HospitalInspections.org

Based on record review and staff interview, it has been determined that the hospital failed to meet the Condition of Participation of Patient's Rights relative to care in a safe setting for 1 sample patient, Patient ID # 1.

Findings are as follows:

The hospital failed to provide Patient ID#1 who is actively psychotic, the necessary supervision to maintain complete safety while a patient on the Intensive Treatment Unit (ITU). (refer to A-144)

Based on record review, surveyor observation, staff interviews, and policy review, it has been determined that the hospital failed to provide physical safety for 1 of 1 patient, Patient, ID #1 who did not receive appropriate supervision while being treated on the Intensive Treatment Unit (ITU).

Findings are as follows:

Surveyor review of the medical record for Patient ID #1 revealed s/he was admitted to the hospital in April 2021 with diagnoses including, but not limited to, schizoaffective disorder, depressed mood, and polysubstance dependence. S/he was actively experiencing auditory hallucinations, aggression, and disorganized thinking and was subsequently transferred to the ITU for increased monitoring and safety. On 8/10/2021, while still on the ITU, Patient ID #1 attempted to gouge his right eye out with a plastic spoon while under the supervision of hospital staff.

The hospital's document titled "Benton Guidelines", states, in part,
" These guidelines were developed to ensure that each unit maintains a safe environment for everyone..."

-SEARCHES ...Utensil counts will occur before leaving the eating area ..."

The hospital's "Patient Observation Policy," last approved in February 2020, states, in part,
"Definitions: ...

3.0) 5-minutes: Requires an assigned staff member to visually observe and document the patient safety status at the ordered interval ...

3.1) 5-Minute Observation- This is an enhanced level of observation. It is suitable for patients that pose a significant risk of self-injury, uncontrollable behavior, or suicidal risk/thoughts and behavior ..."

Review of the medical record for Patient ID #1 revealed s/he was admitted in April 2021.

Patient ID #1 has a diagnosis of schizoaffective disorder, depressed mood, and polysubstance dependence.
This patient was actively experiencing auditory hallucinations, aggression, and disorganized thinking. The patient was transferred to the ITU for inceased monitoring and safety.

Review of Patient ID #1's Provider Orders reveal s/he is on 5-minute observation checks.

Review of the 5-minute check form from the date and time of the incident, reveals the 5-minute checks were performed and signed off as completed, by the Mental Health Worker (MHW) Staff D.

Review of the video surveillance for the date of the incident, 8/10/2021, reveals at 4:49 PM the patient left the common area of the ITU and went into his/her bedroom with a plastic spoon and a cup in his/her hand, closed the bedroom door, and was now out of view from the MHW, Staff D, and the Security Guard, Staff F, who were responsible for observation of this patient and present at the viewing window.
When Patient ID #1 went to his/her bedroom with the spoon and cup in his/her hand the MHW and Security Guard failed to enter the ITU area and retrieve the plastic spoon and cup before he left the common area. As a direct result of this failure, the patient entered his/her room with a spoon which was then used by the patient in an attempt to gouge his/her right eye out.

Review of this surveillance reveals the patient was not visualized from 4:49 PM through 5:05 PM when s/he exited the bedroom without the possession of the spoon or cup.

During an interview on 8/12/2021 at approximately 12:00 PM, with the MHW, Staff A who initially gave the patient his/her dinner items, he stated he was very sure he gave the patient only one plastic spoon.

During an interview on 8/12/2021, at approximately 12:00 PM, with the Supervising Registered Nurse, Staff E, he stated the physician should have been called and a body search should have been done on this patient when the spoon was not found.

Review of the "Utensil Count" form dated 8/10/2021 reveals at "Dinner" the patient received 2 utensils and returned 2 utensils at dinner, despite the interview with the MHW, Staff A, who stated he gave Patient ID #1 the meal and reported he was sure he gave one plastic spoon. When Staff A was asked if he had signed the Utensil Count sheet, he stated he did not, and did not recognize the initials on the 8/10/2021 utensil count form.

During an interview with the unit nurse, Staff B, on 8/13/2021, the nurse for Patient ID #1, who was present during the incident, stated when she asked the patient s/he denied receiving a utensil. Additionally, she revealed the utensil count form is completed by the staff who leaves the tray, and the staff who collects the tray from the patients. She stated a room search was completed by security, nursing and MHW staff, and no utensil was identified. When asked if a body search had been performed, Staff B stated she was planning to but had not been done.

Review of the video surveillance for 8/10/2021 reveals at 5:28 PM the patient re-enters his/her room and closes the door. S/he exits the bedroom at 5:34 PM with the spoon in his/her hand, and drops the spoon in front of the ITU entry door. At 5:34 PM, s/he then went back to the bedroom and closed the door. The Security Guard Staff G, at the ITU door, then entered the ITU with gloved hands and removed the spoon from the floor as the MHW, Staff D remained in her chair outside the viewing window. Staff G noted the spoon with bloody residue and brought it to Nurse Staff B. At 5:36 PM the patient was observed exiting the bedroom and began speaking to the Security Officer Staff G at the ITU door, the MHW, Staff D was also present at the viewing window.
At 5:48 PM Nurse Staff B, 1 MHW and 2 Security Officers entered the ITU, Nurse Staff B is then noted tending to Patient ID #1's right eye.

During an interview on 8/12/2021 at 3:30 PM, and 8/13/2021, at approximately 9:30 PM, with the Chief Nursing Officer and the Risk Manager, both acknowledged that hospital policy was not followed related to Utensil Counts, and 5-minute observation status, additionally, both stated that when the spoon was not found it is then considered contraband, which would constitute a body search being performed.