HospitalInspections.org

Based on observation and interview the Hospital failed to provide care in a safe setting for patients on two out of three behavioral health units at their facility.

Findings include:

The Surveyors toured the inpatient floors with the Chief Operating Officer (COO), Chief Nursing Officer (CNO), and the Interim Chief Nursing Officer (ICNO) on 12/20/18 at 1:15 P.M. While touring 3 West, the Surveyors identified hinges on four doors in the main hall of the inpatient behavioral health unit and one door accessing the patient outdoor porch area as ligature risks. The Surveyors observed that the pay phone outside of the outdoor porch had a long metal phone cord and was identified as a ligature risk. The Surveyors then toured 4 West which had an identical floor plan. The Surveyors identified four doors in the hall of the inpatient behavioral health unit and the door for patients to access the outside porch as ligature risks.

The COO acknowledged that the hinges on both floors and the phone located on 3 West were ligature risks. The COO said that he would check to see if there were already plans in place to change these ligature risks. The COO asked the Maintenance Manager to meet with the Surveyors.

The Surveyors met with the Maintenance Manager on 12/20/18 at 2:00 P.M. The Maintenance Manager said that many of the hinges were already changed on 3 West and 4 West and that there were no plans to change the hinges on the ten doors that were identified. The Maintenance Manager said that the phones were already changed and that the pay phone on 3 West should have been replaced already and that it must have been missed.

The COO acknowledged that the hinges and telephone cord were ligature risks and there was no plan to change them.

Based on interview and record review the facility failed to track adverse patient events, analyze their causes, and implement preventive actions throughout the Hospital.

Findings include:

The Surveyors met with the Risk Manager on 12/18/18, at 9:14 A.M. and requested incident reports on Patient #1 involving a staff assault on a patient, Patient #2 involving a patient sexually assaulting another patient, and Patient #3 involving a patient's sudden death at the facility.

1. Patient #1's incident report, dated 10/16/18 indicated that on 8/29/18, Patient #1 was in the bathroom on 3 West on 1:1 observation by Mental Health Worker 1 (MHW #1). Patient #1 started throwing soap and water around the sink and MHW #1 attempted to redirect Patient #1. Patient #1 then attempted to grab a pen out of MHW #1's pocket and MHW #1 yelled for assistance. Mental Health Worker #2 (MHW #2) responded and Patient #1 voiced his/her intent to harm MHW #2. MHW #1 then physically held Patient #1 against the bathroom door by placing her forearm into the upper chest of Patient #1 and used an expletive telling Patient #1 to stop hurting staff. Patient #1 stated that he/she was frightened and was asking MHW #1 to stop when other staff, Registered Nurse #1 (RN #1) and Mental Health Worker #3 (MHW #3), arrived. Staff continued to hold Patient #1 for a few minutes until Patient #1 calmed down and then escorted Patient #1 back to his/her room.

The incident report indicated that MHW #1's physical hold of Patient #1 was inconsistent with the requirements of the Department of Mental Health (DMH) regulation 27.13, Human Rights, and DMH Policy #03-1, Human Rights and that it could be determined that staff held Patient #1's arms against his/her will constituting physical restraint and that a Restraint or Seclusion form was not completed at that time, in violation of the requirements of 104 CMR 27.12, Prevention of Restraint and Seclusion and Requirements When Used.

Surveyors interviewed the Risk Manager on 12/18/18, at 11:20 A.M. The Risk Manager said that the investigation was conducted by the DMH's Office of Investigation (OI). The Risk Manager said that the OI staff are not employed by the Hospital and he has no involvement in the investigation. The Risk Manager said that when the OI conducts an investigation on behalf of the Hospital he has no knowledge of who they interview, when the investigation takes place, or when the investigation is completed. The Risk Manager said that while an investigation is being conducted by the OI the Hospital has no access to the investigation.

Surveyors interviewed the Chief Operating Officer (COO) on 12/18/18, at 11:47 A.M. The COO said that Patient #1's investigation was conducted by the OI. The COO said that he did not know about the progress of the investigation until it was completed on 10/12/18. The COO said that the completed investigation was sent to the DMH Southeast Area Director (not an employee of the hospital) who then sent the report to him on 10/16/18. The COO said that MHW #1 was suspended with pay on 8/31/18 pending the outcome of the investigation. The COO said that as a result of the investigation, MHW #1 was suspended without pay for 5 days and reported to work on 11/21/18. The COO said that there was no disciplinary actions for any other staff members and that there were no corrective actions implemented as a result of this incident. The COO acknowledged that the Quality Department and Risk Manager were not involved in the investigation and no corrective actions were implemented as a result of this incident.

2. Patient #2's incident report, dated 10/4/18, indicated that on 10/3/18, at 12:30 P.M. MHW #4 observed Patient #4 inappropriately commenting on Patient #2's buttocks and Patient #4 was redirected. The incident report indicated that, a short time later, Patient #4 was observed kissing Patient #2 on the cheek and again was re-directed. At 1:55 P.M., Patient #2 reported that Patient #4 reached down Patient #2's pants and poked him/her in the rectum.

Surveyors interviewed the Risk Manager on 12/19/18, at 11:00 A.M. The Risk Manager said that he was not involved in the investigation of Patient #2's incident and that the OI was investigating. The Risk Manager again acknowledged that no Hospital staff were involved in the investigation. The Risk Manager said that he believed that the investigation involving Patient #2 was complete but was unable to produce a report.

3. Patient #3's incident report dated 8/3/18 indicated that, on 8/2/18, at 9:00 A.M., Patient #3 was observed exiting his/her room to get his/her medications from the medication nurse. Patient #3 was observed walking in the hallway when he/she stopped and said "I don't feel right" or words to that effect and then collapsed to the floor. Patient #3 was unresponsive and not breathing. Staff started Cardiopulmonary Resuscitation (CPR) and called 911. Emergency Medical Services (EMS) arrived and took over CPR. Patient #3 was transported to an area hospital where he/she was pronounced dead at 9:44 A.M.

Surveyors interviewed the Risk Manager on 12/19/18, at 11:00 A.M. The Risk Manager said that he was not involved in the investigation of Patient #3's incident and that the OI was investigating. The Risk Manager again acknowledged that no Hospital staff were involved in Patient #3's investigation. The Risk Manager said that the investigation involving Patient #3 was ongoing and that he had no access to the investigation.

Surveyors interviewed the COO on 12/19/18 at 12:15 P. M. The COO acknowledged that, when the OI is conducting an investigation, the Hospital is not involved in the investigation. The COO said that after the OI's investigation is completed the Hospital then decides if any corrective measures are taken.