| 61 |
GUAM MEMORIAL HOSPITAL AUTHORITY |
655000 |
499 NORTH SABANA DRIVE |
BARRIGADA |
GU |
96913 |
2013-09-20 |
319 |
E |
0 |
1 |
JK1T11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on inerviews and record reviews, the facility must ensure that a resident (Residents 5 and 8) who displays mental or psychosicial adjustment difficulty receives appropriate treatment and services to correct the assessed problem. Resident 5 was readmitted to the facility on June13, 2013 with a [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. According to an interview with LN 1 during the initial tour of the facility on (MONTH) 18, 2013 at approximately 9:23 AM, the resident was recently moved to a room closer to the nursing station because the facility became aware that the resident ' might want to hurt or kill ' themselves. During the tour, the resident was not observed to be in their assigned resident room. Throughout the morning and early afternoon of (MONTH) 18, the resident was observed to be self-propelling herself throughout the facility and outside to the patio located at the front entrance of the facility. An interview with the resident at approximately 1:30 PM on (MONTH) 18, 2013 was done, and they indicated they would be going to an off-campus appointment at 2:30 PM for the remainder of the afternoon. The resident said they felt okay' , and enjoyed going outdoors for fresh air. When asked about their mood, they indicated that they had recently been moved to another room, because a friend called the facility and reported that they (the resident) was trying to cut and kill myself with a knife . She added that it was 'a misunderstanding ', and that she was okay now. An interview was done with LN 3 on (MONTH) 19, 2013 at approximately 5:10 PM. The staff person stated that they were not the assigned staff for the resident that shift, and that toward the end of the shift (3 PM - 11 PM) they took a phone call from the friend of the resident on (MONTH) 13, 2013. LN 3 said the caller sounded worried and like they were about to cry , and asked for nursing staff to go check on Resident 5 in their room because I (the caller) think (the resident) may have, or may be trying to cut herself with a knife. The caller told LN 3 that they were worried about the resident because they (the caller and the resident) had just been arguing on the phone. LN 3 reported that earlier during the shift they had observed Resident 5 to be restless and about to cry, and looked mad . LN 3 said they then reported this information to the shift Charge Nurse, and then they went to check on the resident and took the knife away from the resident. LN 3 said that she heard the staff say that the door was locked , and responded to other staff that the door can't be locked because there is no lock on the doors . LN 3 said that staff then thought that the resident might have barricaded the door closed. LN 3 said the door was finally opened and they checked on the resident. LN 3 stated that she was not aware of the resident ever doing this in the past to her knowledge. The staff person added that security was informed to watch her just in case (the resident) does something else. Review of the nursing notes on (MONTH) 13, 2013 timed at 11:20PM read, The girlfriend of this patient called and said Can you go see (resident) in her room, she might slice her wrist. CNA and other nurse went to patient's room. Patient still awake, CNA found a kitchen knife and removed the knife in her room. Patient was up in wheelchair and went upstairs. I went upstairsand give knife to security and told him to watch this patient. On (MONTH) 14, 2013 at 10PM, an entry in the nursing notes read, Called Dr. (attending) informed him about the patients mental state last night. Was informed of suicidal ideation and acting out last night. Incident report was filed. Dr. (attending) ordering to have mental consult and monitor patient and on Level 1 suicide protocol until seen by mental health personnel . . Review of the physician's order [REDACTED]. However, there was also a telephone order by the physician dated (MONTH) 14, 2013 3:15PM obtained from the 3PM-11PM shift (MONTH) go out on pass today with friends for 3-4 hours. This order was obtained apparently prior to the physician being notified of the subsequent request for Suicide Watch order related to the events taking place the previous day. Further record review indicated that the physician's orders [REDACTED]. The order also stated, Initiate the Physical Environment Safety for Suicidal Patient (involve Safety, Security, and Facilities Maintenance). The physician order [REDACTED]. The physician also indicated Patient Transfers (staff must remain in constant attendance of the patient during transfers) 1:1 escorts on transfers (Level 1 & 2), Psychiatric/Behavioral Health Consultation, and Provide patient/family education on suicide precautions. Subsequent daily orders did not include 1:1 escorts on transfers. Based on review of the physician's order [REDACTED]. Review of the nursing notes revealed that the following assessments of the resident were documented related to her being on Suicide Watch Precautions ordered on (MONTH) 14, 2013 at 10PM from the event that took place on (MONTH) 13, 2013 (Note: Assessments were to have been made and documented every two hours, per physician's order [REDACTED].>September 15, 2013 -12:15AM -2:38AM -4:32AM -7:04AM -1:57PM -2:06PM -2:10PM -3:00PM -5:58PM -8:08PM -10:08PM September 16, 2013 -12:45AM -2:44AM -6:11AM -7:41PM -7:46PM -7:49PM -10:07PM September 17, 2013 -1:03AM -4:13AM -6:44AM -10:21AM -10:24AM -5:00PM -8:00PM September 18, 2013 -12:56AM -3:05AM -5:07AM -11:22AM -11:26AM -11:28AM -1:32PM -10:22PM September 19, 2013 -1:13 AM -3:07AM -5:06AM -1:39PM -1:42PM -1:44PM -4:30PM -6:40PM -8:35PM -10:22PM An interview with LN 2 on (MONTH) 19, 2013 at 5:10PM was done related to the resident and suicide watch. She stated that the assessments that were ordered by the physician as part of the Suicide Watch every two hours should have been completed and documented every two hours. When asked about the resident leaving the facility with a 'pass' , she also says that should not have taken place in light of the resident event on (MONTH) 13, 2013 precipitating the Suicide Watch on (MONTH) 14, 2103 at 10PM. She also added that the resident should not have been allowed to leave the facility on a 'pass' if the physician had been notified timely on (MONTH) 13, 2013. There were several disconnects that should not have happened after the incident took place. She should not have been allowed to leave the facility, and the nurses should be doing the assessments every two hours and documenting them as long as the order is in place . She was unclear as to why the initial suicide protocol order stipulated escorts on transfers, but subsequent orders did not. Finding 2: Resident 8 was admitted to the facility on (MONTH) 10, 2013 with a [DIAGNOSES REDACTED]. During an interview with the resident while completing the initial tour on (MONTH) 18, 2013, he was returning from physical therapy, and stated that he was 'sore, but okay' Review of the residents medical record indicated that the Social Worker had documented an interview with the resident on (MONTH) 18, 2013 at 3:19PM that Resident stated that he had been feeling sad due to his present medical condition and severe pain to both legs. He noted that he has thoughts of hurting himself when he experiences severe pain .This worker discussed counseling at GBHWC (Guam Behavioral Health and Wellness Clinic) .And he agreed. Review of the Medication Administration Record [REDACTED]. Further record review on (MONTH) 20, 2013 revealed that the resident was transferred to and seen by a mental health professional on (MONTH) 19, 2013. Nursing notes revealed that the patient returned from GBHWC at 6PM. There was no documentation from GBHWC regarding the evaluation. The only documentation from GBHWC was a one-page document titled Discharge Instructions that said to Return to GBHWC if you feel like harming yourself or others , and to Call the crises line if you feel you need to talk to somebody . Review of the SNU Resident Appointment Communication Form had been completed by Guam Memorial Hospital Skilled Nursing Unit, but the part for the treating physician/clinician to whom the resident was transferred to be seen for evaluation was blank. Review of nursing notes did not include any reference to or assessments related to suicide ideation or risks factors for suicide. An interview with LN 2 was done on (MONTH) 20, 2013 at 11:37AM. She stated that whenever a resident goes out to another facility for treatment or referral, the treating facility at which the resident was seen is supposed to forward a copy of any clinical notes or assessments done while at the treating facility, as well as completion of a SNU Resident Appointment Communication Form . She concurred that there was nothing in the resident ' s medical record from GBHWC other than the one-page discharge instructions addressed to the resident. When asked the behavioral/mental status of the resident related to the potential suicide ideation they were evaluated for, as well as continued plan of care, she responded I will need to have the social worker contact GBHWC to find out what their discharge instructions were and whether or not he still needs to be observed per the suicide watch protocol. An interview was done with SW 2 on (MONTH) 20, 2013 at approximately 11:57AM related to her interaction with resident and the notes she documented in the medical record on (MONTH) 18, 2013. She indicated that the resident reported to her thoughts of suicide. I was interviewing the resident, and he told me of his thoughts to hurt and harm himself. That's when I made sure the referral was made for him to be seen by GBHWC. She added, I didn ' t tell the charge nurse about the suicide ideation, only his depression. I should have told her so they would have been watching him closely, and not just made the note in his record. |
2018-07-01 |