The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SSM HEALTH ST ANTHONY HOSPITAL - OKLAHOMA CITY 1000 NORTH LEE AVENUE OKLAHOMA CITY, OK 73101 Oct. 9, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review, interview, and observation, the hospital failed to ensure patients were provided a safe environment in that:

I. there were free of ligature risks and contrabands which could be accessed by patients and used to harm self or others, such as plastic bags, large hygiene supplies, continuous positive airway pressure (CPAP) equipment, and step stools. (Refer to A-0144)

II. patients were not monitored to the degree that minimized the risk of patients leaving without authorization (AWOL) and/or doing harm to themselves or others. (Refer to Tag A-0144)

III. the patient care units had no adequate staff to meet the need of patients. ( Refer to Tag A-0395)

IV. the nursing staff failed to assign and supervise non-licensed staff to meet the needs of the patients (Refer to Tag A-0395)

V. nursing leadership failed to ensure that all staff were qualified and competent to meet the needs of the patients. (Refer to Tag A- 0397)


These failed practices were associated with a patient's suicidal death by hanging with contraband and a patient leaving AWOL, and had the potential for all patients to have an increased risk of undesirable outcome due to environmental risks and lack of supervision and monitoring.


Findings:

On 09/20/18 at 12:26 pm, the CEO and members of the hospital leadership team were notified of the Immediate Jeopardy conditions identified for the adult and geriatric psychiatric patients.


On 10/09/18 at 3:30 pm, an exit conference was held with the facility's leadership and no acceptable plan of removal was submitted prior to surveyors leaving the facility.

On 10/03/18 at 12:15 am, the facility submitted a plan of removal consisting of the following:

* Developed new policy and process for improved safety and cleaniness monitoring checks, and staff (clinical and environmental services) education for contraband identification, removal, and reporting.

* Increased staffing level and create role of designated, dedicated rounding staff, who will have no other patient care assignments, and capped patient census for geriatric at 16 patients and adult unit to 15 patients.

* Modified staff assignment sheets and educate staff regarding sheets and new process. New assignments include those during breaks and lunches.

* Developed role of designated, dedicated rounding staff, and staff educated.

* Developed tools to audit designated, dedicated rounding staff, daily timely staff assignments for Registered Nurse (RN) and Mental health Technician (MHT)
including timeframes and reporting.


On 10/03/18 at 2:07 pm, the surveyors accepted the plan of removal.


On 10/09/18 at 3:14 pm, the surveyors verified the hospital's plan of removal of the immediacy by:

A. Observations
On 10/09/18 at 10: 43 am, patient rooms on the adult and geriatric units were examined for contraband and other safety risk, Mental Health Technicians and Nurses communicating with new ear piece radio systems, and observed watch on clipboard (time synchronized to selected time) to eliminated variance of use of multiple clocks.

B. Interviews
On 10/09/18, from 10:43 am to 3:05 pm, surveyors interviewed 10 non-leadership staff from 7-3, 3-11, and 11-7 shifts from the adult and the geriatric units. All staff stated understanding regarding the role designated, dedicated rounding staff, demonstrated how the new rounding sheets documented events, and how staff communicated with one another. All staff verified they had no other assignment in addition to rounding staff. All staff explained how patients were tracked when moving from activity to activity. All staff stated they had retraining on identifying contraband to include hygiene products, plastic bags, and CPAP equipment including line of sight orders for any patient at reach to him/herself.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review, interview, and observation, the hospital failed to ensure patients were provided a safe environment in that:

I. there were ligature risks and contrabands which could be accessed by patients and used to harm self or others, such as plastic bags, large bottle of hygiene supplies, continuous positive airway pressure (CPAP) equipment, and step stools.

II. patients were not monitored to the degree that minimized the risk of patients leaving without authorization (AWOL) and/or doing harm to themselves or others.

These failed practices were associated with a patient's suicidal death by hanging with contraband and a patient leaving AWOL, and had the potential for all patients to have an increased risk of undesirable outcomes due to environmental risks and lack of supervision and monitoring.

Findings:

I. Contraband and Environmental Risks
A review of the event and investigation reports showed, on 09/06/18, when in the bathroom, Patient #17 hung him/herself using his/her CPAP's carrying case with strap, the bathroom door, and a stepstool. Patient #17 was pulseless with no respirations, and CPR initiated. Patient #17 was transported to another facility by EMSA, and subsequently expired.

A review of the policy titled, "Acute-Care Patient Safety and Room Safety Checks (03/18)" documented staff would perform safety assessments and room safety checks of patients as necessary to help ensure the safety of patient care and safety of the therapeutic environment...thorough safety assessments of patients and their personal effects were to be performed prior to and /or during their integration. The policy documented safety checks should reduce the presence of weapons, contraband, drugs and/or other items that posed a safety risk, and such items should be secured, sent home, or disposed of properly. The policy failed to address the potential hazards of using non-mental health constructed furniture such as office chairs, step stools, and CPAP equipment.

A review of the policy titled, "Safety Assessment (12/17)" defined contraband to include weapons or items that could be used as weapons, sharps, razors, tobacco products, alcohol, and/or drugs (illicit and/or prescription), lighter/matches, aerosol containers and mirrors. The policy failed to address plastic bags, large bottles of hygiene products, belts, or straps.

A review of the policy titled, "Use of Home CPAP-BiPAP [Bilevel positive airway pressure] for Sleep Apnea (08/18)" documented patients were allowed to use their home CPAP/BiPAP equipment. The policy documented an expected outcome that included safety was assessed and maintained on a continuous basis throughout the patient's hospitalization . The policy failed to address the management of the patient who was at risk to harm him/herself that required the use of CPAP/BiPAP.

On 09/19/18 at 9:00am, Staff A stated, the hospital had recently changed the policy and process use of CPAPs and patients could not use their personal CPAP, but must use the hospital's equipment.

On 09/19/18 at 10:36 am, Staff K stated, contraband included cigarettes, lighters, plastic bags, toiletries containing alcohol or aerosol, baby powder, or big bottles of toiletries. Staff K stated, personal CPAP equipment was used after respiratory therapy checked the equipment, got an order, and added water. Staff K stated, on the adult unit, patient with CPAP had to sleep in a gerichair in the day room. Staff K did not address use of step stool.

On 09/19/18 at 10:30 am, Staff H stated, contraband included toiletries containing alcohol, and plastic bags, and was not aware of any change regarding suicidal patients with sleep apnea and CPAP equipment. Staff K did not address use of step stool.

On 09/19/18 at 2:11 pm, Staff M stated, contraband included plastic bags, lighter, glass, and string, and stated, CPAP should not have straps and no step stool could be put in a patient's room.

On 09/19/18 at 2:30 pm, Staff E stated, contraband included pencils in patient rooms, utensils, plastic bags, and handbags, and stated, recently CPAP equipment was kept out of the patient's room until the patient needed it. Staff K did not address use of step stool.

On 09/17/18 at 3:12 pm, surveyors observed in Room 175, a small plastic bag amongst patient belongings on a shelf.

On 09/17/18 at 4: 04 pm, surveyors observed in Room 153, a large shampoo bottle amongst patient belongings on a shelf.

On 09/17/18 at 4:06 pm, surveyors observed in Room 155, a plastic emesis bag by the patient's bed.

On 09/17/18 at 4:16 pm, surveyors observed in Room 154, a plastic emesis bag by the patient's bed.


II. Monitoring Patients

A. Monitoring Process

A review of the policy titled, "Observation Rounds (12/17)" documented all patients would be observed every 15 minutes, not to exceed 20 minutes, and observation rounds were utilized to ensure patient safety and to identify at-risk behaviors and/or acting out behaviors that needed to be addressed.

The policy showed:

* the Charge Nurse would make rounding assignments, and oversee the rounding process.

* patients would be visually assessed for well-being and safety.

* staff were to contact the Charge Nurse to ask for help if they got behind on the rounds.

* an "appropriate" handoff to another staff must be done before rounding staff left unit.

* RN/LPN would round every two hours during shift

* all off-going staff would remain on the unit until oncoming shift comes out of report unless approved by Charge Nurse.

The policy failed to address the rounding staff's specific role in evaluating the patient's environment for risks. The policy failed to address expectations for the rounding staff when patients were in the bathroom.

On 09/19/18 at 10:36 am, Staff K discussed the rounding process. Staff K stated, a clipboard held each patient's rounding sheet, and it was the expectation that every 15 minutes, rounding staff should know the location of every patient. Staff K stated, the nurse's signature on the rounding sheet indicated the rounding sheet was complete and did not represent the nurse had assessed the patient. Staff K said, starting the week prior when a patient goes for therapy, the patient's rounding sheet would be given to the MHT who accompanied the patient.

A review of the policy titled, "Patient Room Doors Lock-unlock, Guidelines for (12/17)" documented, rounds would be made through out the shift by the charge nurse or designee to monitor compliance of the door lock/unlock processes and to monitor patients that were in their rooms.

On 09/19/18 at 2:10 pm, Staff J stated, the rounding staff would have approximately 14 patient rounding sheets on the clipboard to monitor.

On 09/19/18 at 10:26 am, Staff A stated, nurse rounds consisted of sometime within a two hour period the nurse checked on the patient's condition, and said, the time that this evaluation was performed, but was not documented in the medical record.

On 09/19/18 at 2:11 pm, Staff M stated, hand off report mainly consisted off-going MHTs discussing patients with on-coming MHT. Staff M stated, most rounds were every 15 minutes unless the nurse told the MHT otherwise. Staff M stated, if there was a patient event that required his/her participation, the clipboard would be put down, and documentation would be completed later.

On 09/19/18 at 2:30 pm, Staff E stated, MHTs would give report to other MHTs, and usually one MHT would round for approximately 16 patients. Staff E stated, the signage of the nurse on the rounding sheet indicated the nurse had seen the patient.

09/19/18 at 3:13 pm, Patient F stated, the nurse signature on the rounding sheet indicated the nurse checked that the rounding sheet had been complete.


B. Monitoring Process Issues

A review of multiple random rounding sheets showed the following issues:

* On 06/11/18 between 1:15 pm and 1:45 pm, Patient # 18's rounding sheet showed the rounding MHT documented the patient was alert. During this time, the physician documented Patient #18 was repeatedly chasing the physician around the unit, and saying "You are a commie, you have kidnapped me and imprisoned me here...".

* On 06/23/18 between 8:30 am and 3:00 pm, Patient # 18's rounding sheet showed location as "OTH", which indicated "other", but had no explanation where the patient was.

* On 06/22/18 between 10:30 am and 11:00 am, Patient #18's rounding sheet showed location as "TAS", which indicated the patient was with a therapist and could be located outside or in the fitness room.

* On 07/05/18 between 1:45 pm and 2:30 pm, Patient #3's rounding sheet was completed in advance to real time. it was documented the patient had "non-verbal ideations", and the location and behaviors were blank for the time period. A review of the nursing notes showed a 2:02 pm entry regarding the Patient #3, but the medical record also contained an emergency department admission note from the main campus at 2:38 pm. (If the patient was on the unit from 1:45 pm to 2:00 pm, it was not reflected on the rounding sheet.

* On 08/14/18 between 9:15 pm and 11:00 pm, Patient #20's rounding sheet indicated the patient was sleeping, but the nursing notes at 10:27 pm documented the patient was yelling.

*On 09/02/18 between 4:00 pm and 8:30 pm, Patient #2's rounding sheet indicated the patient was "OTF" [off the floor], but the medical record contained an emergency department admission note from the main campus at 5:00 pm.

*The rounding sheet had a signature line beneath the heading of "Nurse Rounded at least every 2 hours" per shifts 11-7, 7-3, and 3-11. The form did not indicate at what time the nursing rounds occurred. On 06/19/18: 3-11 shift for Patient #18 was not signed by nurse. On 06/20/18 7-3 shift, for Patient #18 was not signed by nurse. On 07/05/18 7-3 shift for Patient #3 was not signed by nurse. On 03/27/18 7-3 shift for Patient #16 was not signed by nurse. On 09/04/18: 3-11, 09/05/18: 3-11, and 09/15/18: 7-3 shift for Patient #17 was not signed by nurse.


On 09/17/18 at 3:12 pm, surveyors observed one MHT in the day room, Staff F was assigned to complete the rounding sheets for 15 patients. Two patients (Patient #22, Patient # 23, and Patient # 24) of 15 patients were in bed in separate rooms and the others were in the day room. Surveyors requested the 15 minutes rounding sheets for those patients in their bedrooms.

The rounding sheets showed the following:

* Patient # 22: At 4:00 pm, rounding sheet's last entry was 3: 30 pm

* Patient #23: At 3:45 pm, round sheet was completed in advance of real time for the patient's location, ideation, and initialed, but no behavior documented. At 3:53 pm, the surveyors observed the hall leading to Patient # 23's room and did not see staff enter until 3:56 pm. Staff D said Staff V was assigned to the hall and if he/she did rounds he/she would sign the rounding sheet. Staff F (who was the rounding staff for 15 patients) said he/she should not signed the rounding sheet that was behind in observations.

* Patient #24: At 4:13 pm, rounding sheet's last entry was 3:54 pm.


C. Patient Self-Harm

A review of the event and investigation report showed, on 09/06/18, when in the bathroom, Patient # 17 hung him/herself using his/her CPAP's carrying case with strap, the bathroom door, and a stepstool.

The report showed:

* at 11:00 pm, Staff E stated, Patient # 17 got up to go to the bathroom and Staff E remained in hall with bedroom door opened and bathroom door cracked

* at 11:15 pm, Staff I went into Patient #17's room to take vital signs

* at 11:.17 pm, Staff E stated he/she told the nurse that Patient # 17 was unresponsive.


A review of Patient # 17's medical record showed, Patient #17 was admitted on [DATE], with the diagnosis of major depressive disorder and the physician ordered "Suicide precautions every 15 minutes".

On 09/05/18 at 1:17 pm, Staff U documented, Patient #17 had a potential to self harm and a recent history of intentional drug overdose, and scored 100% affirmative answers on the Columbia Suicide Severity Rating Scale.

A review of Patient # 17's medical record rounding sheets showed, Patient #17 as "sleeping" from 9:00 pm to 11:00 pm which was the last rounding sheet entry.

On 09/19/18 at 2:10 pm, Staff I stated, the 11-7 shift usually staffed with one MHT for the shift. Staff I stated, on 09/06/18 he/she was coming on the shift, and got report from the off-going MHTs. Staff I went into Patient #17's room to get vital signs, did not see Patient # 17 in the bedroom. Staff I left the room, went looking for Staff E to inquire as to the patient's location, but subsequently found the Staff E. Staff E said, Patient #17 was in the bathroom. Staff I got no response from knocking at the bathroom door, tried his/her key and it did not work, got assistance from Staff E to unlock the bathroom door, and Patient #17 was found unresponsive and pulseless on the bathroom floor with the CPAP carrying case strap around his/her neck..

On 09/19/18 at 2:30 pm, Staff E stated he/she was in the hall giving report when Patient #17 was in the bathroom.


D. Minimized AWOL Risk

A review of the event and investigation report showed, on 07/08/18, Patient # 1 was in the outside courtyard with five other patients when the Staff J, Mental Health Technician (MHT) assigned to monitor the patients left the courtyard to go into the dining area to make a pot of coffee for his assigned patients. The dining area was adjacent to courtyard and accessible through a glass door. Patient #1 scaled the fence and went AWOL in the MHT's absence.

A review of the policies titled, "Away Without Leave (AWOL) Patient (11/17)" and "Elopement Precaution (12/17)" failed to show how to minimize the risk of AWOL when patients were in the outside courtyard and requested fluids from the dining room.

On 09/19/18 at 2:10 pm, Staff J stated, on 07/08/18 his/her assigned patients were in the courtyard, while he/she was making coffee in the dining room. Patient #1 came into the dining room from the outside requesting to go to the day room. Staff J said, when he/she turned away from the patient, and thought Patient #1 went to the day room, but the patient went back outside and climbed over the fence in the courtyard and left the facility's property. Staff J stated, he/she went on break and upon return was told of the AWOL. Patient #1 was discovered missing when a therapist was looking for the patient to do a fitness walk.

On 09/19/18 at 10:30 am, Staff H stated, "TSA" [therapist] came to get patients for sessions, but the assigned MHT still kept the patients rounding sheet. Staff H stated, the MHT should listen to the nurse and not TSA regarding the patient's schedule. Staff H stated, when the session was over the patient will be allowed to go outside. Staff H said, sometimes staff are on cell phone when outside.

On 09/19/18 at 10:36 am, Staff K stated, sometimes MHT monitor patients in the dining room and outside courtyard simultaneouly. Staff K said the patients may be in the courtyard, and the MHT would make coffee in the adjacent dining room monitoring the patients through the glass window and door. Staff K said the door from the courtyard to the dining room would be unlocked for patients coming from group to the courtyard.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record review, observation, and interview, the hospital failed to ensure:

I. the registered nurse evaluated and supervised the completion of the patient 15 minute round sheets for 3 of 20 (Patient # 22, 23, and 24) records reviewed.

II. the registered nurse physically assessed the well-being and safety of patients every two hours.

These failed practices resulted in round sheets being completed by a mental health technician (MHT) who did not physically view the location of the patient and the facility not being able to show that the RN/LPN tphysically assessed patients for well-being and safety every two hours.

Findings:

A policy titled "Observation Rounds (12/17)" the charge nurse will make observation round assignments based on rounding requirements and physician precaution orders...The charge nurse will oversee the rounding process...Staff must ask for help if getting behind on observation rounds...Charge nurse must be notified so assistance can be provided...The Registered Nurse (RN)/Licensed Practical Nurse (LPN) will make observation rounds every two hours during the shift, visually assessing the patient's will-being and safety, and ensuring the patient is not in distress.

I. MHT completion of round sheet

On 09/17/18 at 3:53 pm, the surveyors observed the patient round sheets were with Staff F. Staff F was 15 minutes behind or prefilling round sheets with the patients location, ideation and signature.

On 09/17/18 at 3:12 pm, surveyors observed one MHT in the day room, Staff F was assigned to complete the rounding sheets for 15 patients. Three patients (Patient #22, 23, and 24) of 15 patients were in bed in separate rooms and the others were in the day room. Surveyors requested the 15 minutes rounding sheets for those patients in their bedrooms and the rounding sheets showed the following:

* Patient # 22: At 4:00 pm, rounding sheet's last entry was 3: 30 pm

* Patient #23: At 3:45 pm, round sheet was completed in advance of real time for the patient's location, ideation, and initialed, but no behavior documented. At 3:53 pm, the surveyors observed the hall leading to Patient # 23's room and did not see staff enter until 3:56 pm. Staff D said, Staff V was assigned to the hall and if he/she did rounds he/she would sign the rounding sheet. Staff F (who was the rounding staff for 15 patients) said, he/she should not signed the rounding sheet that was behind in observations.

* Patient #24: At 4:13 pm, rounding sheet's last entry was 3:54 pm.


On 09/17/18 at 3:55 pm, Staff A stated, my expectation is that the mental health technician who physically viewed the patients location would complete the round sheet.

On 09/17/18 at 4:00 pm, Staff F stated the staff who is watching the patient should complete the charting.


II. Nurse rounded at least 2 hours

A review of document titled "Observation Rounds" had one line for the signature of RN/LPN for nurse rounding at least every two hours.

A review of document titled "Observation Rounds" requires a RN/LPN signature beneath the heading of "Nurse Rounded at least every 2 hours" per shifts 11-7, 7-3, and 3-11. The form does not indicate at what time the nursing rounds occurred.

A review of patient record # 1 on 07/18/18 the 7 am to 3 pm shift showed patient went AWOL. Staff K signed the box that the nurse rounded at least every 2 hours.

A review of patient record # 3 on 07/05/18: 7-3 shift was not signed by a nurse.

A review of patient record # 16 on 03/27/18: 7-3 shift was not signed by a nurse.

A review of patient record # 17 on 09/04/18: 3-11, 09/05/18: 3-11, and 09/15/18: 7-3 was not signed by a nurse.

A review of patient record # 18 on 06/19/18: 3-11 and 06/20/18: 7-3 shift was not signed by nurse.

On 09/19/18 at 2:56 pm, Staff I stated the observation round sheet reflects the nurse checks to make sure its completed.

On 09/19/18 at 3:20, Staff F stated the observation round sheet reflects that the mental health technician is doing rounds.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on observation and interview, the hospital failed to ensure:

I. Patient care assignments were completed at the beginning of the shift for 19 of 19 patients on the adult unit on 09/17/18.

II. Gero Unit (1 South) was not staffed according to the hospital's staffing matrix for the following: 9/6/18 on the 11-7 shift and 9/10/18 on the 11-7 shift.

These failed practices has the potential to result in patients not being assessed and accounted for on round sheet for 15 minute intervals and for MHT to not know their initial assignment for the shift and resulted in the gero unit (1 South) not have the required nursing staff.

Findings:

I. Patient Care Assignments

A policy titled "Observation Rounds" stated, the charge nurse will make observation round assignments at the beginning of the shift and adjust the assignments during the shift as necessary including coverage for break(s), and meal break.

On 09/17/18 at 4:18 pm, the surveyors were observing the adult unit. Surveyors heard Staff V state that rounds had not been completed yet.

On 09/17/18 at 4:18 pm, surveyors verified Staff V's comment with Staff A by saying that is what you heard.


II. Gero Unit Staffing

A document titled "Staffing Guideline Worksheet" showed for a patient census of 16 the nurse staffing should reflect 2 RN and 2 MHT on the 11-7 shift.

A review of the daily staffing sheet for 09/06/18 and 09/10/18 the 11-7 shift shows the patient census was 16. The staffing ratio was 1 RN, 1 LPN and 1 MHT.

On 09/19/18 at 2:35 pm, Staff J stated, there should be two MHT on the 11-7 shift.

On 09/19/18 at 2:45 pm, Staff I stated, when he/she had worked there has only been two nurses and one MHT; and the MHT has to complete patient vital sign, 15 minute rounds, assist patient to the bathroom, get water for the patient and notify nurse if patient needs medications; and it was difficult.