CT hospital failed to keep patient from swallowing batteries, wires, other objects: report

A psychiatric patient at Yale New Haven Hospital continued to swallow wires out of surgical masks, as well as batteries and other objects, despite orders of one-to-one observation, according to a federal inspection triggered by a complaint.

The inspection was conducted by the Centers for Medicare and Medicaid Services and is posted on the website hospitalinspections.org. The director of the site confirmed all data regarding such an inspection comes directly from the Centers for Medicare and Medicaid Services.

Dana Marnane, a spokeswoman for Yale New Haven Health, said in a statement, “Yale New Haven Hospital cooperated fully with the … investigation, created a plan, inclusive of staff retraining, to ensure the safety of the patient, which was accepted. Yale New Haven Hospital takes our responsibility to protect patients seriously and is committed to providing the safest and highest quality of care possible.”

The patient was brought to the Emergency Department on July 12, 2022, complaining of abdominal pain and stated he or she felt depressed and suicidal after swallowing two batteries. The patient was diagnosed with schizoaffective disorder, bipolar disorder and pica, an eating disorder, characterized by swallowing non-food objects.

The batteries were removed via an endoscopy. One-to-one observation was ordered and the patient was assessed at being at high risk for suicide, the report states.

On July 13, the patient’s clothes were returned, two batteries were found in a jacket pocket, which the patient then swallowed, according to the report. The observational association stated she did not see that happen, the report states.

On July 16, the patient admitted to their one-to-one sitter that while in the restroom they took an 8-centimeter wire out of a surgical mask and swallowed it. It was removed from the duodenal bulb at the lower end of the stomach, the report stated.

“The report recommendation was to ensure very close supervision to prevent foreign body ingestion and do not give masks with metal components in it,” the report said.

Between July 16 and Aug. 22, 2022, the patient “remained hospitalized and swallowed objects 10 more times requiring endoscopic removal,” the inspection report stated.

“The hospital failed to ensure that safety precautions were effective while the patient was in the ED and the psychiatric unit, failed to document monitoring observations to include location, activity, and behaviors, and failed to conduct investigations to determine how the patient was able to repeatedly ingest objects while hospitalized,” the report said.

On July 17, the patient swallowed a paper clip he or she found on the floor and ingested while the observer was sleeping. It was removed, according to the report. On July 18, batteries were still visible on an X-ray and medication was given to expedite excretion.

On July 25, according to the report, the patient swallowed a mask wire and two colored pencils, which were removed by an endoscopy, “but no formal education was provided to all staff. The Nurse Manager stated that she could not recall if staff checked patient rooms and garbage bins on the unit for masks with wires in them.”

According to the inspection report, the patient swallowed mask wires on July 27, July 29, July 30 and July 31.

“A significant event note dated 8/13/22 at 6:32 PM noted (the patient) had an overwhelming urge to swallow something and found a new patient who ‘didn’t know the rules,’ took the remote from the new patient, removed the battery, went to the bathroom, and swallowed it,” the report stated.

The next day, the patient reported breaking a toothbrush and swallowing half of it, which was removed, the report stated. Further, “Nurse’s notes dated 8/31/22 at 1:55 PM noted the patient reported taking a ‘golf pencil’ from the nursing station, then went into the bathroom and ingested it,” according to the report.

As corrective actions, “The suicide risk screening, assessment and precaution policy, and the Patient Level of Observation (Psychiatry and non-Psychiatry) were reviewed by the organization,” the report stated.

“Nursing staff on the inpatient Psychiatric unit and the Emergency Department will be re-educated on patient observation consistent to the above policies. Hand off communication between patient observers for this patient will only occur in the patient’s room. Hand off communication and review of the environment at change of shift and each transfer will be documented. The patient’s care plan will be reviewed and updated on an ongoing basis and after any significant event. The patient’s care plan will be audited after any significant event. Random audits will be conducted.”

The website hospitalinspections.org is maintained by the Association of Health Care Journalists.

Ed Stannard can be reached at estannard@courant.com.