HospitalInspections.org

Based on observation and interview, the hospital failed to ensure:
1. Behavioral health patients could not access ligatures and sharps for one (Hope Unit) of one behavioral health units.
2. Recognition of injury for one (Patient #3) of six patients.

Findings:

HOPE UNIT

On 05/07/25 from 10:26 AM to 10:44 AM during a tour of the Hope Unit, the following was observed:

1. North hallway patient storage supply room door was not closed and the room contained ink pens, a purse strap and a hung closet rod, as well as two approximately 1x1 inch ceramic tiles not adhered to the floor.
2. Seclusion room 309A with wall trim not adhered to the wall and the white disc of a concealed fire sprinkler was not flush to the ceiling and extended down approximately one inch from the ceiling.
3. Anteroom of seclusion room 309A with an open supply closet door and the closet contained boxes of BD Insyte IV needles.
4. North hallway electrical panel door was not flush to wall and had a loose screw.

On 05/07/25 from 10:26 AM to 10:44 AM, Staff G stated the supply room doors were supposed to be closed and locked and patients could use the items inside to harm themselves or others.

On 05/08/25 from 9:43 AM to 10:03 AM, Staff A stated the following:
1. We fixed the trim. Patients could have used it to cut themselves.
2. We fixed the fire sprinkler. The white disc was a thin piece of metal and could have been broken off and patients could have cut themselves with it.
3. Patients have access to the north hallway and could have used the loose screw to scratch themselves.


PATIENT #3

Review of policy #GBR 2024-09 titled "Fall Prevention" revised 09/17/2024 read in part, "Post Fall Procedures/Management ...If patient does hit their head or it is unknown if the patient hit their head, assessments shall include vitals and Glasgow Coma Scale (GCS) assessments at appropriate intervals. i Record vital signs every hour for 12 hours ii Record a GCS every 15 minutes for 1 hour, then every 30 minutes for 2 hours, then every hour for 12 hours."

Review of the medical record showed the patient admitted to the hospital with acute psychosis and hallucinations, sustained an unwitnessed fall with injury and did not show monitoring to assess for brain injury. Specifically:

1. Nursing flowsheet data dated 02/27/25 at 1:00 PM read in part, "Disoriented x 4."
2. An internal medicine consult note dated 02/27/25 at 1:49 PM read in part, "admission to the Hope unit due to acute psychosis with hallucinations ...Patient is currently oriented to ...name only."
3. Patient Post Fall Evaluation dated 02/27/25 at 8:39 PM showed the patient had an unwitnessed fall on 02/27/25 at 8:10 PM.
4. X-ray of right ribs result dated 02/27/25 read in part, "(Received on 02/27/2025 10:34:07 PM) Reason for Exam: Pain ...Impression: Non-displaced fractures of the right 8th and 9th ribs."
5. Post Fall Huddle dated 02/27/25 at 9:00 PM read in part, "Did Patient hit his/her head? 'NO' ...Fall witnessed? 'NO.'"
6. A nursing note dated 02/27/25 at 11:20 PM read in part, "2010 [8:10 PM] ...Thought processes disorganized and confused."
7. An internal document dated 02/28/25 at 8:29 AM read in part, "Date of Occurrence Feb 27, 2025 8:10 PM ...Occurrence Type Fall While Walking (unwitnessed)."
8. Nursing flowsheet data showed vital signs were obtained after the fall on 02/27/25 at 8:39 PM. (11 missed sets of vital signs)
9. Nursing flowsheet data showed Glasgow Coma Scale was assessed after the fall on 02/27/25 at 8:39 PM. (17 missed GCS assessments)

On 05/07/25 at 2:27 PM, Staff H reviewed the medical record and the policy and stated:

1. Vital signs were not done every hour for 12 hours.
2. Glasgow Coma Scale was not done every 15 minutes for 1 hour, then every 30 minutes for 2 hours, then every hour for 12 hours.
3. The risk to the patient was staff being unaware of something occurring with the patient like a brain bleed or a fracture.

On 05/08/25 at 11:12 AM, Staff B reviewed the medical record and the policy and stated a good nursing practice for an unwitnessed fall in the behavioral health unit was to perform a head to toe assessment and to follow the policy for a patient having hit their head.