Heywood Hospital -

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 40928 Based on review of medical records, policies and interviews, the Hospital failed to ensure constant observation was maintained for two patients (Patient #1 and #2) out of a total sample of 10 patients, failed to ensure environmental safety checks were completed per policy for Patient #1, failed to notify the physician when Patient #1 ’ s psychosis symptoms escalated and allowed Patient #1 to remain in possession of a broken piece of metal and broken coat hangers in their room. Cross Reference: Patient Rights: Care in a Safe Setting (0144)”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 40928 Based on review of medical records, policies and interviews, the Hospital failed to ensure constant observation was maintained for two patients (Patient #1 and #2) out of a total sample of 10 patients, failed to ensure environmental safety checks were completed per policy for Patient 1, failed to notify the physician when Patient #1’s psychosis symptoms escalated and allowed Patient #1 to remain in possession of a broken piece of metal and broken coat hangers in their room. Findings included: Review of the Hospital Policy titled ‘Heywood Hospital Constant Observation (1:1/ Safety Specialist) and Frequent Safety Checks Policy, dated 8/18/24, indicated: -Constant Observation is defined as continuous, close visual observation of a patient. Observation of a patient includes ensuring the patient is breathing and physically safe, including during toileting and while visitors are present. Staff must be within arm’s reach plus 10 inches of the patient at all times, including when toileting and showering. -The Safety Specialist will conduct an environmental safety check of the patient’s room at the beginning of each shift for all patients on Constant Observation to identify safety hazards. This includes identifying objects in the room that may pose a danger to the patient. Review of the Hospital Policy titled ‘Code 100/ Violent or Aggressive Person Policy’, revised 1/29/24, indicated: -Code 100- code called to indicate a need for additional staff response to an event involving a patient, visitor or staff member displaying a substantial threat to self/others. -Code 100 team- any available staff member not currently involved in direct patient care -Call a Code 100 when use of all least restrictive alternatives (i.e. verbal de-escalation and defusing techniques) have failed and there is a risk that the patient will harm others or themselves. Review of Hospital document titled ‘Patient Rights Statement’, dated12/1/24, indicated patients have the right to expect that the treatment, care, and services they receive are provided in a safe manner. 1) Patient #1 was brought by police to the Hospital’s Emergency Department (ED) on 10/30/25 at 6:35 A.M. On 10/30/25 at 7:35 A.M., Patient #1 was ordered to be placed on a Section 12 (involuntary hospitalization if a risk is posed to self or others). On 10/30/25 at 7:52 A.M., Patient #1 was assessed to be high risk for suicide. While in the ED, Patient #1’s Creatine Kinase (CK- a blood test used to detect muscle or heart damage) level was at 5356 (normal range is between 55-170) and Patient #1 was admitted to the Hospital’s medicine service for psychosis (when a person has loss of contact with reality and may involve paranoia, agitation, hallucinations and delusions) and rhabdomyolysis (a life threatening condition in which the muscles begin to breakdown leading to muscle death) and transferred to an inpatient medical unit. Review of Physician #3’s Internal Medicine History & Physical Note dated 10/30/25 at 8:50 A.M., indicated Patient #1 was uncooperative and shouting and orders were placed for continuous cardiac monitoring, peripheral intravenous (IV- a method of administering fluids, or medications into a vein) fluids, and anti-psychotic medication as needed. Review of Physician #2’s Geriatric Psych Consult Note dated 10/30/25 at 11:30 A.M., indicated the Patient appeared to have untreated psychotic disorder and was acutely disorganized in their thought process, paranoid and with persecutory delusions. Patient #1’s judgement and insight appeared to be severely impaired, and they were in an acute psychotic state. On 10/30/25 at 3:27 P.M., Physician #3 ordered 1:1 constant observation for Patient #1. Review of a Nurse’s Note dated 10/30/25 at 3:31 P.M., indicated Patient #1 remained on Section 12 in the hospital for safety, pending medical clearance. Patient #1 continued to have delusional and paranoid thoughts at that time. Review of Nurse Shift Assessment dated 10/30/25 at 10:52 P.M. indicated Patient #1 was admitted with acute psychosis and that Patient #1 refused cardiac monitoring, refused IV fluids, pulled their peripheral IV out, and refused Haldol (an antipsychotic medication). The assessment further indicated that Patient #1 was paranoid and accusatory, uncooperative, trying to leave their room and security was called. Review of Nurse Note dated 10/31/25 at 6:11 A.M., indicated Patient #1 was showing psychosis behaviors, the nursing supervisor and security were in Patient #1’s room and the MD was aware via text. The Note further indicated that at approximately 1:41 A.M., a Code 100 was called, the police department was called, and Patient #1 escaped. Review of Physician #1’s Hospital Discharge Summary dated 10/31/25 at 2:16 A.M., indicated that around 9:00 P.M. on 10/30/25, Physician #1 was notified by nursing that Patient #1 had pulled their peripheral IV access out and in response Physician #1 ordered a physical restraint and noted that an intramuscular (IM) Haldol had already been ordered. The Summary indicated Physician #1 was notified that nursing personnel preferred to leave Patient #1 alone that night as Patient #1 was not being disruptive and the restraint would require a full hold down. The Note further indicated that on 10/31/25 at approximately 1:40 A.M., a Code 100 was called and as Physician #1 was enroute to the Code 100, they were notified Patient #1 had jumped out of the window and eloped. During an interview on 11/13/25 at 7:44 A.M., Registered Nurse (RN) #1 said at the start of their 7:00 P.M.- 7:00 A.M. shift, it was reported that Patient #1 had been aggressive in the community prior to arrival, was being treated for rhabdomyolysis with IV fluids, required 1:1 observation and was a Section 12 patient. RN #1 said Patient #1 pulled their peripheral IV access out and removed their cardiac monitoring after RN#1 started their shift. RN#1 said 3 different nurses tried to reinsert a peripheral IV device but were unsuccessful. RN #1 said Patient #1 thought the nurses were trying to hurt them by putting something through their IV line. RN #1 said they notified Physician #1 that Patient #1 had removed the peripheral IV access and the telemetry leads and the physician placed a new order for soft wrist restraints. RN #1 notified Nursing Supervisor #2 of the new order for soft wrist restraints but felt it wasn’t safe to approach Patient #1. RN#1 said that Nursing Supervisor #2 informed Physician #1. RN #1 said around 1:00 A.M. on 10/31/25, Patient #1 woke up and started throwing blankets and squirting ketchup all over the room. RN #1 said they called Nursing Supervisor #1 and security was alerted. RN #1 said when they went into Patient #1’s room, Patient #1 had ripped the metal piece of a wall mounted suction machine off and had it in their hand, pulled a coat hanger apart and had a piece in their hand that was pointy. RN #1 said 3 security guards and Nursing Supervisor #1 all responded to Patient #1’s room. RN#1 said Patient #1 kept the items in their hands and if anyone tried to approach them, Patient #1 would say “Don’t make me do it.” RN #1 said Patient #1 seemed to be a threat to others at that time. RN #1 said Security Officer #1 asked the rest of the staff to exit the room and remain in the hallway while they tried to talk to Patient #1. RN#1 said Patient #1 was pacing in the room and kept the makeshift weapons in their hand. RN #1 said the Security Officer eventually left the room and Patient#1 seemed a little less agitated, but they still had the makeshift weapon in their hands. RN #1 said that when security left, Security Officer #1 told them to call security again if there were any other problems. RN #1 said a short time after security left the unit, Patient #1 pulled the call bell out of the wall and Security Officer #1 returned to the room to talk to Patient #1 again and left Patient #1 alone in their room while Patient #1 still had the makeshift weapons in their hands. RN #1 said after security left the unit again, the decision was made to call the police to assist with restraining Patient #1 and shortly after that a Code 100 was called. RN #1 said after police were called, Patient #1 started hitting the window with the metal suction piece, the glass broke and they were throwing pieces of glass at the doorway so no one could come in. RN #1 said Patient #1 went out of the broken window onto the roof and they kept the metal suction piece in their hand. RN #1 said as the police followed Patient #1 onto the roof, Patient #1 jumped off the roof and ran from the hospital into the woods. During an interview on 11/13/25 at 8:15 A.M., Security Officer #1 said they were called to Patient #1’s room around 1:00 A.M. because Patient #1 was destroying the room. Security Officer #1 said Patient #1 was agitated and pacing the room, saying they thought someone was behind the curtain in the room and wanted to kill them. Security Officer #1 said Patient #1 had a coat hanger in one hand and a piece of metal from the wall in their other hand. Security Officer #1 said these could be considered potential weapons and they felt that Patient #1 could have potentially harmed themself or someone else. Security Officer #1 said Patient #1 tried to grab at Nursing Supervisor #1. Security Officer #1 said they asked the other staff to leave Patient #1’s room to give them space but Patient #1 would not give Security Officer #1 the potential weapons despite asking a few times. Security Officer #1 said they didn’t want to agitate Patient #1 further, so they cleared the call and told nursing staff not to interact with Patient #1 and to call security if the Patient became a problem. Security Officer #1 said Patient #1 still had the potential weapons in their hands when the call was cleared. Security Officer #1 said a short time after leaving Patient #1’s unit, they got another call from Nursing Supervisor #1 to go back to Patient #1’s room because they ripped the call bell out of the wall. Security Officer #1 said Patient #1 had the metal piece in their hand and was throwing it at the window at that time. Security Officer #1 said they turned the call bell off and asked Patient #1 to sit down. Security Officer #1 said they cleared that call and left the unit again. Security Officer #1 said shortly after this they got a call from Nursing Supervisor #1 asking security to call the police and then a Code 100 was called. Security Officer #1 said when they arrived to Patient #1’s room, staff reported Patient #1 was on the roof after breaking the window. Security Officer #1 said the police arrived and while trying to talk to Patient #1, they jumped from the roof and ran into the woods. During an interview on 11/13/25 at 6:26 A.M., Physician #1 said the evening of 10/30/25 they were notified by the nurse that Patient #1 had pulled their IV out and was refusing to allow the IV access to be put back in. Physician #1 said they put in orders for soft wrist restraints in response. Physician #1 said after they put the order in for the soft restraints, nursing staff said they wanted to leave Patient #1 alone and that Patient #1 was being calm and cooperative. Physician #1 said there was no further communication from nursing staff after that until about 1:40 A.M., so they assumed Patient #1 was doing okay. Physician #1 said they were first made aware of Patient #1’s behaviors at 1:40 A.M. and that if they had been notified earlier, they would have adjusted the treatment plan for Patient #1 and performed an evaluation. Physician #1 said they would have expected to be notified of Patient #1 pacing, wanting to leave their room or unit, becoming disruptive and failing to give up items that could be used as potential weapons as Patient #1 lacked capacity and could be a threat to themself or others. Physician #1 said earlier intervention should have occurred. 2) Patient #2 arrived at the Emergency Department (ED) on 9/20/25 after attempting to hurt themself. Patient #2 was hitting their head against the wall with thoughts of suicide and wanting to strangle themself. Review of Patient #2’s medical record indicated they were assessed as a high risk for suicide on 9/20/25 and an order was placed on 9/20/25 for 1:1 observation. Review of Emergency Department Sign-out Note dated 9/23/25 at 7:12 A.M. indicated that Patient #2 attempted strangulation. Review of Nurse’s Note dated 9/22/25 at 7:17 P.M. indicated that Patient #2 had gone to the bathroom and became unresponsive to the Safety Specialist (a person who has received training and orientation to provide constant observation). The Note indicated the Safety Specialist got the attention of another nurse, who opened the bathroom door and found Patient #2 lying on their side with their socks tied around their neck. The Note indicated Patient #2 was unresponsive, the socks were removed and afterwards Patient #2 became responsive. During an interview on 11/13/25 at 1:00 P.M., Safety Specialist #1 said they were assigned as Patient #2’s 1:1 constant observer that shift. Safety Specialist #1 said the report received at the start of their shift was that Patient #2 had a history of suicide attempts, was a high risk for suicide and that the 1:1 observer should have eyes on Patient #2 at all times. Safety Specialist #1 said Patient #2 asked to use the bathroom and since Patient #2 was the opposite gender, they shut the door to the bathroom and did not maintain eye contact on Patient #2 as ordered. Safety Specialist #1 said they were listening through the door and would knock on the door every few seconds to make sure Patient #2 was okay. Safety Specialist #1 said they knocked on the door and didn’t get a response, so they waited a few seconds and knocked again and still didn’t get an answer, so they notified Registered Nurse (RN) #3 that Patient #2 was in the bathroom and wasn’t responsive. Safety Specialist #1 said they opened the bathroom door together and Patient #2 was on the floor with socks around their neck. Safety Specialist #1 said they immediately removed the socks and sat Patient #2 up. Safety Specialist #1 said Patient #2 said they were trying to kill themselves. Safety Specialist #1 said after the event, the Hospital sent a message to staff that they should use paper booties for high-risk patients rather than socks. Safety Specialist #1 said for patients that require a 1:1 and have the same gender as the 1:1, the 1:1 will leave the bathroom door open slightly to maintain eye contact, but if the patient and 1:1 have different genders, the door will be shut. During an interview on 11/14/25 at 10:04 A.M., RN #3 said Safety Specialist #1 notified them Patient #2 was in the bathroom and not answering. RN #3 said when they opened the door, Patient #2 was on the floor with socks tied around their neck. RN #3 said they shouted for help, removed the socks, rolled Patient #2 on their back and Patient #2’s color came back. RN#3 said patients that are high risk and ordered for a 1:1 should have a line of sight always maintained by staff. During an interview on 11/18/25 at 2:00 P.M., the Director of Risk Management, Patient Safety, and Regulatory Affairs said the Hospital had investigated this event and educated staff that paper booties are available for high-risk patients. The Director said the expectation is that the 1:1 will always maintain visual contact of the patient, even while using the bathroom.”