HospitalInspections.org

Based on medical record reviews, document reviews and interviews, the Governing Body was not effective in carrying out it's responsibility to ensure that patients are provided care in a safe setting on the Behavioral Health Unit, which contributed to the death of patient MR#1.

Specifically, the Governing Body did not provide oversight to ensure that policies and procedures were followed regarding the patient's right to receive adequate medical and Mental Health Services; and to ensure development of adequate policies and procedures to provide a secure and safe environment for patients.

Findings include:

1. The medical care was not consistent with prevailing standards of practice as demonstrated by failure of the medical staff to review, and re-evaluate MR #1's abnormal vital signs, (increased heart rate and blood pressure), while she was hospitalized on the Behavioral Health Unit from December 31, 2009 to January 14, 2010, when the patient died.
Mental Health monitoring was inadequate and in-effective as the patient continued to have increased paranoia and auditory hallucinations, without adequate observation.

Although 15 minute checks were recorded on the Levels of Observation Flow Sheet (Mental Health policy #041) as to the patient's location (in bed, TV room), there is no provision on the form to document if the patient was breathing. The current condition of the patient is not reflected on the monitoring form. Staff interviews indicated that the room was checked and the bed covers were lifted to observe the patient, who according to interviews "appeared to be breathing."
However, interview with the Medical Examiner on 1/4/10 at 4:45 PM revealed that the patient probably had been dead between 1 to 2 hours up to the time her body was found.
See Citation at A 049.

2. Staff failed to provide care to patient MR #1 in a safe environment by not observing the patient while on the unit to prevent any injury to her. According to nurse progress notes, the patient was discovered removing a radiator cover in order to escape the unit on January 5, 2010. She sustained an injury to her wrist. Staff placed the patient under constant observation on 1/5/10 for only one day (discontinued 1/6/10) after this incident.

In addition, staff failed to adequately conduct room checks and check visitor's bags to ensure a safe environment as per facility policy. Based on interview with Staff # 1, conducted on January 25, 2010 at 11:05 AM, a plastic bag containing sanitary napkins was given to the patient by her husband, either on 1/9 or 1/10/10. This bag was in the patient's possession for a few days despite staff documentation of unit checks and monitoring of the patient and patient's room. It was not detected on the unit until it was found over her head, face and nose on January 14, 2010. See Citation at S144,
#5.

3. Staff failed to provide adequate security since the Visitor's check-in log was not completed by the patient's husband or staff on 1/9/10, as per facility policy. Only the husband's name and time of arrival is recorded.
There is no indication that a plastic bag containing sanitary napkins was recorded as checked in by staff, when the husband brought it on the unit to visit the patient. According to the physician progress note, after the patient expired, the husband indicated he came on 1/10/10, but the log indicates the husband came 1/9/10.
See Citation at A 144.

Based on medical record review, observation and staff and patient interview, the hospital failed to protect each patient's right to be free from injury or death.

Findings are:

1. Staff failed to provide medical care and monitoring in accordance with facility policy and procedure and within standards of practice. See A 049 and A144.

2. Staff failed to ensure patient and staff security since visitors were not properly checked in or out of the unit and packages that were brought in were not searched and recorded as required per policy.
See A 144.

3. Staff failed to properly monitor patient's rooms and bathrooms to ensure that patients are safe, and that items that are potentially harmful to patients are removed from the environment. See A144.

Based on medical record reviews, policy reviews and interviews, the medical staff did not provide adequate medical care for a patient (MR #1).

Findings include:

The medical staff did not monitor and re-evaluate MR #1's vital signs during her hospitalization on the Behavioral Health Unit (BHU). This forty-three year old patient was admitted to the unit on December 31, 2009 after she had been stabilized in an intensive care unit having overdosed on Vasotec and Histamine. During her hospitalization in the intensive care unit, the patient's pulse rate ranged from 93 - 112 and on one occasion to a high of 127 on December 31, 2010 when she was transferred to the BHU. According to the psychiatrist, the hospitalist had stated that the patient's tachycardia was not an "acute concern" and that there was no need for further monitoring. However, there were abnormal deviations in the patient's pulse rates after admission to BHU, but staff failed to do a medical re-evaluation of her.

The patient's admitting diagnoses on the BHU were Depression with Psychosis and Schizoaffective Disorder Bipolar type.The patient's medical history included 3 prior attempts at suicide.

Upon admission to the unit, the patient's vital signs were temperature 100.4F, pulse -131, respiration 18 and B/P-120/82.

According to the facility's policy, vital signs were to be taken twice per day on the BHU as stated by Staff #1 on January 25, 2010 at 2:00 PM. The following findings were noted thereafter when the patient's temperature was within normal limits:
*the pulse rate increased to 133 with a B/P of 156/92 at 8:00 AM on; *January 3, 2010 when the temperature was 99F, and 8:00 PM that day it *had increased further to 138 with a B/P of 143/92;
*On January 4, 2010 at 4:00 PM the pulse-131 and B/P 188/105;
*On January 5, 2010 at 8:00 AM pulse of 130 and B/P of 164/98;
*On January 8, 2010 at 4:00 PM the pulse was 137 and B/P 142/96;
*On January 10, 2010 at 8:00 AM the pulse was 122, B/P 146/91;
*On January 11, 2010 at 8:00 PM pulse was 142 and B/P 127/94;
*On January 12, 2010 at 8:00 AM, pulse 137 with B/P 125/94 and at 8:00 PM 119 and 130/84;
*On January 13, 2010 at 8:00 PM the pulse was 132 and B/P 150/102. There were no further vital signs obtained up to the patient's death on January 14, 2010 at 8:22 AM when she was found in asystole.

On the other occasions, the patient refused to have her vital signs taken. These included
January 6, 2010 at at 8:00 PM;
throughout the day on January 7, and 9, 2010;
January 8, 2010 at 8:00 AM;
January 10, 2010 at 8:00 PM;
and on January 11, 2010 at 8:00 AM.
Staff acceded to the patient's requests not to have vitals taken, although policy and procedures require them.

Except for January 13, 2010 at 8:00 AM when the pulse was 109 and January 12, 2010 at 8:00 PM when the pulse was 119, the patient's lowest recorded pulse rate was 120. These findings significantly exceeded normal ranges.

The nursing staff documentation on January 4, 2010 at 10:00 AM revealed the patient reported that she had a "history 4 years ago of being on Altace to control HR." There was no evidence that the nursing staff reported these findings to a physician. Furthermore, there was no evidence that the physician monitored and re-assessed these findings or requested follow-up consultations for the changes in pulse and blood pressure, any time after the patient was admitted to the unit.

Staff #2 stated during an interview on January 26, 2010 at approximately 12:15 PM, that the patient's elevated vital signs were not a concern.
However, the physician failed to reassess the patient in light of the abnormal pulse and blood pressures.

Based on medical record reviews, document reviews, policy reviews and interviews, it was determined that the facility failed to provide care in a safe environment to prevent harm to, and death of a patient (MR #1).

Findings include:

1. Staff failed to adequately monitor and care for MR #1 on the Behavioral Health Unit (BHU). This failure contributed to the patient's death. This 43 year old patient was admitted to the intensive care unit at this facility. She had overdosed when she attempted to commit suicide with her husband's medications. The patient had a longstanding psychiatric history and had made 3 previous attempts in the past 6 months to commit suicide. The patient was intubated and stabilized before she was transferred to the Behavioral Health Unit on December 31, 2009 with diagnoses of Schizoaffective Disorder Bipolar type and Depression with Psychosis. Upon admission to the BHU, the psychiatrist and nursing staff documented that the patient was having auditory hallucinations, tellings her to kill herself. She was depressed, withdrawn, guarded, and her affect was blunted.

On January 5, 2010, a technician found the patient taking apart the radiator in her bathroom to "get out" despite 15 minute checks to determine the patient's activity and location. The patient stated that she wanted to "get out" and further stated that "she wanted to die. The patient also said I'm so tired. I just want to die."
According to the Lethality Assessment by nursing of 12/31/09, the patient was listed as a low to moderate risk for suicide. However, this is inconsistent with the patient history of 3 prior attempts at Suicide 6 months before. The only plan regarding her suicide risk was the Interdisciplinary Treatment Plan of 1/4/10. The intervention was to "try and talk about her hearing voices and ask for help at the DAY Program". The patient refused to sign the plan, but "reports saying that she will come to staff". In addition, the Nursing Flow Sheets for 1/12 and 1/13 indicate the patient was continuing to be positive for Halluccinations.
Therefore, given the patient's history and ongoing symptoms, staff failed to provide a safe physical environment for her. Staff also failed to adequately and effectively plan the patient's care and monitor her.

2. The nurse's note of 12/31/09 indicates the patient said, " the voices keep telling me do kill herself." On January 7, 2010 the patient reported having "bad thoughts and auditory hallucinations."
The next day the patient also told the staff that she felt that "other patients are talking about me." On January 10, 2010, the patient's behavior and mood was described as "unpredictable" and two days later she "continued to be depressed and preoccupied with continued auditory hallucinations." Progress notes continued to indicate that the voices were telling her to harm herself, as noted on January 13, 2010, the day prior to the patient's death.

During an interview conducted on January 25, 2010 at 11:00 AM with Staff, it was revealed that the patient's husband told staff he had visited the unit on January 10, 2010 and provided the patient with a plastic bag of sanitary napkins. However, the visit was not logged in the visitor's log as per facility's policy. Furthermore, the facility staff failed to search the patient's husband and any packages brought in as required per policy. The facility also requires 15 minute checks to determine the location of each patient, and routine checks of patients' rooms and bathrooms to ensure that items potentially harmful to patients are removed from the environment and therefore not available for patient harm. However, the plastic bag containing the sanitary napkins was not noticed during rounds after the visit of the patient's husband on either 1/9/2010 or 1/10/10. It cannot be validated which day the husband visited, because the incomplete visitor log indicated 1/9/10, while the patient's husband stated to staff he visited on 1/10/10.
The bag that contained the sanitary napkins was not discovered until the patient was found dead on 1/14/2010 with the same plastic bag over her head.

3. The patient was noted to have an abnormal pulse rate of 132 and B/P of 150/102 at 8:00 PM on January 13, 2010. In an addendum written at 5:05 PM on January 14, 2010, a nurse documented that the patient told the staff that she wanted to be left alone and did not want her vital signs taken after 10:30 PM that night. This information was not documented on the "Vital Signs Record" form, where at a minimum, according to this form, the vital signs should have been taken at 12:00 midnight, 4:00 AM and at 8:00 AM that morning. There was no evidence that staff relayed the abnormal findings noted at 8:00 PM the night of January 13, 2010 to the patient's physician. Furthermore, there was no evidence of ongoing attempts by staff to re-check the patient's vital signs throughout that evening and during the night, which should have been done, especially in view of the patient's abnormal pulse and blood pressure readings.

During an interview with the patient's physician on 1/26/2010, Staff #2 said, as per policy, vital signs are to be taken regardless of the patient request, unless there is a physician's order to the contrary. There was no physician order not to take vital signs.

4. At 8:22 AM on January 14, 2010, the patient was found by Staff #8 in her bed covered with a blanket with the plastic bag that previously contained the sanitary napkins over her head, covering her "head, eyes and nose but not mouth," according to Staff #1, #8, and #9.The patient was found in asystole with "jaws clenched shut," making intubation "impossible." Resuscitative measures were taken but were later determined to be "futile." She was pronounced dead at 8:44 AM that morning.

Staff #9, during an interview on January 26, 2010 at approximately 11:20 AM, stated that she saw the patient on her bed on January 14, 2010 in bed, stiff, cold and mottled, with a plastic bag (which previously contained the sanitary napkins) over her head, covering her nose but not her mouth.

During an interview conducted on January 26, 2010 at 2:15 PM, Staff #8 stated that she found the patient in her bed on January 14, 2010 between 8:15 AM and 8:30 AM with a bag over her head and it was up to her nose. The bag was described as having been "snug" over the patient's face "but not vacuum sealed."

According to staff interviews, the patient had been seen outside her doorway around 6:45 AM, and sitting on her bed around 7:15 AM. The staff interviews indicated that bed and room checks were performed every 15 minutes up to 8:00 AM. According to the interviews the patient was found between 8:15-8:30 AM. However, according to the interview with the medical examiner on 2/4/2010 at 4:45 PM, the patient was dead somewhere between 1 and 2 hours before being discovered. Given this information, staff accounting of bed and room checks for patient MR #1, is not reliable or accurate. There is no documented evidence the patient was alive and breathing during the bed checks, between one to two hours before she was found.

5. As per facility policy, staff failed to ensure that all visitors document in the visitor log their time of arrival and time of departure from the unit, and that all required columns are completed. According to the visitor log, the patient's husband visited on January 9, 2010 at 2:30 PM, but he could have visited on January 10th according to the husband. Staff did not document the time out for this visit nor the name of the person to be visited.
In addition, 88 of 114 documented visits to the unit between 1/06/10 and 1/20/10 did not have any documentation for the "time out" for those visits. Twenty-nine visits did not indicate "time in." Furthermore, eleven visitors did not document the relationship to the patient being visited.
For all 114 documented visits to the unit, there was no documentation to indicate if visitors brought any packages on the unit. According to the facility policy, Search of Patient's and Belongings, #026, all plastic bags are considered contraband and potentially dangerous.