HospitalInspections.org

Based on record review, interview and video review, the facility failed to protect personal privacy of patients (A143), failed to ensure patients were appropriately monitored when locked in the seclusion room (A145), failed to develop and implement a policy for the use of "open seclusion" (A167), and failed to ensure a physician's order was obtained for the use of a restraint or seclusion (A168). The facility inpatient census was nine.

Based on record review and interview, the facility failed to protect the personal privacy of patients when staff utilized text messaging to communicate patient health information. This affected three (Patients #1, #2 and #4) of eight Behavioral Health Unit patients reviewed. The census was nine.

Findings include:

1. Review of Patient #2's medical record revealed on 12/23/18 the physician requested the nurse "text him" the patient's medication list from her last admission.

2. Review of Patient #4's medical record revealed the nurse texted the physician twice on 12/23/18 to update him on the patient's condition.

3. Review of interview documentation from investigation documentation revealed Patient #1 became agitated on 12/20/18. The physician was contacted via text by Staff D.

During interview on 01/02/18 at 1:44 P.M., Staff A stated it was never acceptable to text patient health information.

Based on record review, interview and video review, the facility failed to ensure patients were appropriately monitored when locked in the seclusion room. This affected one (Patient #1) of eight Behavioral Health Unit medical records reviewed. This had the potential to affect all patients receiving services in the behavioral unit of the facility. The behavioral health unit census was five.

Findings include:

Review of the medical record for Patient #1 revealed an admission date of 12/18/18 and a primary diagnosis of bipolar disorder and mild intellectual disability. The medical record revealed on 12/20/18 at 12:48 P.M., Patient #1 was taken to "open seclusion" to calm and deescalate. The medical record contained no documentation of a physcian order authorizing the use of seclusion nor was there documentation Patient #1 was being continuously monitored while in seclusion. The patient was found in the seclusion room unresponsive at 2:05 P.M. and died.

On 12/24/18 at 11:32 A.M. Staff D, who was on duty at the time of the incident, was interviewed as part of the faciliy investigation. The documentation stated Staff D was asked to describe how Patient #1 "hit" staff as described in her documentation. Staff D stated the patient was grabbing at staff and hit her in the bathroom. Staff D stated she tried to deescalate the patient, as he/she was jumping and excited. Staff D gave the patient Crayons to color and that did not work. Staff D stated the patient could not be redirected. Staff D stated he/she called the psychiatrist. Staff D was asked if she called or texted. Staff D stated she texted the physcian. Staff D was asked what she told the psychiatrist and she stated she texted that the patient was violent and hitting people. Medication was ordered. Staff D was asked if the psychiatrist gave an order for seclusion and she stated no. Staff D was asked if she placed the patient in seclusion and locked the door. Staff D stated she didn't know what else to do. Staff D was asked if she informed the physician of the seclusion and she said no. Staff D was asked if there was a reason she did not inform the physician and Staff D did not respond to the question. When asked of the location of the aggressive behavior, Staff D stated that it was near the nurses station. Staff D said Patient #1 was upsetting another patient.

Review of the written statement completed by Staff F revealed at approximately 1:20 P.M. on 12/20/18, Staff F returned to the unit after delivering probate papers to the local probate court. When Staff F got to the unit he/she informed Staff D that he/she had not eaten and was going down to the cafeteria to get lunch. After returning from the cafeteria, Staff F was informed Patient #1 had been placed in seclusion while Staff F was gone due to urinating on the floor and becoming increasingly agitated. Staff F looked on the camera monitor and saw the patient in the seclusion room. At that time, Patient #1 was awake and walking around the room. Staff F then put supplies away while Staff D took medications back to the patient. After putting supplies away, Staff D ate lunch. Upon returning to the unit from lunch, Staff F looked at the camera monitor and saw Patient #1 lying on the bed in the seclusion room and appeared to be sleeping. Staff F described the patient as lying on the left side with his/her head off the side of the bed, with no blanket. Staff F put gloves on and went to make the patient more comfortable. When Staff F got to the seclusion room, he/she looked through the window of the door and saw that there were pieces of the patient's incontinent brief on the floor. Staff F then went to get an incontinent brief with the intent of cleaning up the patient. When Staff F returned to the seclusion room, the patient appeared to still be sleeping. Staff F stated that when he/she entered the seclusion room he/she called the patient's name and the patient did not respond. Staff F assumed the patient was sleeping due to receiving medication. Staff F decided to clean up the floor prior to trying to arouse the patient. After Staff F cleaned the floor, he/she called the patient's name again and lifted the patient's head. At that time, the patient's face was purple in color and that there were pieces of the incontinent brief in the patient's mouth. Staff F ran out into the hallway and yelled for Staff D and told him/her to call a code. Staff F then returned back to the patient to try to arouse him/her while trying to clear the airway of debris. Staff D began chest compressions after calling the code. Almost immediately after, the code team came to the unit and transported the patient to the emergency room, where he later died.

Review of the seclusion room video recorded on 12/20/18 revealed the following sequence of events:

-At 12:49:15 P.M., the patient was forced into the seclusion room by staff that cannot be seen. Patient #1's feet are seen sliding on the floor as staff appear to push the patient into the seclusion room.

-At 1:31:47 P.M., the door opened and a staff member was standing in the door way.

-At 1:32:14 P.M., the staff member left the room. The patient attempted to leave the room as well and was pushed back into the room with the door. The door was locked, not allowing the patient to leave the room.

-At 1:40:26 P.M. the patient is seen pulling apart the incontinent brief and chewing it up.

-At 1:42:01 P.M., the patient was coughing with contents coming out of his mouth. The patient took several steps and gagged. He is using accessory muscles of the neck.

-At 1:43:15 P.M., the patient picked up pieces of the incontinent brief and placed them back in his mouth. The patient goes to the door, then turns and walks away.

-At 1:43:30 the patient walks around the bed and is using accessory muscles in the neck to breathe. He bends over, places his hands on his knees and coughs.

-At 1:43:38 P.M., the patient is at the door, but due to the angle of the camera, the patient cannot be seen clearly.

-At 1:43:49 P.M., Patient #1 is struggling to breathe and using accessory muscles.

-At 1:43:52 P.M., the patient sits on the edge of the bed, gasping for air, using accessory muscles to breathe. He gets up and walks to other side of the bed. He stops again and gasps for air.

-At 1:44:18 P.M., the patient goes to the door again, appears to be beating on the door and looking through the window. The patient walks around bed, puts his hands on his knees and tries to catch is breath.

-At 1:44:39 P.M., the patient returns to the door. He walks around the room again, gasping for air.

-At 1:44:47 P.M., the patient was back at the door and appears to be beating on the door, but unable to tell due to the camera angle. He walks around the room again, gasping for air.

At 1:45:13 P.M., the patient is on the bed on his hands and knees. He then lays on the bed on his right side, lifting his head off the bed and gasping for air. His chest can be seen rising and falling dramatically.

At 1:45:27 P.M., the patient gets out of bed, picks up more pieces of the incontinent brief and chews. The patient goes back to the door.

-At 1:45:54 P.M., the patient goes back to the bed. He gets on his hands and knees, then lays on his right side with his head up, gasping for air. The patient then sits up on the side of the bed. His arms are shaking and he is gasping for air, using accessory muscles in his neck and chest.

-At 1:46:28 P.M., the patient lays back down again, then sits up, gasping for air, using accessory muscles. He continues to get up and down, struggling to breathe.

-At 1:48:14, the patient is restless. He tries to prop himself up on his right arm but cannot. He attempts to stand but cannot and lays back down, using accessory muscles to breathe.

-At 1:49:04 P.M., the patient continues to attempt to get out of bed several times but cannot, and drops himself onto the bed, gasping for air.

-At 1:50:39 the patient again sits up on the side of the bed, swaying back and forth. He slowly starts to slump over to his left side. He lays back down, with this head and right arm hanging off the side of the bed.

-At 1:52:00 P.M., Patient #1 is not moving. His respirations are nine breaths per minute.

-At 1:54:00 P.M., the patient's breaths are seven per minute and irregular.

-At 1:56:00 P.M., the patient's breaths are three per minute.

-At 1:57:20 P.M., Patient #1 stops breathing.

-At 2:03:24 P.M., the door to the seclusion room opens and Staff F enters, pauses at the door, then proceeds to clean the floor.

-At 2:05:11 P.M.., Staff F goes over to the patient, attempts to arouse him and lifts the patient's head onto the bed. Staff F leaves the room at 2:05:26 P.M. Twenty seconds later Staff F reenters the room, and checks the patient's mouth.

-At 2:06:35 P.M., Staff D enters the room and at 2:06:50 P.M., starts chest compressions.

-At 2:08:20 P.M., the code team enters the room.

During interview on 01/02/19 at 1:44 P.M. with Staff A, a request was made for the facility policy/procedure related to the use of "open seclusion". Staff A stated she was uncertain if there was a policy related to "open seclusion.."

During interview on 1/03/19 at 8:32 A.M. with Staff A, Staff B and Staff C, a request was made for the policy/procedure and staff education/training related to "open seclusion." All three staff confirmed there was no policy/procedure and no staff education/training related to "open seclusion."

During interview on 01/03/19 at 8:50 A.M., Staff C stated staff are aware and were aware that patients are to be continuously monitored by staff when in seclusion or restraints. This is what is expected of staff. He/she also stated that there is no documentation of staff training on this and they have found this to be an issue, and stated that the manager talks with staff but does not document or have them sign when they receive training.

Review of the facility policy titled "Restraint/Seclusion", revised July 2011, made no reference to "open seclusion."

No documented definition of "open seclusion" was provided during the survey.

Based record review and interview, the facility failed to develop and implement a policy for the use of "open seclusion." This affected four (Patients #1, #2, #5 and #9) of four patients reviewed who were placed in "open seclusion". The census was nine.

Findings include:

1. Patient #2 was admitted to the Behavioral Health Unit on 12/23/18 with a primary diagnosis of bipolar disorder.

Review of Patient #2's medical record revealed she was in "open seclusion" for a period of time on 12/23/18, 12/25/18 and 12/26/18.

2. Patient #5 was admitted to the facility on 12/18/18 with a primary diagnosis of schizophrenia and was legally blind.

Review of Patient #5's medical record revealed he was in "open seclusion" for a period of time on 12/19/18 and 12/20/18.

3. Patient #9 was admitted to the facility on 10/17/18 with a primary diagnosis of autism spectrum disorder.

Review of Patient #9's medical record revealed he was placed in "open seclusion" for a period of time on 10/20/18.

4. Patient #1 was admitted to the facility on 12/18/18 with a primary diagnosis of bipolar disorder and mild intellectual disability.

Review of patient #1's medical record revealed he was placed in "open seclusion" for a period of time on 12/20/18. Review of investigation documentation involving Patient #1 also revealed the door was locked during his episode of "open seclusion".

During interview on 01/02/19 at 1:44 P.M. with Staff A, a request was made for the facility policy/procedure related to the use of "open seclusion". Staff A stated she was uncertain if there was a policy related to "open seclusion.."

During interview on 01/03/19 at 8:32 A.M. with Staff A, Staff B and Staff C, a request was made for the policy/procedure and staff education/training related to "open seclusion." All three staff confirmed there was no policy/procedure and no staff education/training related to "open seclusion."

During interview on 01/03/19 at 8:50 A.M., Staff C stated staff are aware and were aware that patients are to be continuously monitored by staff when in seclusion or restraints. This is what is expected of staff. He/she also stated that there is no documentation of staff training on this and they have found this to be an issue, and stated that the manager talks with staff but does not document or have them sign when they receive training.

Review of the facility policy titled "Restraint/Seclusion", revised July 2011, made no reference to "open seclusion."

No documented definition of "open seclusion" was provided during the survey.

Based on record review and interview, the facility failed to ensure a physician order was obtained prior to the use of restraints or seclusion. This affected four (Patients #1, #2, #5 and #9) of four patients who were placed in "open seclusion". The census was nine.

Findings include:

1. Patient #1 was admitted to the facility on 12/18/18 with a primary diagnosis of bipolar disorder and mild intellectual disability.

Review of patient #1's medical record revealed he was placed in "open seclusion" for a period of time on 12/20/18. Review of investigation documentation involving Patient #1 also revealed the door was locked during his episode of "open seclusion". There was no documented physician order for the use of seclusion.

2. Patient #2 was admitted to the Behavioral Health Unit on 12/23/18 with a primary diagnosis of bipolar disorder.

Review of Patient #2's medical record revealed she was in "open seclusion" for a period of time on 12/23/18, 12/25/18 and 12/26/18. There was no documented physician order for the use of seclusion.

3. Patient #5 was admitted to the facility on 12/18/18 with a primary diagnosis of schizophrenia and was legally blind.

Review of Patient #5's medical record revealed he was in "open seclusion" for a period of time on 12/19/18 and 12/20/18. There was no documented physician order for the use of seclusion.

4. Patient #9 was admitted to the facility on 10/17/18 with a primary diagnosis of autism spectrum disorder.

Review of Patient #9's medical record revealed he was placed in "open seclusion" for a period of time on 10/20/18. There was no documented physician order for the use of seclusion.

During interview on 01/03/19 at 8:32 A.M., Staff A, Staff B and Staff C confirmed there were no physician orders for the use of seclusion for Patient's #1, #2, #5 and #9. All three staff also confirmed there was no policy related to the use of "open seclusion."

The faciliy policy titled "Restraint/Seclusion", revised July 2011, stated "a physician's order is required each time a patient is placed in seclusion and/or restraint."

No documented definition of "open seclusion" was provided during the survey.