HospitalInspections.org

Based on a review of documentation and an interview with staff, the facility failed to appoint a chief executive officer to be responsible for managing the hospital.

Findings were:

Patient #1's vital signs were assessed at the following times:
- 8:12 pm on 1-22-17
- 10:46 pm on 1-22-17
- 1:00 am on 1-23-17
- 8:04 am on 1-23-17
- 1:40 pm on 1-23-17

Facility policy ED-VS titled "Emergency Department Vital Sign Reassessment Guidelines" states, in part:
"Guideline
...
2. Vital sign reassessment will be based on patient acuity level and will be updated with any change in patient acuity status during ED[emergency department] stay:
...
b. Level 2: at least every 30 minutes until stable then hourly."

Observation sheets were completed during patient #1's stay in the emergency room. Review of the observation sheets reveal a gap in regular observations (to be performed every 15 minutes), as the patient's behavior was documented at 10:45 pm on 1-22-17 and not again until 12:45 pm on 1-23-17.

Facility policy PC-245 titled "Guidelines for Management of the Patient Under Suicide Precautions" states, in part:
"Procedure
...
Suicide Risk Screening and Assessment:
...
2. The Emergency Department (ED) Registered Nurses will only screen patients admitted to the ED with a primary focus/complaint of a behavioral issue(s) and/or, if the RN has any clinical concerns for any patients presenting with risk for self-harm:
3. Any patient that has a 'YES' answer to any of the suicide risk screening questions will be placed on suicide precautions and the RN will assign patient observation monitoring immediately. An LIP (Licensed Independent Practitioner) order will be generated in order to gain further suicide risk assessment by the assigned LIP and determine an ongoing safety observation and monitoring level. Safe environment and patient safety guidelines will be documented and implemented.
...
Heightened Observations:
Level 1 = Standard Observation - Monitor and observe minimally every 15 minutes. Staff visually observes the patient at least every 15 minutes and monitors their well-being and physical and mental safety."

The above was confirmed in an interview with the Quality Director on the afternoon of 4-24-17.