Adair Acute Care at Osawatomie State Hospital

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 43388 Based on document review, record review, and interview, the Hospital failed to ensure the supervision of nursing care provided to patients. The cumulative effect of the failure to supervise the nursing care for each patient resulted in an Immediate Jeopardy (IJ), a situation in which noncompliance has caused or is likely to cause injury, serious harm, serious impairment, or death. On 02/09/24 at 4:38 PM, the facility was notified that an IJ existed at 42 CFR 482.23(b)(3), A0395, A registered nurse must supervise and evaluate the nursing care for each patient. On 02/11/24 at 12:24 PM, the facility submitted an acceptable plan of removal that was verified on 02/12/24 at 11:29 AM, prior to survey exit. The plan of removal included: 1. [Hospital] will implement a band status system by which patients who have been assigned 1:1 or continuous line of sight status can be easily identified by staff. This band will be removed if the 1:1 or continuous line of sight observational status is lifted. Should the patient remove their band, the removed band would be confiscated and destroyed, the patient would be educated, and a new band placed. 2. Patients who are assigned an observational status higher than 15-minute checks will have their timed check sheet printed in a different color to distinguish them from patients on 15-minute checks. The admitting nurse accepts the patient and is informed of their status and the admitting nurse assigns the mental health technician (MHT) staff to the patient requiring the elevated status, verbally informing the receiving staff both of their assignment and the patient’s status. The MHT records their observations on the specially colored time check street. 3. Policy titled, “Observational Status,” details the different levels of supervision necessary for patients with varying levels of specific acuity. 4. Policy titled, “Therapeutic Precautions,” details the specific steps taken when a patient who is identified as likely to swallow items or has a known history of swallowing items is admitted. This policy gives detailed instructions on the procedure for safe treatment of such patients. 5. Starting on 02/10/24, all nursing staff on duty will be trained on the new form and procedures detailed in policy, “Therapeutic Precautions” and “Observational Status.” From 02/10/24 forward, all staff will be trained on this policy and procedure prior to the start of their next shift. Supervisors will be responsible, each shift, that education was completed, and rosters will be submitted to the Nursing Educator and Chief Executive Officer (CEO). 6. Nursing educator is responsible for monitoring and ensuring that education is complete. Policies “Observational Status” and “Therapeutic Precautions” have been updated and approved by CEO and Governing Body to address patient safety. 7. The nursing admission note will indicate which staff member accepted the patient to the unit and that observational status/therapeutic precaution handoff was completed. 8. A Quality Assurance Performance Improvement (QAPI) goal has been started 02/10/24, that ten timed check sheet audits will be performed daily by nursing supervisor and/or designee and turned into the Chief Nursing Officer (CNO), with a goal of 95% (percent) compliance for accuracy. The audits will be reviewed by the CNO and reported to compliance on a monthly basis to ensure timeliness, irregular intervals, and use of appropriate time check sheet. 9. A QAPI goal has been started 02/10/24, that all nurse admission notes will be reviewed daily by the nurse supervisor or designee to ensure 100% of nurse admission notes include documentation of observational status/therapeutic precaution handoff. The audits will be reviewed by the CNO and reported to compliance monthly. Findings Include: 1. The hospital failed to ensure the supervision of nursing care for each patient (Refer to A-0395).”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 43388 Based on policy review, document review, record review, and interview, the Hospital failed to ensure the supervision and evaluation of nursing care for 2 patients (Patient 5 and Patient 4) of 9 patients reviewed, who ingested non-food items that required surgical intervention to remove the objects. The cumulative effect of this deficiency resulted in an Immediate Jeopardy (IJ), a situation in which noncompliance has caused or is likely to cause serious injury, serious harm, serious impairment, or death. Findings Include: Review of the Hospital’s policy titled, “Therapeutic Precautions,” dated 01/05/23, showed, “The purpose of a therapeutic precautions policy is to identify clinical treatment guidelines and precautionary measures which assist the hospital in maintaining the safety of the patient, staff, and others . . . Therapeutic precautions . . . is defined as safety measures taken in addition to observational status to further protect patients, staff and others. Therapeutic precautions include general, suicide prevention, aggression/assault, sexual acting out, sexual aggression, elopement, seizure, fall risk, medical equipment . . . and other medical precautions . . . when security or nursing staff hand off supervision to the unit staff they will indicate if a therapeutic precaution has been assigned.” Review of the Hospital’s policy titled, “Observational Status,” dated 05/11/23, showed “When the patient is taken to the unit, security and/or nursing staff will hand off supervision to the unit staff and indicate the level of observation currently assigned . . . The nurse will assign staff to monitor the patient at the frequency and intensity specified by the assigned status . . . Unit observation with 15-minute checks . . . will be in place for all patients except those that are deemed to require closer observation . . . Unit observation with Line of Sight. This observational status will be considered for patients who display extreme aggression, self-injurious behavior or other dangerous behaviors that require closer observation or for those at risk of being victimized. This consideration is made in accordance with individual patient need . . . Unit observation with 1:1. This observational status will be considered for patients who display self-injurious behavior or other dangerous behaviors that require closer observation. This consideration is made in accordance with individual patient needs. The RN will assign a specific staff member to have constant 1:1 supervision of the patient. Staff will complete [Timed Check Sheet] and provide care. Nursing Staff will remain in the personal proximity within 5 feet (unless specified by physician orders) of the patient and must maintain visual contact of the patient at all times (including while using the restroom, taking a shower and when sleeping). Report any change in behavior . . .” Review of the Hospital’s document titled, “Timed Check Sheet,” dated 05/2023, showed a 2-page document. The first page included columns to document time, initials, location, and comment. Additionally, the first page included space for the patient stick, date, and shift. Below, status which can be checked to indicate line of sight, 1:1, or 15-minute observational levels. Below that included location codes, meal/snack consumption’s and whether the patient took a shower or not. Below that included lines for staff to document any notes. The second page also included space for a patient sticker and the continuation of notes. Below that was space for staff to document their initials and printed full name and title and space for the nurse sign-off. Patient 5 Review of Patient 5’s clinical record showed that Patient 5 was admitted for the treatment of borderline personality disorder (a mental disorder characterized by the instability in mood, behavior, and functioning), generalized anxiety disorder (a condition with exaggerated tension, worrying, and nervousness about daily life events), and suicidal ideation (thoughts of killing oneself) with failed attempts. Patient 5’s record showed that Patient 5 has had six admissions since May 2023. Further review showed that Patient 5 has a history of swallowing foreign objects from at least two previous admissions at the above-named hospital. Review of Patient 5’s “Physician Orders,” signed and dated 12/14/23 at 9:00 PM showed that the Physician placed Patient 5 on 1:1 status for suicidal ideation and self-harming behaviors. Review of Patient 5’s “Time Check Sheet” dated 12/14/23, showed that Patient 5 was on the day hall at 8:59 PM. Further review of the time check sheet showed that staff failed to identify the observation status that Patient 5 was on. At 9:44 PM on 12/14/23, Staff documented on the timed check sheet that Patient 5 was in the bathroom. Review of Patient 5’s “General Progress Note,” dated 12/14/23 at 11:08 PM, showed that Staff L, Registered Nurse (RN), documented “. . . [Patient 5] was led to A1 where she was put on a 1:1 for suicidal ideation and was oriented to the staff and Unit. While on a 1:1, Patient went to the bathroom and immediately after using the bathroom, [Patient 5] stated to [Staff P, Mental Health Technician (MHT)] ‘I have just swallowed the frames of my eyeglasses.’ [Patient 5] then showed [Staff P, MHT] her eyeglasses, minus the frames . . . [Patient 5] was escorted by . . . security personnel to the ambulance . . . for onward transfer to [Acute Care Hospital].” Review of Patient 5’s “General Progress Note,” dated 12/18/23 at 1:16 PM, showed that Staff Q, RN, documented “Nurse [at acute care hospital] reports that [Patient 5] has signed consent for the EGD [Esophagogastroduodenoscopy, a procedure that exams the upper GI tract. Tools can be attached to the endoscope to retrieve swallowed items.] and she believes the procedure may be completed today. [The acute care nurse] states that reports show eyeglass pieces along with an ‘unidentified electronic device’ needing removed.” During an interview on 02/09/24 at 11:29 AM, Patient 5 stated that she was doing well right now and not struggling. Patient 5 stated that when she ingested the glasses, no staff were with her in the bathroom. During an interview on 02/09/24 at 11:48 AM, Staff O, RN, stated that her supervisor had informed her that Patient 5 would need to be placed on a 1:1 and that she had forgotten to tell the mental health technicians (MHTs) that Patient 5 was on 1:1 observational status. Staff O stated that she was so busy assisting the doctor with admission paperwork that it hadn’t crossed her mind. Staff O stated that Patient 5 had gone into the bathroom on her own and swallowed the frames to her glasses. Staff O clarified that at the time she had swallowed the glasses, she had not told the MHTs of the observation status yet. During an interview on 02/09/24 at 3:09 PM, Staff P, MHT, stated that the MHTs were not informed that Patient 5 was on 1:1 observation status until after she swallowed the glasses. Staff P stated that nobody went to the bathroom with her because she was not 1:1 at that time. During an interview on 02/09/24 at 3:22 PM, Staff N, MHT, stated that after Patient 5 swallowed the frames of the eyeglasses, the MHTs were informed that Patient 5 was on 1:1 observation status. Staff N stated that Patient 5 had gone to the bathroom on her own because she was not on 1:1 status. During an interview on 02/09/24 at 1:40 PM, Staff C, Chief Nursing Officer (CNO), stated that she did not investigate the incident from a nursing standpoint. During an interview on 02/09/24 at 2:01 PM, Staff B, Nurse Risk Manager (RNRM), stated that the incident regarding Patient 5 ingesting the frames of her eyeglasses was not investigated. Staff B stated that swallowing items was her baseline, and it would not have triggered an investigation. Staff B stated that she did not interview any of the staff individually. Staff B stated that she was unaware that the MHTs were not notified of Patient 5’s observational status. Staff B stated that she was under the impression they were told, but that an MHT was not designated for the 1:1 assignment. Patient 4 Review of Patient 4’s clinical record showed that Patient 4 was admitted for the treatment of borderline personality disorder and schizoaffective disorder, bipolar type (a mental disorder in which a person experiences a combination of symptoms of delusions, hallucinations, disorganized speech, disorganized behavior shown with manic or impulsive actions that have negative consequences). Patient 4 displays antisocial personality disorder (an enduring pattern of behavior characterized by disregard for, and violation of, the rights of others) and has a history of self-harming behaviors, including the ingestion of non-food items at a previous admission. Patient 4 was admitted after a suicidal attempt. Review of “General Progress Note,” dated 11/16/23 at 8:39 PM, showed, “Patient arrived in the admission suite at [7:05 PM]. She was cooperative with the admission process . . . being admitted for making delusional statements about being, seeing, and hearing demons . . . Patient has observational status of 15-minute checks for aggression risk, AWOL [absent without official leave] risk, and a self-care failure.” Review of “General Progress Note,” dated 11/17/23 at 6:09 PM, showed “[Patient 4] casually advised me that she swallowed a spoon earlier . . . Patient put on 1:1 status for safety.” Review of “General Progress Note,” dated 11/17/23 at 5:49 PM, showed “I was with patient as 1:1 from [5:05 PM to 5:42 PM] . . . Patient talked to unseen others and took toothpaste roll out of white folder and swallowed some.” Review of “Physical Intervention” note, dated 11/22/23 at 3:10 PM, showed, “[Patient 4] reported that she had swallowed a toothbrush and [lip balm] while in the shower room. Shower room was searched, and the items were not located. They were missing from her hygiene box. Physician was notified. Order was entered for 1:1 for patient safety due to potential of her swallowing other items. A short time later she told her 1:1 staff that she felt like hitting someone. As 1:1 staff was notifying fellow RN, [Patient 4] approached peer [record number] hitting her in the head.” Review of “General Progress Note,” dated 11/27/23 at 5:42 PM, showed “[Patient 4] has required multiple physical interventions over the holiday weekend due to aggressive and self-harm behaviors. On 11/23 [11/23/23] at 1239 [12:39 PM] she required physical intervention due to attempting to ingest a spoon and tea bag then hitting at staff when they provided redirection. She was escorted to seclusion where she pulled a button from her shirt, broke it and used it to make lacerations to her arms. She was sent out to [Acute Care Hospital] on 11/23 [11/23/23] at 1350 [1:50 PM] for evaluation and treatment for her lacerations. While there she eloped from their care and had to be picked up by law enforcement. She returned from [Acute Care Hospital] on 11/23 [11/23/23] at 1532 [3:32 PM]. On 11/24 [11/24/23] at 0937 [9:37 AM], [Patient 4] required physical intervention. She was demanding to be sent to jail stating she was going to hit people until she was sent to jail. On 11/25 [11/25/23] at 1150 [11:50 AM] [Patient 4] required physical intervention due to grabbing a plastic spoon and attempting to put it in her mouth. She then punched the covering physician in the face and back of the head and began hitting the staff sitting her 1:1. [Patient 4] has refused to meet to complete therapeutic debriefings. Changes: On 11/25 [11/25/23], [Patient 4] was placed on 2:1 observational status due to her self-harm behaviors and hitting staff, An order for paper utensils remains necessary. [Patient 4] was transferred to [hall] on 11/24 [11/24/23] in order for her to be able to have a private restroom due to infection control purposes. She will remain in the care of the red treatment team. Physician increased Haldol [medication used to treat schizophrenia] to help with aggression and impulsivity.” Review of “General Progress Note,” dated 11/29/23 at 3:17 PM, showed, “I was on the 1:1 with [Patient 4] . . . Pt asked for a journal and pen, she got these items and appeared to go to write and then she shoved the pen down her throat, when staff tried to get closer to her she swallowed the pen and she stated that she was confused and don’t know why she swallowed it.” Review of “General Progress Note,” dated 12/03/23 at 11:39 PM, showed, “Review 11/27/23 to 12/2/23 . . . On 11/29 and 12/21 [sic] she swallowed a patient pen and was taken to [Acute Care Hospital] and had them surgically removed and on 11/30, a toothbrush and [lip balm] was also found from when she swallowed a week and half ago . . . due to her swallowing pens and cutting herself, [Patient 4] is on 2:1 (staff being within arm’s length of [Patient 4]) while awake and 1:1 while asleep in bed and there is to be no regular pens on unit.” Review of “General Progress Note,” dated 12/08/23 at 1:15 PM, showed, “MHT notified nursing that [Patient 4] ran up the . . . hallway from the direction of her room, she was tearful and verbalized she swallowed a fork. She was sat in day hall, and began profusely vomiting, her airway remained opened, she remained alert, stated she picked the fork up off of the table after lunch.” Further review showed that Patient 4 was taken by ambulance to an acute care hospital where it took two attempts to remove the fork. Review of “Physical Intervention,” note, dated 12/16/23 at 12:59 PM, showed “[Patient 4] approached staff and requested IM [intramuscular] medications, staff encouraged PO [by mouth] medications and [Patient 4] stated, ‘I can’t I’m going to hurt myself.” Physician was notified and order received for IM chlorpromazine [medication used to treat certain mental or mood disorders such as schizophrenia or psychosis] 50 mg [milligrams]. [Patient 4] received without incident. I informed unit nursing staff that [Patient 4] was feeling unsafe and vigilance was necessary for safety. [Patient 4] requested hygiene box, staff assisted her in putting toothpaste on her toothbrush for her safety. While brushing her teeth, [Patient 4] moved the toothbrush to the back of her throat, staff intervened, stepped closer to [Patient 4] ask her to stop behavior. [Patient 4] immediately stopped and continued to brush her teeth appropriately, staffed thanked [Patient 4] for redirecting and she quickly shoved the toothbrush into the back of her throat and pushed staff away. Staff attempted to take toothbrush but was unsuccessful but continued to encourage her to spit it out. Nursing staff pulled personal panic alarm in an attempt to secure addition assistance. [Patient 4] stated, ‘I swallowed it because you told everyone that I wanted to go to the hospital, and I wasn’t even thinking about going to the hospital.’” Further review of Patient 4’s medical record showed that Patient 4 then ran to the group room and attempted to put a patient pen in her mouth. The hospital failed to ensure nursing services were supervised and provided according to patient need resulting in Patient 5 and Patient 4 requiring surgical intervention to remove nonfood items ingested while receiving psychiatric care.”