HospitalInspections.org

Based on observation of facility video footage in Room 3A -329 on the Behavioral Health Unit dated 01/04/2024 from 8:36 a.m. to 12:12 p.m., facility staff interviews, Patient #1's medical record review of "flowsheets" and "encounter problems", and facility policy and procedure review, the facility failed to follow policy and procedure for hourly safety observation to support a safe environment and to prevent patient self-harm and suicide event on two (2) of two (2) days of survey.

Findings Include:

Cross Refer to A-0385/482.23 for the facility's failure to provide a safe environment to prevent patient self-harm and suicide while not following policy and procedure for hourly patient safety observation.

During the exit conference on 01/12/2024 at 2:00 p.m. with the Chief Executive Officer, the Chief Nursing Officer, the Director of Risk Management, and the Director of Accreditation survey findings related to alleged complaints were discussed. No further documentation was provided for review during the exit conference.

Based on observation of facility video footage of patient #1's room 3A -329 on the Behavioral Health Unit dated 01/04/2024 from 8:36 a.m. to 12:12 p.m. facility staff interviews, medical record review of "flowsheets" and "encounter problems," for Patient #1, and facility policy and procedure review, the facility's nursing staff failed to deliver appropriate nursing services which followed the patient's plan of care and facility policies and procedures on two (2) of two (2) days of survey.

Findings Include:

Observation of facility video footage of Patient #1's room, 3A -329 on the Behavioral Health Unit, dated 01/04/2024 from 8:36 a.m. to 12:12 p.m. with the Director of Risk Management and Director of Accreditation revealed:

08:17:10 a.m. Patient #1 enters room from hallway.
08:17:16a.m. Patient #1 enters bathroom from room.
08:24:45 a.m. Patient #1 exits bathroom to room, stands and looks around room.
08:25:32 a.m. Patient #1 walks to hall door looking towards TV/Camera wall.
08:25:38 a.m. Patient #1 shuts door to hall.
08:27:47 a.m. Patient #1 enters bathroom.
08:29:06 a.m. Patient #1 exits bathroom, standing in room with arms across chest swaying back and forth.
08:29:57 a.m. Patient #1 walks to chair by the window and sits.
08:31:01 a.m. Registered Nurse (RN #1) enters patient room from hallway interacts with patient.
08:33:42 a.m. Patient walks to the bathroom with water pitcher-RN #1 present in room.
08:34:12 Patient #1 exits the bathroom with water pitcher in hand. Places water pitcher on bedside table.
08:36:56 a.m. RN #1 exited patient's room to hallway.
08:37:08 a.m. Patient #1 enters bathroom.
08:39:15 a.m. Patient #1 exits bathroom standing in room swaying back and forth with hands in pants pockets gazing towards the TV/camera wall.
08:40:32 a.m. Patient #1 walks back to the water pitcher takes a drink, sits in chair by window.
08:45:57 a.m. Patient #1 enters bathroom.
08:53:18 a.m. Patient #1 exits bathroom, walks to wall with TV and Personal belongings shelf and walks back toward the bathroom. Patient #1-out of camera view.
08:53:44 a.m. Patient #1 enters bathroom.
08:53:57 a.m. Patient #1 exits bathroom. While holding the door open the patient looks up at top right corner of door. Patient #1 comes further into the room beside the bed and stands holding on the bed rail, slightly bends over several times as if sick or crying, flexes right hand, looks up with painful expression.
08:54:13 a.m. Patient #1 turns and re-enters the bathroom.
08:56:53 a.m. Patient #1 closes bathroom door. Patient is inside the bathroom.
09:01:02 a.m. Patient #1 opens bathroom door.
09:01:05 a.m. Patient #1 walks to the bed and sits down, shuffles feet, looks around the room, and rocks back and forth.
09:03:50 a.m. Patient #1 lays down on the bed on right side.
09:08:24 a.m. Patient #1 gets out of bed and walks to the bathroom.
09:08:25 a.m. Patient #1 enters bathroom.
09:12:41 a.m. Dark colored strap/belt appears on the top right corner of the door between the door frame and door.
09:12:45 a.m. Patient #1 closes bathroom door from inside the bathroom, after four (4) attempts the door latch catches and the door remains closed, the dark colored strap/belt remains visible.
11:55:17 a.m. RN #1 re-enters patient's room. Opens bathroom door. Belt loop was released.
11:55:32 a.m. RN #1 pushes code button on the wall.
11:55:40 a.m. RN #1 reenters the bathroom.
11:55:46 a.m. RN #1 pushes code button again and calls for help
11:56:04 a.m. Sitter enters room to assist.
11:56:13 a.m. Sitter exits room.
11:56:19 a.m. Two (2) Staff members enter the room to assist.
11:56:24 a.m. One (1) of the staff members exits the room.
11:56:59 a.m. Staff pull patient #1 out of bathroom between bathroom and patient room.
11:57:12 a.m. Staff who exited the room at 11:56:24 a.m. re-enter the patient's room.
11:57:28 a.m. Attending physician enters Patient #1's room, Cardiopulmonary Resuscitation in progress.
11:57:35 a.m. Another staff member enters patient #1's room with a backboard.
11:57:41 a.m. Staff move bed, Cardiopulmonary Resuscitation continues.
11:57:50 a.m. Cardiac monitor arrives, Cardiopulmonary Resuscitation continues.
11:58:07 a.m. Belt placed on floor beside patient, Cardiopulmonary Resuscitation continues.
11:58:17 a.m. Crash cart arrives, Cardiopulmonary Resuscitation continues.
11:58:37 a.m. Code team arrives, Cardiopulmonary Resuscitation continues.
12:12:00 p.m. Code was stopped, return to spontaneous circulation was not achieved.

An interview with the Director of Risk Management on 01/11/2024 at 12:20 p.m., confirmed the hourly safety checks on Patient #1 were not made per the facility policy and physician ordered plan of care after her review of the facility video footage of Patient #1's room 3A -329 on the Behavioral Health Unit dated 01/04/2024 from 8:36 a.m. to 12:12 p.m.

An interview with the Director of Accreditation on 01/11/2024 at 12:20 p.m. confirmed the hourly safety checks on Patient #1 were not made per the facility policy and physician ordered plan of care after her review of the facility video footage of Patient #1's room 3A -329 on the Behavioral Health Unit dated 01/04/2024 from 8:36 a.m. to 12:12 p.m.

An interview with Director of Accreditation on 01/12/2024 at 10:30 a.m. confirmed hourly checks for the suicide level precaution level one (1) in the Suicide Policy and Procedure, policy number PPM5054, dated 7/16, Last revised 6/21, is the same level of observation as the behavioral health unit's standard observation for patient safety.

Interview with Director of Behavioral Health (DBH) on 01/12/2024 at 10:50 a.m., confirmed Patient #1 was on physician ordered routine safety precautions with hourly safety checks; no suicide precaution order was given by the attending physician. Additionally, the DBH revealed during a staff debriefing of the event on 01/08/2024, RN #1 did not perform hourly safety observations on Patient #1 on 01/04/2024 between 8:36 a.m. - 11:55 a.m. due to managing issues with other patients and other duties and RN #1 did not delegate patient safety checks to one (1) of two (2) behavioral health assistants (BHA) who were in the Behavioral Health Unit day room with patients.


Review of medical record titled, "Flowsheets" for Patient #1 on 01/04/2024 and facility video footage of Patient #1's room, 3A-329, dated 01/04/2024 from 8:36 a.m. to 12:12 p.m. revealed a discrepancy in documentation. Documentation at 9:26 a.m. by RN #1 states " ...patient; awake." Review of facility video footage of Patient #1's room revealed no observation of staff entering Patient #1's room, 3A-329, from 8:36 a.m. - 11:55 a.m. when patient #1 was found unresponsive.

Review of the medical record titled, "Encounter Problems" for Patient #1, revealed " ...Intervention: Develop and Maintain Individualized Safety Plan ...Provide immediate and ongoing protective physical environment ...Conduct environment of care safety checks ...Be alert to warning signs of suicidal ...behavior ...Note: Denial for suicidal ideation or agreement to a safety plan does not invalidate suicide risk ...".

Review of facility policy and procedure, "Suicide Precaution", policy number PPM5054, dated 7/16, Last revised 6/21 revealed " ...Patients who demonstrate or verbalize feelings of depression, hopelessness, or have vague suicidal ideations may be placed on suicide watch and observations...Orders for suicide precautions are based on a clinical assessment and depends on categories listed ....A. Level I ...expressing feelings/thoughts of suicide with no specific plan ...Check patients whereabouts ...every hour ... ".

During the exit conference on 01/12/2024 at 2:00 p.m. with the Chief Executive Officer, Chief Nursing Officer, the Director of Risk Management, and the Director of Accreditation survey findings related to alleged complaints were discussed. No further documentation was provided for review during the exit conference.

Based on observation of facility video footage of patient #1's room 3A -329 of the Behavioral Health Unit dated 01/04/2024 from 8:36 a.m. to 12:12 p.m., facility staff interviews, medical record review of "flowsheets" and "encounter problems," for Patient #1, and facility policy and procedure review, the facility's nursing staff failed to adhere to facility patient safety policies and procedures to prevent patient self-harm and suicide event on two (2) of two (2) days of survey.

Findings Include:

Cross Refer to A-0385/482.23 for the facility's failure to ensure nursing staff followed policies and procedures.

During the exit conference on 01/12/2024 at 2:00 p.m. with the Chief Executive Officer, the Chief Nursing Officer, the Director of Risk Management, and the Director of Accreditation survey findings related to alleged complaints were discussed. No further documentation was provided for review during the exit conference.

Based on observation of facility video footage of Patient #1's room 3A-329 on the Behavioral Health Unit dated 01/04/2024 from 8:36 a.m. to 12:12 p.m. facility staff interviews, and medical record review of "flowsheets" for Patient #1, the facility failed to provide accurate documentation of required hourly rounding to ensure patient safety and prevent self-harm on two (2) of two (2) days of survey.

Findings Include:

Observation of facility video footage of Patient #1's Room 3A -329 of the Behavioral Health Unit dated 01/04/2024 from 8:36 a.m. to 12:12 p.m. with the Director of Risk Management and Director of Accreditation revealed:

08:17:10 a.m. Patient #1 enters room from hallway.
08:17:16a.m. Patient #1 enters bathroom from room.
08:24:45 a.m. Patient #1 exits bathroom to room, stands and looks around room.
08:25:32 a.m. Patient #1 walks to hall door looking towards TV/Camera wall.
08:25:38 a.m. Patient #1 shuts door to hall.
08:27:47 a.m. Patient #1 enters bathroom.
08:29:06 a.m. Patient #1 exits bathroom to room standing with arms across chest swaying back and forth.
08:29:57 a.m. Patient #1 walks to chair by the window and sits.
08:31:01 a.m. Registered Nurse (RN #1) enters patient room from hallway interacts with patient.
08:33:42 a.m. Patient #1 walks to the bathroom with water pitcher-RN #1 present in room.
08:34:12 Patient #1 exits the bathroom with water pitcher in hand. Places water pitcher on bedside table.
08:36:56 a.m. RN #1 exited patient's room to hallway.
08:37:08 a.m. Patient #1 enters bathroom.
08:39:15 a.m. Patient #1 exits bathroom standing in room swaying back and forth with hands in pants pockets gazing towards the TV/camera wall.
08:40:32 a.m. Patient #1 walks back to the water pitcher takes a drink, sits in chair by window.
08:45:57 a.m. Patient #1 enters bathroom.
08:53:18 a.m. Patient #1 exits bathroom, walks to wall with TV and Personal
belongings shelf and walks back toward the bathroom. Patient-out of camera view.
08:53:44 a.m. Patient #1 enters bathroom.
08:53:57 a.m. Patient #1 exits bathroom. While holding the door open the patient looks up at top right corner of door. Patient #1 comes further into the room beside the bed and stands holding on the bed rail, slightly bends over several times as if sick or crying, flexes right hand, looks up with painful expression.
08:54:13 a.m. Patient #1 turns and re-enters the bathroom.
08:56:53 a.m. Patient #1 closes bathroom door. Patient is inside the bathroom.
09:01:02 a.m. Patient #1 opens bathroom door.
09:01:05 a.m. Patient #1 walks to the bed and sits down, shuffles his
feet, looks around the room, and rocks back and forth.
09:03:50 a.m. Patient #1 lays down on the bed on his right side.
09:08:24 a.m. Patient #1 gets out of bed and walks to the bathroom.
09:08:25 a.m. Patient #1 enters bathroom.
09:12:41 a.m. Dark colored strap/belt appears on the top right corner of the door between the door frame and door.
09:12:45 a.m. Patient #1 closes bathroom door from inside the bathroom, after four (4) attempts the door latch catches and the door remains closed, the dark colored strap/belt remains visible.
11:55:17 a.m. RN #1 re-enters patient's room. Opens bathroom door. Belt loop was released.
11:55:32 a.m. RN #1 pushes code button on the wall.
11:55:40 a.m. RN #1 reenters the bathroom.
11:55:46 a.m. RN #1 pushes code button again and calls for help.
11:56:04 a.m. Sitter enters room to assist.
11:56:13 a.m. Sitter exits room.
11:56:19 a.m. Two (2) Staff members enter the room to assist.
11:56:24 a.m. One (1) of the staff members exit the room.
11:56:59 a.m. Staff pull patient out of bathroom between bathroom and patient room.
11:57:12 a.m. Staff who exited the room at 11:56:24 a.m. re-enters Paient #1's room.
11:57:28 a.m. Attending physician enters the room, Cardiopulmonary Resuscitation in progress.
11:57:35 a.m. Another staff member enters the room with a backboard.
11:57:41 a.m. Staff move bed, Cardiopulmonary Resuscitation continues.
11:57:50 a.m. Cardiac monitor arrives, Cardiopulmonary Resuscitation continues.
11:58:07 a.m. Belt placed on floor beside Ptient #1, Cardiopulmonary Resuscitation continues.
11:58:17 a.m. Crash cart arrives, Cardiopulmonary Resuscitation continues.
11:58:37 a.m. Code team arrives, Cardiopulmonary Resuscitation continues.
12:12:00 p.m. Code was stopped, return to spontaneous circulation was not achieved.

An interview with the Director of Risk Management on 01/11/2024 at 12:20 p.m.,
confirmed the hourly safety checks were not made on Ptient #1, every hour per the facility policy and physician orders based on her observation and review of the video footage dated 01/04/2024 from 8:36 a.m. to 12:12 p.m. of the Behavioral Health Unit Floor Three (3) room 3A-329.

An interview with the Director of Accreditation on 01/11/2024 at 12:20 p.m. confirmed the hourly safety checks were not made on Paient #1, every hour per the facility policy and physician orders based on her observation and review of the video footage dated 01/04/2024 from 8:36 a.m. to 12:12 am. of the Behavioral Health Unit Floor Three (3) Room 3A-329.

An interview with the Director of Behavioral Health (DBH) on 01/12/2024 at 10:50 a.m., confirmed Patient #1 was on physician ordered routine safety precautions with hourly safety checks and no suicide precaution order was given by the attending physician. Additionally, the DBH revealed, during a staff debriefing of the event on 01/08/2024, RN #1 did not make routine safety observations on Patient #1 on 01/04/2024 between 8:36 a.m. - 11:55 a.m. due to managing issues with other patients/other duties and RN #1 did not delegate patient safety checks to one (1) of two (2) behavioral health assistants (BHA) who were in the behavioral health unit day room with patients.

Review of medical record titled, "Flowsheets" for Patient #1 on 01/04/2024 and facility video footage of Patient #1's room, 3A-329, dated 01/04/2024 from 8:36 a.m. to 12:12 p.m. revealed a discrepancy in documentation. Documentation at 9:26 a.m. on flowsheet by RN #1 states " ...patient; awake." Review of facility video footage of Patient #1's room revealed no observation of staff entering Patient #1's room from 8:36 a.m. - 11:55 a.m. when Patient #1 was found unresponsive.

During the exit conference on 01/12/2024 at 2:00 p.m. with the Chief Executive Officer, Chief Nursing Officer, the Director of Risk Management, and the Director of Accreditation survey findings related to alleged complaints were discussed. No further documentation was provided for review during the exit conference.