HospitalInspections.org

Based on observation, interview and record review, the facility failed to provide patients care in a safe setting for 2 of 2 patients (ID#3 and 6).

Findings include:

Review of facility document titled Patient Rights and Responsibilities showed the following information:
-Receive physical and emotional care in a safe setting, which includes environmental safety, infection control and access to protective/ security services; to the extent the facility can control that environment.

Review of facility policy titled: Suicide Prevention Plan," dated 1/2024 showed the following information:

Policy: Nexus Health System (NHS) is dedicated to making a positive impact in the lives of individuals served by using evidence-based screening tools which focus on mental health.

NHS staff will maintain patient rights, dignity, and privacy at all times. It is not the intention of this policy to isolate or publicly identify at-risk patients. In general, patients at-risk will be assisted in identifying clothing of their own that meets ligature resistant standards and maintains their dignity and individuality.

NHS staff will utilize these procedures in conjunction with other accepted standards of clinical practice to ensure patients at-risk have their medical and psychological needs addressed.

II. Suicide Precautions and Environmental interventions
Certain measures will be taken to reduce and mitigate the risk of self-harm. An order is needed for suicide precautions ...
A. Suicide Precautions
The nurse may initiate suicide precautions for a patient who exhibits active suicide thoughts and/or behavior, or who is admitted for a prior attempted suicide. The nurse will notify the responsible provider and obtain an order. These preventative precautions shall, at minimum, include the following:
1. (1:1) observation- ongoing observation performed by designated staff who remain within arm's length at all times.
a. When a patient is in the bathroom or shower, the designated staff will maintain 1:1 observation within arm's length at all times.
B. Environmental Interventions
2. Room Preparation and Precautions ("Room Safety Sweep") staff will work to eliminate "pinch points" and identify items which could be used as an attachment point.
Remove from the patient's room, at minimum, the following items. [This is not intended to be an exhaustive list but are examples of preventative precautions]
a. Remove all zip ties, up to six inches, on cables, including call light
b. Remove oxygen and suction regulators and gauges
c. Remove all tubing including oxygen and suction
d. Remove telephone cord, call light cords, and television cords
e. Remove gloves, trash can, and trash can liners ...

Review of facility Environmental Risk Assessment showed the following:
Risk Identified: Plastic garbage bags.
Environmental mitigation: Plastic bags replaced with paper bags in areas accessible to patients.
(call light cords were not identified as risk)

Observation on 10/23/24 in 6 of 6 patient rooms showed multiple ligature tie off points including shower grab bars, faucets, toilet, toilet paper holder, wall-mounted paper towel holder and each had call light pull cords.

Medical record review on 10/23/24 for current patient (ID# 3) showed the following:
Active order for 1:1 observation level placed on 9/26/24.

Nursing note dated 10/1/24 stated: patient had taken scissors for rec therapy group to her room. When asked to give them back she denied. Shortly after 1:1 heard the scissors open and staff sked for them back again. At that point the patient placed the scissors to her neck and staff took them from her, code called...Pt then grabbed at this RNs chest, later stating she was trying to get the pen to stab herself.
Nursing note 10/10/24 stated patient had rough morning with her emotions. Stated several times to sitter and staff RN that she had a plan to commit suicide because her life was not worth living. She spoke in great detail about previous 13 failed suicide attempts ...

Nursing note 10/13/24 pt tried to tie self with trash bag.

Medical record review on 10/23/24 for current patient (ID# 6) showed the following:
Nursing note dated 10/13/24 stated patient wrote a note to nurse saying she wanted to kill herself. Nurse Practitioner was notified. Patient went to her room and the pull cord from her bathroom shower she had chewed off the wall around her neck.

Interview with nursing administrator (M) on 10/23/24 at 2:30 PM she stated she was not sure how the patient (ID#3) got a plastic trash bag and was able to attempt self-harm, while on 1:1. She also confirmed patient (ID#6) had an order for 1:1 but it was downgraded on 9/23/24 to QPM for 1:1 while the patient was in her room at night.

Based on interview and record review, the hospital failed to:

A. develop a restraint policy that defines the required patient assessment & monitoring to include: specific vital signs, frequency, and duration of monitoring for drug restraints.

B. ensure that 4 of 4 patients who received a "drug restraint" to control behaviors were assessed per facility-stated process [ Patient ID # 1, 2 , 3, 7 ].

Findings included:

A) Restraint policy issues:

- Record review of facility policy titled " Restraints," last revised 4/2023, read:

Definitions:

3. DRUG USED AS A RESTRAINT : is a medication used to control behavior or to restrict the patients freedom of movement and is not a standard treatment or dosage for the patient's condition. If the use of the medication for the paint meets the definition is a drug used as a restraint, the assessment , monitoring, and documentation requirements apply.

Continued review of this policy failed to show any specific required vital sign monitoring to include frequency and duration for patients given a drug restraint.

- Record review of facility protocol titled " Behavioral Emergency Medication Administration Protocol," last revised 02/21/2023 showed:

E. Monitoring: Staff will assess the patient at predetermined intervals to evaluate the effectiveness of the interventions and medication and document findings. Effectiveness may be determined using multiple objective assessment tools such as behavioral scales, pain scale, vital signs or other data sources.

Continued review of this policy failed to show any specific required vital sign monitoring to include frequency and duration for patients given a drug restraint.

Further review of this same policy showed:

- "no definition of "behavioral emergency medication."

-"references to only the use of intranasal (IN) midazolam (Versed) and the availability of reversal agent such as flumazenil (Romazicon).

Review of sampled patients' Medication Administration Records (MAR) showed Intramuscular (IM) administration of Thorazine, Geodon, Zyprexa, Ativan to manage aggressive, out-of-control behaviors.

[Thorazine, Geodon, Zyprexa are classified as anti-psychotic drugs; Ativan is a sedative]

B) Assessment of patients post-drug restraint administration:

Record review of the facility "Restraint Log: Chemical Restraint Audit section," dated September & October 2024, showed Patient IDs # 1 , 2, 3, 7 had been administered a "chemical restraint."

During an interview on 10/23/2024 at 1:45 PM with Staff ID-A, chief clinical officer, she stated when patents were administered a chemical restraint, their vital signs were monitored every 15 minutes for an hour; longer if needed. Vital signs included: blood pressure, heart rate, respirations, and oxygen saturation levels. She verified this monitoring process was not defined in the facility restraint policies.

Record review on 10/23/2024 of four (4) of 4 sampled patients was conducted with Staff-ID-E, RN. This review showed:

-Patient ID # 7:

Ativan 1 milligram (mg) IM was administered on 10/8/2024 at 1641. There were no vital signs recorded before or after administration.


-Patient ID # 1 :

a) Geodon 20 mg IM was administered on 9/30/2024 at 1614. Vital signs were taken 4 times. There were no times recorded for any of the 4 vital sign measurements.

b) Geodon 20 mg IM was administered on 10/3/2024 at 1445. Vital signs were measured at 1445 and 1500. Vital signs were not taken again until 6 hours later at 2100. Two sets of vital signs were missed [1515 and 1530].

-Patient ID# 2:

a) Thorazine 50 mg IM was administered on 09/28/2024 at 1225. Vital signs were recorded four times : beginning almost an hour after administration at 1752. Heart rate was missed twice.

b) Thorazine 50 mg IM was administered on 10/04/2024 at 1700. Vital signs were recorded four times ; heart rate was missed twice.


Patient ID # 3:

Zyprexa 10 mg IM was administered on 10/13/2024 at 1916. Vital signs were recorded four times at 15 minute intervals. Temperature was missed three times; heart rate was missed twice; and oxygen saturation was missed once.

The above findings were verified by Staff ID-E, RN at the time if review.