TL5-9 AFTER ACTION REPORT ON FLOODING OF INPATIENT PSYCH 12/31/10
Transferred phones to receiving unit and then transferred them back to previous unit (Infusion), as well as recovery of phones to BH extensions. Both internal & Qwest involved.
Informed Information desk as to what could be shared, and how visitors & discharge rides would be handled. We escorted both ways.
Notified nursing supervisor, Registrations/Admissions, EVS, and Pharmacy.
Discussed safety concerns with EVS.
Collaboration with Pharmacy re. Pyxis codes, receiving of pt. meds, med rm code, faxes, etc. No bar coding at SFHC. Security of RX pads on 3East and on 10th floor.
Continuation of documentation of safety checks q 15 minutes, but done continuously when not able to provide 1:1 s on all patients. Used 2 CNAs to assist highest acuity pts. first night.
Identified greatest safety issues as being: glass windows, bathroom plumbing, & no sprinklers on 10 North as too easy for psych pt. to damage creating another flood.
Locks installed on non-pt rooms, and on door to stairs by central elevators. Security in place at north end of 10 North.
Overbed tables which contain mirrors and mirrors removed from pt. rooms.
All metal protrusions removed from rooms as much as possible. White boards, BP dials, crucifies, etc. removed. Each room was different, so could not assume similar for safety.
Manager made inventory of each room’s unsafe items, working with facilities, and then resolved prior to manager and facilities leaving at approx 9pm on Friday.
Bed cords tied with tough plastic security ties. Call bells removed.
Head and foot boards removed as could have been used as weapons. This created an issue as 7 electric beds needed source of power to keep air mattresses inflated, so traded out mattresses on Saturday.
Plumbing fixtures that could be removed were tied with tough security plastic ties.
Dressers boarded shut; handles left on to secure the board. Pt. closets locked shut, as was valuables drawer.
No seclusion capability since rooms had glass windows. If seclusion were needed, restraints would have been considered.
North elevators used by staff and center core elevators locked. Locked stairwells.
Ongoing log of unit SBARQ issues with suggestions maintained from the start. All staff shared feedback and ideas for safety and treatment.
Communication with dietary to use plastic ware, etc. on the trays.
Portable tables put in place for communal eating as tray tables had been removed due to mirrors inside. Bedside stands also removed so less ability to barricade in room as beds not bolted in place.
Had chair shortage with what patients needed in group room, sitters, and then worse on Monday as infusion needed. Staff also did not have adequate chairs, particularity that could be used under a desk to do computer work.
Established group room with TV under heavy staff monitoring. Patients grouped with treatment process or socialization activities. One pt. to go out to their room at a time, so could be monitored. Staff stood outside all bathroom doors when bathrooms used by patients, and hall bathroom locked. No showers taken by patients, but provided alternative options for personal hygiene issues during these two days. All shower rods removed on Friday.
Lab provided finger sticks, as glucometer not programmed for PH. Lab directed to use North elevators and announce to security their arrival.
Removed computer carts (WOWs)andlaundry carts for safety reasons.
Staff kept in halls at all times for monitoring.
Needed more computers and received these a little after need established.
No admissions to inpatient psychiatric unit on PH 10. Placement and discharge options identified. Last patient left at 1715 on Monday the January 3, 2011.
Press release notifying community of decision to close unit and inpatient services. went out at
Supply confusions - Inpatient Psych brought all their medical supplies, so storage was challenging. Also Infusion and Medical had used this area for supplies so sorting supplies impossible.
Everyone safe.