Citing psychiatric patient safety concerns, state disciplines Waterbury Hospital

State regulators have disciplined Waterbury Hospital after unannounced visits found multiple violations of care standards, including the continued use of psychiatric patient beds with side rails in the days after a patient used one to attempt suicide by hanging. The patient ultimately died.

In agreeing to a consent order with the state Department of Public Health, the hospital did not admit wrongdoing or fault. The order requires the hospital to pay a $5,000 fine and hire a clinical consulting firm to conduct onsite reviews and make recommendations for improvements. The hospital must also develop or revise certain policies and provide training to staff.

The consent order, signed Jan. 11, also incorporates the terms of a previous consent order that the hospital agreed to in February 2010.

The visits that led to the consent order signed this month took place from August through October 2010. Many of the violations regulators cited involved the hospital’s psychiatric unit.

Hospital spokesman Matt Burgard said that since the incidents cited in the report, the hospital conducted a thorough internal review of the unit, acquired new equipment and furniture, including beds, and enhanced safety measures used in the unit.

“We take this very seriously and we’re making a lot of efforts to address the concerns raised by the consent order,” he said.

In a report, state regulators cited the case of a person identified as Patient #1, who was admitted to the hospital after a suicide attempt. Two days after being admitted, Patient #1 told a nurse that he or she wanted to die. The patient was to be checked every 15 minutes, but 10 minutes after being checked, the patient’s roommate said someone needed to check on Patient #1.

Patient #1 was found hanging from the side rail of the bed with a sheet around his or her neck. The patient received treatment in the intensive care unit, but died three days later.

Five days after Patient #1 was found hanging from the side rail and two days after the patient’s death, 19 adult patients receiving treatment in the psychiatric unit were still in beds with side rails, according to the report. Some of those patients had recently attempted suicide or self-harm, the report said.

The nurse administrator told state regulators that all patients get suicide risk assessments when they are admitted, as well as on every shift. But the report said that once side rails were known to pose a safety risk, the staff failed to reassess patients for that risk.

Two days after Patient #1’s death and after the surveyor inquired, physicians conducted side rail safety assessments for all patients, according to the report. The hospital also developed a plan to address safety issues on the unit, requiring nursing staff to include side rails in their risk assessments and document it each shift.

The report also took issue with staffing levels for the psychiatric unit. Staffing was based on having an average of 19 patients in the unit, even though it had the capacity for 30. The director of acute care behavioral health services told regulators that the unit’s staffing guidelines did not reflect requirements for cases in which there were more than 19 patients in the unit, but said if the number of patients or acuity was high, staffing would increase. But according to the report, the director also said that there was no system in place to measure patient acuity. In addition, the report said, between July 18 and Aug. 4, 2010, patient census on the unit was higher than 19 for 10 days, but staffing was not increased on eight of them.

In addition, the report identified potential safety hazards in the hospital’s behavioral health unit, including non-breakaway clothes hooks inside patient closets; closet door hinges, bathroom door knobs and bedroom door locks that posed strangulation risks; and hand towel dispensers in patient rooms that could be used as weapons. A hospital committee had previously identified that the closet door hinges and door knobs could pose risks but they had not been addressed, according to the report.

Two other situations cited in the report related to patient privacy. In one case, a social worker used a lounge with other patients present to conduct an assessment of a patient who had recently attempted suicide. At one point, the patient said, “I don’t want anyone to hear,” according to the report. After the surveyor inquired, the patient and social worker moved to a private area.

In another case, a patient who was suicidal was found to have a knife hidden in his or her bedroom and was then placed in a hospital lounge 24 hours a day for safety. At night, the patient’s mattress was brought to the lounge, which the report said was an open area for the general population to use and provided no privacy.

The report also cited the cases of three patients who had dementia and were considered at risk of falling. The patients were put in medical restraint vests, but the report said there was no documentation indicating that there had been attempts to use less restrictive measures first.

Waterbury Hospital is in the process of forming a joint venture with the city’s St. Mary’s Hospital and LHP Hospital Group, a Texas company, that would lead to a new, single medical center for the city.