Becker's Clinical Quality & Infection Control

13 INFECTION CONTROL & PATIENT SAFETY Connecticut hospital cited after patient swallows batteries By Mackenzie Bean C MS cited Connecticut Valley Hospital in Middletown for failing to properly monitor a psychiatric patient at risk of self-harm, according to the Hartford Courant. e patient was taken to Middlesex Hos- pital, also in Middletown, aer swallowing two batteries from a pair of headphones provided by a nurse May 8. He required emergency surgery and a colonoscopy to remove the batteries. e patient had been admitted to Middlesex Hospital five other times since February for other acts of self-harm, undergoing a total of six surgeries. is prompted the Middlesex surgeon who operated on him to file a com- plaint with the Department of Public Health. Regulators visited the state-run hospital June 11 and found staff members failed to "ade- quately supervise" patients or "maintain con- tinuous observations," according to a CMS inspection report emailed to Becker's. CMS placed the hospital on "immediate jeopardy" June 11. at status was lied June 16. "e department takes patient care and safe- ty very seriously," the Department of Mental Health and Addiction Services, which oversees the hospital, said in a statement to Becker's. "In light of a recent finding by [CMS] related to a CMS survey, DMHAS has taken immediate actions to modify neces- sary treatment to ensure appropriate care is provided to patients at the agency's hospital." e patient involved in the complaint has since been transferred to a more secure treat- ment setting. Hospital leaders also retrained employees and increased physician round- ing, among other actions, according to the Hartford Courant. n Mississippi VA hospital cited over patient's death By Mackenzie Bean H ealth officials cited Gulf Coast Veterans Health Care System for the 2017 death of a patient whom staff members failed to perform timely resuscitation on, according to a federal report cited by ABC affiliate WLOX. The Department of Veterans Affairs Office of Inspector Gener- al released its report on the incident Aug. 6. The patient died in late 2017, less than 24 hours after being admitted to the Biloxi, Miss.-based health system's behavioral health unit. The report found staff members failed to conduct regular 15-minute checks on the patient, as ordered by a physician. When employees found the patient unresponsive, they "did not quickly assess the patient, act with a sense of urgency, alert the care team, immediately initiate basic life support, locate the nearest automated external defibrillator, nor acti- vate the community 9-911 emergency response system, all of which were required by policy," the report said. The OIG could not determine whether appropriate resuscita- tion efforts would've saved the patient. "We recognize opportunities for improvements in our practice and corrective actions are being implemented to address the recommendations," Bryan Matthews, director of Gulf Coast Veterans Health Care System, said in written comments includ- ed in OIG's report. The health system has since retrained employees on how to respond to medical emergencies, among other corrective actions. n 5 most common sentinel events so far in 2019 By Mackenzie Bean I ncidents involving retained foreign objects were the most common sentinel event in the first half of 2019, according to data The Joint Commission released Aug. 14. The Joint Commission defines a sentinel event as a patient safety event that results in death, perma- nent harm, severe temporary harm or intervention required to sustain life. The latest data includes several new sentinel event categories, including anesthesia-related events, criminal events and environmental events. The Joint Commission reviewed 436 reports of sentinel events in the first six months of the year, 83 percent of which were voluntarily reported to the accrediting body. The five most frequently reported sentinel events for the first half of 2019: 1. Unintended retention of a foreign body — 60 reported events 2. Wrong-site surgery — 29 3. Fall — 25 4. Suicide (inpatient) — 21 5. Suicide (off-site) — 21 n

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