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Based on observation and interview, the facility failed to meet the requirements for the Condition of Participation (CoP) for Patients' Rights. The deficient practice is evidenced by failing to ensure that patients received care in a safe setting as having a patient care environment with hazards that presented: 1.) Ligature risks and 2.) Unsafe patient room door locks. (See findings under A-0144)

Based on observation and interview, the hospital failed to ensure that patients received care in a safe setting as evidenced by having a patient care environment with hazards that presented: 1.) Ligature risks and 2.) Unsafe patient room door locks.
Findings:

1.) Ligature Risk

On 10/07/2024 between 3:20 p.m. and 3:50 p.m., a tour of the hospital's first floor patient bathrooms revealed the following potential ligature points that could be used by a patient:
-Main lobby - 2 bathroom toilet seats,
- Administration conference room - bathroom toilet seat, door knob, water sprinkler and removable ceiling tiles with other structural ligature points,
- Administration conference room bathroom anteroom - water sprinkler and removable ceiling tiles with other structural ligature points,
- 1 South men's and women's showers located prior to entering the unit - toilet seats, shower room toilet seat on the unit,
- 1 West patient rooms 176, 178, 180-185, 187, patient bathroom located at the end of the hall on the left - toilet seats,
- 1 Tower seclusion room, patient rooms 110-116 - toilet seats.

In an interview on 10/07/2024 at 3:50 p.m., S2PI Dir verified the toilet seats, water sprinklers and structural support above the ceiling tiles as potential ligature points. She also verified all areas identified are used by patients potentially with suicidal ideation.

On 10/08/2024 between 9:30 a.m. and 10:30 a.m.,a tour of the hospital's second floor patient rooms and bathrooms revealed the following ligature points that could be used by the patient:
- 2 South bathroom by laundry room toilet seat;
- 2 South Extension rooms 245, 247, 256, 258 toilet seats, removable ceiling tiles with other structural ligature points;
- 2 North Enhanced boys bathrooms by laundry, in shower rooms and seclusion room toilet seats. No toilets located in patient rooms;
- 2 West hallway bathroom and patient rooms 278-279 toilet seats;
- 2 Tower seclusion room bathroom and patient rooms 228-231 toilet seats

On 10/08/2024 between 1:30 p.m. and 2:10 p.m., a tour of the hospitals 3rd and 4th floors patient bathrooms revealed toilet seat ligature points in the following rooms:
- 3rd floor Adult Enhanced unit seclusion room toilet, patient rooms 333-339, 341 and the 2 shower room toilets;
- 3 South patient rooms 358, 360, 362, 364-371 and 2 shower rooms at the end of the hall;
- 3 West patient rooms 380-389 and shower room on the left at the end of the hall;
- 3 Tower patient rooms 310- 316, the hall bathroom and seclusion room;
- 4 ASD seclusion room bathroom toilet and 2 hallway bathroom toilets;
- 4 West 4 hallway bathroom toilets. No bathrooms in patient rooms.
- 4 Tower patient rooms 409- 413


2.) Unsafe patient room door locks

During the hospital tour on 10/07/2024 and 10/08/2024 an observation of all the hospital patient room locks revealed they automatically locked upon closing and staff had to utilize a key to access. The hospital has 128 licensed patient rooms. This presents as a patient safety issue as a patient could place an object in the key hole rendering key access useless. The patient would then be locked in the room and could harm themselves or others while staff attempted to gain access.

In an interview on 10/8/2024 at 2:10 p.m. S2PI Dir verified the above findings for the ligature and patient room door lock safety issues.

In an interview on 10/08/2024 at 2:20 p.m., S1Adm verbalized an understanding of the potential safety issues with the toilet ligature risk and patient doors automatically locking. He stated, he had not thought about those as issues.

In an interview on 10/08/2024 at 2:20 p.m., S3Plant Operations Manager verified the locks on all patient rooms automatically lock when the door is closed. He also verified that it is possible for a patient to place something in the keyhole rendering it impossible to open the patient door with a key. He stated he would have to be contacted to come and remove the entire door handle and lock and if it were after hours it would take some time for maintenance to drive to the hospital and complete the removal.


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Based on record review and interview, the hospital's performance improvement activities program failed to implement actions to prevent recurrence of adverse patient events following a patient's elopement from a secured unit for 1 (Patient #5) of 2 patients (Patients #3, #5) reviewed for elopement events in a total sample of 9.
Findings:

Review of the facility's LDH Self Report (initial and final) dated 10/08/2024 revealed the following:
On 10/07/2024 at 9:24 a.m., S4Counselor was exiting through the rear doors of 2 North (Adolescent Boys Enhanced Unit) when Patient #5 ran behind her and tried to leave the unit. S4Counselor can be seen trying to push him back in, however she was overpowered. At 9:26:33 a.m., Patient #5 left through the outpatient clinic doors, ran through hallway, and then to the outside. He was chased by staff, however they were not able to catch him.

Review of the facility's investigation results revealed: There were multiple staff present on the milieu at the time of the incident; however, the patient took advantage of a moment when a staff member was exiting the unit to leave. Despite the staff's immediate efforts to retrieve the patient they were unsuccessful. The patient has since been located by local police and has returned to our facility. To improve overall safety, we have set up a meeting to discuss deactivating the 2 North exit door that leads to the outpatient area. We will continue to assess for opportunities for improvement related to patient safety.

On 10/09/2024 at 11:15 a.m., an interview with S2PI Dir confirmed no changes had been made to address the traffic flow through the secured unit into an unsecured area of the hospital, and the door had not yet been deactivated.

On 10/09/2024 at 12:45 p.m., an interview with S5MHT confirmed there were 9 boys on the 2 North Adolescent Boys Enhanced Unit unit the morning of 10/07/2024 when she arrived for her shift. She stated Patient #5 had been discharged earlier and was waiting for transportation. When the discharge was canceled, Patient #5 had become very upset and was in the timeout room, cooling off. When S4Counselor walked into the unit and through toward the back exit door, he followed her and stopped at the laundry room where S6MHT was doing laundry. When S4Counselor went down the hall and out the exit door, S5MHT saw Patient #5 running down the hall to catch the door before it closed. S5MHT and S6MHT immediately followed him out of the door, into the hallway and outside the building. Patient #5 went underneath the ramp railing and down the hill before they could catch up with him. S5MHT confirmed there had been no changes to the staff using the unit as a walkthrough area to get to the unsecured area in the outpatient clinic, and that the traffic flow is fairly heavy for this purpose at all times during the day, including today.

On 10/09/2024 at 1:07 p.m., an interview with S6MHT confirmed she was on the 2 North unit the morning of 10/07/2024 to transport Patient #5 to another facility following his discharge. While she was on the unit, the discharge got canceled due to placement issues. Patient #5 got upset, and was crying. He went into the quiet room with the door open, and kept coming in and out of the room. When S4Counselor came into the unit to pass through to the outpatient clinic, Patient #5 followed her as far as the laundry room near the hallway to the outpatient clinic exit door. When S4Counselor went through the exit door, Patient #5 bounded down the hallway and grabbed the door before it closed. S6MHT stated she was in the laundry room and didn't see him go out, but S5MHT did see him and they both immediately went after him. S6MHT confirmed that she is on the 2 North unit almost every day and that the traffic flow through the unit to the unsecured outpatient clinic is frequent throughout the day. She confirmed that the door has not yet been deactivated.

Based on record review and interview, the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient as evidenced by failing to administer sliding scale insulin as ordered by the physician and failing to notify the physician of high blood sugar results for 1 (Patient #4) of 2 sampled diabetic patients (Patients #4, #6) in a total sample of 9.
Findings:

Review of the medical record for 17 year old Patient #4 revealed an admit date of 09/16/2024 with diagnoses including depression and diabetes. Review of the physician orders dated 09/16/2024 revealed orders for routine insulin daily as well as blood sugar checks four times daily (before meals and at bedtime) with sliding scale Humulin R insulin to be administered. The physician ordered sliding scale insulin for the following blood sugar results:
0-60, give orange juice and call MD
61-200, no insulin required
201-250, 3 units Humulin R
251-300, 5 units Humulin R
301-350, 7 units Humulin R
351-400, 9 units Humulin R
Over 400, 12 units Humulin R and call MD

Review of the patient's medical record revealed blood sugar results included the following:
09/24/2024 at 11:11 a.m. - result of 478. No documentation of any Humulin R insulin being administered. No documentation of the physician being notified of the high result.
09/23/2024 at 10:56 a.m. - result of 479. No documentation that the physician was notified.
09/22/2024 at 11:01 a.m. - result of 400 with 12 units Humulin R given. Sliding scale physician orders indicate to give 9 units.
09/22/2024 at 2:03 p.m. - result of 424. No documentation that the physician was notified.
09/21/2024 at 8:56 a.m. - result of 436. No documentation that the physician was notified.
09/21/2024 at 11:11 p.m. - result of 455. No documentation that the physician was notified.
09/20/2024 at 9:07 a.m. - result of 429. No documentation that the physician was notified.
09/20/2024 at 7:52 p.m. - result of 357. No documentation of any Humulin R insulin being administered as ordered per sliding scale.
09/19/2024 at 6:26 a.m. - result of 244. No documentation of any Humulin R insulin being administered as ordered per sliding scale.
09/19/2024 at 11:00 a.m. - no blood sugar documented. Nurses note states "off unit".
09/19/2024 at 4:32 p.m. - result of 400 with 12 units Humulin R given. Sliding scale physician orders indicate to give 9 units.
09/18/2024 at 6:27 a.m. - result of 233. No documentation of any Humulin R insulin being administered as ordered per sliding scale.
09/18/2024 at 12:16 p.m. - result of 533. No documentation of any Humulin R insulin being administered as ordered per sliding scale. No documentation that the physician was notified of the high result.

On 10/09/2024 at 2:50 p.m., interview with S2PI Dir confirmed she was unable to locate in the medical record any evidence that the physician was notified of the blood sugar results over 400, as ordered. S2PI Dir further confirmed there was no documented evidence that the physician's orders for sliding scale Humulin R insulin was followed for all blood sugar results.