff complied to do.


3) A housekeeping cart was observed unattended in close proximity to Patients #15 and #14 who had been placed on suicide precautionary status. Both patients had access to a plastic bag that can be used in a self-harming attempt.


4) A male staff member provided one-to-one overnight supervision to Patient #13, a female patient with intellectual disabilities and a history of severe sexual trauma and rape. The patient failed to make more than minimal progress in her psychiatric treatment.


5) Pediatric Patient #24 with a history of self-harming behavior had access to an elastic in scrub pants provided by the hospital. The elastic, can be used for ligature, was part of scrub uniforms distributed to multiple patients in the hospital during the survey.


6. Pediatric Patient #25 was kicked by a staff member in a retaliatory manner.


Refer to A144

Based on record review, interview, and observation, the hospital governing body failed to ensure that services furnished in the facility were provided in a safe manner and failed to ensure a safe patient care environment for patients, and an ongoing quality program that showed improvement in indicators that evidenced improvement of patient health and safety outcomes


Findings included:


1) Patient #8's, suicidal patient, Nurse Narrative Notes dated 09/15/18 at 0850 reflected,the nurse "rushed to [Patient #8's] room...saw the patient on the floor...with a sheet wrapped around his neck...not breathing...called a code blue..." Emergency Medical Care Provider Notes dated 09/15/18 at 0947 reflected, Patient #8 died. During a telephone interview on 09/18/18 at 1320, Hospital Personnel #27 acknowledged that he had not made rounds the morning of 09/15/18 and stated, "If I had checked..."


Patient #19's Comprehensive Psychiatric Evaluation dated 09/21/18 at 1655 reflected, Patient #19's statement that he was suicidal with worsening mood swings. Patient #19's Physician Orders dated 09/23/18 at 1646 reflected, place the patient on line-of-sight staff observation while awake as suicide precaution. Observations on the hospital's PICU unit on 09/24/18 at 2249 and 2250 reflected, Patient #19 was in his room at the end of a hallway and out of direct vision to staff.


Observation on the adult unit on 09/19/18 at approximately 1413 reflected, an unattended housekeeping cart in the hallway between patient rooms 213 and 214. The cart had a medium sized blue plastic bag tied to the outside and was accessible to Patient #15 observed in Room 213 and Patient #14 observed in Room 214. Patient #15's Admission Orders dated 09/19/18 at 0545 reflected, the patient was on suicide precautions. Patient #14's Physician Daily Progress Notes dated 09/19/18 at 1810 reflected, he was suicidal. Hospital Employee #4 was interviewed on 09/19/18 at 1445 and acknowledged the above findings.



Observation in the hospital's Intake Department on 09/25/18 at approximately 1250 reflected a shelf with blue scrub tops and pants of different sizes. Hospital Personnel #35 acknowledged that the elastics could be removed from the scrub pants and provided a string potentially useable for self-harm. Hospital Personnel stated administration "needed to look for alternatives." Observations on the hospital's PICU unit on 09/25/18 during a tour at about 1030 reflected at least four patients in blue scrub tops and pants.


During an interview on 09/25/18 at approximately 1240, Hospital Personnel #35 stated that Hospital Personnel #30 had kicked Patient #25 on the upper right leg, an action that was "retaliatory and inappropriate." Patient #25's Progress Note dated 09/13/18 at 1320 reflected a staff member had kicked the patient and it "appeared to be on purpose."



2) Record review of the log of hospital incidents dated 09/01/18 and 09/12/18 reflected 87 incidents. Twenty-six incidents were classified as "altercations/fights" and made up 29.8 percent of all hospital incidents. Fourteen incidents of "aggressive/combative nature" made up 16.1 percent of all incidents reported during the first twelve days in 09/2018.


Hospital Personnel #35 stated during an interview on 09/25/18, at approximately 1200, that altercations in 09/2018 had increased from 7.6 percent to 30 percent of all incidents within the last month. Combative and aggressive incidents had doubled.

Based on record review, observation, and interview, the hospital failed to ensure that seven of seven patients (Patient #8, #19, #15, #14, #13, #24, #25) receive care in a safe environment.

1. Patient #8 was admitted the early morning hours of 09/14/18. Although assessed to be actively psychotic and with severe stressors that put the patient at high risk to commit suicide, staff failed to monitor Patient #8 effectively. A nurse found the patient not breathing, with a sheet tied around his neck. Patient #8 died.


2. Patient #19 was admitted to thehospital with diagnoses that included severe depression and alcohol use disorder. On admission, the patient was suicidal, had attempted to jump out of a moving car, and suffered from worsening mood swings. Three days into his hospital stay, the patient received bad family news, was actively suicidal, and placed on special staff observation that required direct patient visualization. The patient had asked to have his door closed and requested a bed sheet. During the survey, Patient #19 was not kept in direct staff visualization while the staff member monitoring Patient #19 made safety checks on nine additional patients.


3. A house-keeping cart was observed unattended during the survey. It provided access to a medium size blue plastic bag that can be used for self-harm by Patient #15 and Patient #14. Both patients were on suicide precautionary status and were noted to have impaired and/or poor judgement.


4. Patient #13, a female patient with intellectual disabilities, had been admitted with the history of sexual trauma and rape. Treatment focused on the patient suspiciousness and misinterpretation of reality. Patient #13 was placed on one-to-one staff supervision during the night. A male staff member was assigned to conduct the patient's one-to-one staff supervision the nights of 09/15/18 and 09/16/18. The patient was noted to make minimal treatment progress only.


5. Although Patient #24 had been admitted after a self-harming attempt and was placed on suicide precautions, the patient had access to and removed an elastic from her hospital-provided scrub pants that the patient could have use as a ligature to self-harm. At least four additional patients were observed wearing similar scrubs during the survey.


6. During an aggressive outburst, pediatric Patient #25 threw himself on the floor and hit staff. In a retaliatory fashion, a staff member kicked the patient on the leg.


Findings included:


1. Patient #8's Preadmission Evaluation Intake document dated 09/14/18, at 0404c reflected the 39-year old patient walked into the hospital for assessment. The patient was reported to be suicidal earlier that day. For two days prior to his admission, Patient #8 had heard voices and believed a monitoring device had been placed in his ears and eyes "to hear what I hear, see what I see, think what I think...want to kill my family..." The physician noted Patient #8's risk for suicide was "low...[and] thought content [was] appropriate..."


Patient #8's Behavioral Health Integrative Psychiatric Assessment dated 09/14/18 at 0245 reflected the patient was at risk for suicidal and homicidal ideation, suffered from auditory and command hallucinations, was psychotic, and "interacted with [the] voices during the assessment..." Patient #8 was assessed with "...impaired judgement...poor impulse control...bizarre behavior...closing [his] eye and ear to prevent monitoring..." The document reflected the patient's current stressors were "severe" and he was a "high risk" for suicide, self-harm and/or homicide.


Daily Nursing Assessment dated 09/14/18, at 0710, reflected the patient's pressured speech, he was "angry" and "agitated" and suffered from auditory hallucinations.


Nursing Narrative Notes dated 09/14/18, at 1900, reflected Patient #8 got into an altercation with another patient.


Nursing Narratives dated 09/15/18, at 0720, reflected the patient spoke with the nurse about his unit restriction.


Nurse Narrative Notes dated 09/15/18, at 0850, reflected the nurse "rushed to [Patient #8's] room...saw the patient on the floor...with a sheet wrapped around his neck...not breathing...called a code blue..."


Code Blue Flow sheet dated 09/15/18, at 0856, reflected cardiopulmonary resuscitation (CPR) was initiated at that time. Emergency medical services were notified and arrived at 0909. Patient #8 was transported to an acute care hospital at 0930.


Emergency Medical Care Provider Notes dated 09/15/18, at 0947, reflected Patient #8 was "found with sheet around his neck...asystole [without heart rate] the entire time...cardiac failure, circulatory failure..." Diagnoses included Asphyxiation, Intentional Self-harm, Cardiac Arrest. The physician noted that the patient died.


Hospital Personnel #32 stated during an interview on 09/18/18, at approximately 1300, that the mental health technician [MHT] supervising Patient #8 did not check the patient but documented the patient slept. Patient #8 had tied a sheet around his neck "so tight that it did not become untied when he passed out."


During a telephone interview on 09/18/18 at 1320, Hospital Personnel # 27 acknowledged that he had not make rounds the morning of 09/15/18 and stated, "If I had checked..."



2. Record review of Patient #19's demographic "Face Sheet" reflected the patient was admitted on 09/20/18 at 2051.


Admission Orders dated 09/20/18, at 2112, reflected diagnoses that included Major Depressive Disorder, Severe, and Alcohol Use Disorder, Severe.


Comprehensive Psychiatric Evaluation dated 09/21/18, at 1655, reflected Patient #19's statement that he was suicidal with worsening mood swings. The patient had attempted to jump out of a moving car.


Therapist Notes dated 09/23/18, untimed, reflected Patient #19 found out that his family did not let him go back home due to his substance use. Patient #19 had suicidal thoughts "and wanted his door closed."


Orders dated 09/23/18, at 1646, reflected to renew self harm and suicide precautions and place the patient on line-of-sight staff observation while awake.


Observations on the hospital's PICU unit on 09/24/18, at 2242, reflected Hospital Personnel #36 completed patient rounds. Hospital Personnel #8 informed the surveyor that Hospital Personnel #36 completed "line-of-sight" staff observation on Patient #19. The patient was in the hallway asking staff members for a bed sheet.


During a brief interview on 09/24/18, at 2245, Hospital Personnel #36 stated he was in charge of nine other patients in addition to Patient #19.


Observations on the hospital's PICU unit on 09/24/18, at 2249 and 2250, reflected Hospital Personnel #36 made rounds on his patients and went through one locked door into the little hallway that separated the two wings of the PICU. During that time Patient #19 was in his room at the end of a hallway, not in direct vision to staff at the nurses' station, and out of Personnel #36's direct line of sight.


Record review of the hospital's Provision of Care Patient Monitoring Policy dated 09/26/16 reflected the policy to "provide a safe and secure environment for patients." It reflected the procedure that "patients on Line of Sight monitoring shall stay in the visual view, or in the line of sight, of staff at all times."



3. Observation on the adult unit on 09/19/18, at approximately 1413, reflected an unattended housekeeping cart in the hallway between patient rooms 213 and 214. The cart had a medium sized blue plastic bag tied to the outside. An unidentified housekeeper was observed in Room 210 across the hallway from rooms 213 and 214.


Patient #15 was noted in bed in Room 213. Patient #14 was observed in bed in Room 214, adjacent to 213.


Hospital Personnel #11 was interviewed on 09/19/18, at approximately 1417, and acknowledged the housekeeping cart. Hospital Personnel #11 stated he "kind of had an eye on it" but "not the whole time."


Hospital Personnel #4 was interviewed on 09/19/18 at 1445 and stated the Housekeeper "should have had the cart inside the room."


Patient #15 demographics "face sheet" reflected he was admitted on 09/19/18 at 0742.


Admission orders dated 09/19/18, at 0545, reflected admission diagnoses that included Major Depressive Disorder, Single Episode, Severe. The patient was placed on suicide precautions.


Patient #15's Behavioral Health Integrative Psychiatric Assessment dated 09/19/18, at 0715, reflected his involuntary admission status. Prior to admission, Patient #15 had informed his family of his intent to harm himself. The patient was assessed with suicidal ideation with a "possibly lethal plan" and was noted to be impulsive and have impaired judgment.


Patient #14's Physician Admission Orders dated 09/11/18, at 1633, reflected his pre-admission suicidal plan to overdose on his medications. Patient #14 was placed on suicide precautions.


Patient #14's Physician Orders dated 09/19/18 reflected to continue the order for suicide precautions.


Patient #14's Physician Daily Progress Notes dated 09/19/18, at 1810, reflected the patient had auditory hallucinations. The patient was assessed with poor judgment and insight and was suicidal.



4. Patient #13's Physician Admission Orders dated 09/11/18, at 1401, reflected the patient had a "history of intellectual disabilities" and suffered from paranoia that placed her at risk for self-harm. Physician Orders dated 09/15/18, at 1705, and 09/16/18, at 1730, reflected Patient #13's precautionary status for suicide and self-harm potential.


Patient #13's Behavioral Health Integrative Psychiatric Assessment dated 09/11/18 at 1845 reflected Patient #13's "extensive sexual trauma history." The patient had been raped. The document noted the patient "became tearful" when talking about her history of victimization. The patient received the highest score on the trauma screening tool.


Patient #13's Master Treatment Plan dated 09/12/18 reflected the potential for Post-Traumatic Stress Disorder.


The Psychotic Symptoms Treatment Plan dated 09/14/18 reflected the patient was suspicious and experienced "misinterpretation of reality."


Patient Observation Reports dated 09/15/18, between 0000 and 0700, and 09/16/18, between 0000 and 0700, reflected Patient #13 was one "one-to-one staff [supervision] while sleeping." Both documents reflected male Hospital Personnel #36's initials during those hours.


Physician Progress Notes dated 09/15/18 at 1702 reflected the patient made "minimal progress" in her treatment.


Hospital Personnel #23 was interviewed on 09/19/18, at around 1300, and reviewed the staff assignment sheet that covered the shift dated 09/14/18, at 2300, through 09/15/18, at 0700. Hospital Personnel #23 acknowledged that Hospital Personnel #36 was assigned to Patient #13 to conduct the one-to-one staff supervision. Hospital Personnel #23 stated male staff "usually" did not provide one-to-one staff supervision to female patients.


5. During an interview on 09/25/18, at about 1515, Hospital Personnel #35 acknowledged a previous incident of contraband. On 09/10/18, Patient #24 "picked up the thread and pulled it out of the scrub pants ...staff found it during rounds."


Patient #24's Admission Orders dated 09/04/18, at 1951, reflected the patient was admitted after she had "blockaded herself in the bedroom...trying to use a hammer...and break her arm." Patient #24 was physician ordered to be on suicide precautions.


Patient #24's Physician Orders dated 09/10/18, at 1050, reflected the patient was on suicide precautions.


Observation in the hospital's Intake Department on 09/25/18, at approximately 1250, reflected a shelf with blue scrub tops and pants of different sizes. Hospital Personnel #35 acknowledged that the elastics could be removed from the scrub pants and provided a string that can be used for self-harm. Hospital Personnel stated administration "needed to look for alternatives."


Observations on the hospital's PICU unit on 09/25/18, during a tour at about 1030, reflected at least four patients in blue scrub tops and pants.



6. During an interview on 09/25/18, at approximately 1240, Hospital Personnel #35 stated that Hospital Personnel #30 had kicked Patient #25 on the upper right leg and "it was retaliatory and inappropriate." Hospital Personnel #30 was suspended and terminated from employment.


Patient #25's MOT (Memorandum of Transfer) Admission Orders dated 09/08/18 at 0059 reflected the patient was admitted with Bipolar Disorder, Depression, and Developmental Delay. Prior to admission, the patient required restraints by a police officer and banged his head on the concrete. The patient stated he "wanted to die with the police."


Patient #25's Nursing Narrative Notes dated 09/12/18, at 1845, reflected the patient was restrained by staff members. The patient was "extremely angry and agitated...fell to the ground and started banging head on floor...hit MHT [mental health technician]."


Progress Note dated 09/13/18 at 1320 reflected a staff member had kicked the patient and it "appeared to be on purpose."

Based on record review and interview, the hospital failed to have an ongoing Qyality Assessment and Performance Improvement program that showed measurable improvement in indicators that evidenced improved health outcomes. The incidence of patient altercations and fights had quadrupled between 08/2018 and 09/2018.


Findings included:


Record review of the log of hospital-wide incidents dated 09/01/18 and 09/12/18 reflected 87 incidents. Twenty-six incidents were classified as "altercations/fights" and made up 29.8 percent of all hospital incidents. Fourteen incidents of "aggressive/combative nature" made up 16.1 percent of all incidents reported during the first twelve days in 09/2018.


Hospital Personnel #35 stated during an interview on 09/25/18, at approximately 1200, that altercations in 09/2018 were "about 30 percent" of all incidents and had increased from 7.6 percent from the previous month. Hospital Personnel #35 stated at that time that there were "additional 24 incidents of altercations/fights" between 09/13/18 and survey exit on 09/25/18.


Hospital Personnel #35 acknowledged that aggressive and combative incidents on patient units had doubled from 8.3 percent in 08/2018 to 16.1 percent in 09/2018.

Based on observation, record review, and interview, the hospital failed to ensure that the nursing staff kept a current care plan for two of two patients (Patients #19 and #16).


1) Patient #19 was admitted to the hospital with suicidal ideation and severe depression. Three days into his hospitalization, Patient #19 received disturbing family news. Actively suicidal, Patient #19 was placed on special staff observation that required direct patient visualization. Nursing failed to update the treatment plan to the heightened awareness of Patient #19's suicidality.


2) Patient #16, pediatric/adolescent patient, had fluctuating blood pressures that increased her risk for future heart attack and stroke. The patient's nursing care plan did not reflect the fluctuations in blood pressure.


Findings included:


1) Patient #19's Admission Orders dated 09/20/18, at 2112, reflected diagnoses that included Major Depressive Disorder, Severe, and Alcohol Use Disorder, Severe.


Comprehensive Psychiatric Evaluation dated 09/21/18, at 1655, reflected Patient #19's statement that he was suicidal with worsening mood swings. The patient had attempted to jump out of a moving car.


Therapist Notes dated 09/23/18, untimed, reflected Patient #19 found out that his family did not let him go back home due to his substance use. Patient #19 had suicidal thoughts "and wanted his door closed."


Orders dated 09/23/18, at 1646, reflected to renew self-harm and suicide precautions and place the patient on line-of-sight staff observation while awake.


Patient #19's Master Treatment Plan dated 09/21/18 reflected the patient was on 15-minute staff observation level.


Patient #19's Suicide Thoughts/Plan dated 09/23/18 did not specify the level of staff observation.


During an interview on 09/25/18, at approximately 0925, Hospital Personnel #12 stated that the treatment plan was a "living document" to be updated as needed.



2) Pediatric Patient #16's Admission Orders dated 09/22/18, at 0110, reflected the patient had taken six Hydrocodone tablets and four Tylenol #3 in a self-harming attempt prior to her admission. Patient #16 was suicidal.


Patient #16's Nursing Admission Assessment dated 09/22/18, at 0440, reflected the patient's blood pressure of 115/66 mmHg.


Daily Nursing Assessment dated 09/23/18, at 0800, reflected the patient's blood pressure to be increased to 145/71 mmHg. Nursing Assessment dated 09/24/18, at 0800, reflected the patient's blood pressure of 132/60 mmHg. Nursing Assessment dated 09/24/18, at 1540, reflected the patient's blood pressure as 131/75 mmHg.


On 09/24/18, at approximately 2210, on the hospital's adolescent female unit, the surveyor received a document titled Vital Signs Log dated 09/24/18 for the 1500-to-2300 shift. The document reflected Patient #16's blood pressure to be 142/78 mmHg.


Record review of Patient # 16's treatment plan dated 09/22/18 did not reflect the patient's fluctuating blood pressure.


Hospital Personnel #10 and Hospital Personnel #14 in charge of Patient #16 denied awareness of the patient's fluctuating blood pressure on 09/25/18 at approximately 1105.


Stanford Children's Health warned that "if undiagnosed high blood pressure exists in childhood, young adults in their 20's can begin to exhibit harmful effects on their heart and blood vessels that can lead to heart attacks and stroke" (https://www.stanfordchildrens.org/en/topic/default?id=high-blood-pressure-in-children-and-adolescents-90-P01609)


Clinical Services Treatment Planning Policy dated 03/2018 reflected the purpose "to provide a complete, individualized, holistic plan of care ..."

Based on record review and interview, the hospital failed to ensure an individual comprehensive treatment plan for two of two patients (Patients #19 and #16).


1) Patient #19 was admitted to the hospital with suicidal ideation and severe depression. Three days into his hospitalization, Patient #19 received disturbing family news. Actively suicidal, Patient #19 was placed on special staff observation that required direct patient visualization. The patient's treatment plan did not reflect the heightened awareness of Patient #19's suicidality.


2) Patient #16, pediatric/adolescent patient, had fluctuating blood pressures that increased her risk for future heart attack and stroke. The patient's treatment plan did not reflect interventions for the patient's medical phenomenon.


Findings included:


1) Patient #19's Admission Orders dated 09/20/18, at 2112, reflected diagnoses that included Major Depressive Disorder, Severe, and Alcohol Use Disorder, Severe.


Comprehensive Psychiatric Evaluation dated 09/21/18, at 1655, reflected Patient #19's statement that he was suicidal with worsening mood swings. The patient had attempted to jump out of a moving car.


Therapist Notes dated 09/23/18, untimed, reflected Patient #19 found out that his family did not let him go back home due to his substance use. Patient #19 had suicidal thoughts "and wanted his door closed."


Orders dated 09/23/18, at 1646, reflected to renew self-harm and suicide precautions and place the patient on line-of-sight staff observation while awake.


Patient #19's Master Treatment Plan dated 09/21/18 reflected the patient was on 15-minute staff observation level.


Patient #19's Suicide Thoughts/Plan dated 09/23/18 did not specify the level of staff observation.


During an interview on 09/25/18, at approximately 0925, Hospital Personnel #12 stated that the treatment plan was a "living document" to be updated as needed.



2) Pediatric Patient #16's Admission Orders dated 09/22/18, at 0110, reflected the patient had taken six Hydrocodone tablets and four Tylenol #3 in a self-harming attempt prior to her admission. Patient #16 was suicidal.


Patient #16's Nursing Admission Assessment dated 09/22/18, at 0440, reflected the patient's blood pressure of 115/66 mmHg.


Daily Nursing Assessment dated 09/23/18, at 0800, reflected the patient's blood pressure to be increased to 145/71 mmHg. Nursing Assessment dated 09/24/18 at 0800 reflected the patient's blood pressure of 132/60 mmHg. Nursing Assessment dated 09/24/18 at 1540 reflected the patient's blood pressure as 131/75 mmHg.


On 09/24/18, at approximately 2210, on the hospital's adolescent female unit, the surveyor received a document titled Vital Signs Log dated 09/24/18 for the 1500-to-2300 shift. The document reflected Patient #16's blood pressure to be 142/78 mmHg.


Record review of Patient # 16's treatment plan dated 09/22/18 did not reflect the patient's fluctuating blood pressure.


Hospital Personnel #10 and Hospital Personnel #14 in charge of Patient #16 denied awareness of the patient's fluctuating blood pressure on 09/25/18 at approximately 1105.


Stanford Children's Health warned that "if undiagnosed high blood pressure exists in childhood, young adults in their 20's can begin to exhibit harmful effects on their heart and blood vessels that can lead to heart attacks and stroke" (https://www.stanfordchildrens.org/en/topic/default?id=high-blood-pressure-in-children-and-adolescents-90-P01609)


Clinical Services Treatment Planning Policy dated 03/2018 reflected the purpose "to provide a complete, individualized, holistic plan of care..."