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Based on interview, review of the ongoing facility investigation, and facility policy, it was determined the facility failed to provide care in a safe setting by failing to follow facility policy related to providing one to one (1:1) observation for one (1) of ten (10) sampled patients (Patient #1).

On 07/17/16, Patient #1 was placed in a four (4)-point restraint with chest binder and Patient Aide (PA) #1 was assigned to be 1:1 with the Patient. However, PA #1 walked away from the patient and the resident removed his/herself from the restraint. The staff involved failed to report the incident immediately and failed to remove PA #1 from direct care.

The findings include:

Review of the facility Restraint Policy, dated August 2015, revealed patients placed in four (4)- point restraints are put on 1:1 observation.

Review of the 1:1 Supervision policy, dated March 20105, revealed patients placed on 1:1 supervision are to be monitored constantly to ensure patients receive care in a safe setting.

Review of the Incident Investigations Policy, dated March 2016, revealed reporting of incidents is to be done immediately.

Record review revealed the facility admitted Patient #1 on 07/12/16 with diagnoses, which included Erratic Mood, Aggression, and Suicidal Thoughts. Review of a Seclusion-Restraint Documentation form, dated 07/17/16 at 2:15 AM, revealed at approximately 2:30 PM the patient was placed in a four (4) point restraint with a chest binder with a staff assigned to continuously monitor the patient. Review of Seclusion-Restraint Documentation form, dated 07/17/16 at 2:35 AM, revealed the staff assigned to the patient walked away and the resident was able to get out of the restraints.

Interview with Patient Aide (PA) #1 on 07/21/16 at approximately 8:47 AM, revealed she was assigned to sit on 1:1 observation with Patient #1 who was in a 4 point restraint with a chest binder. She stated she broke the 1:1 observation when she stepped to the side and the patient was not in her direct line of sight. She revealed she had been trained on 1:1 observation stating the patient could never be out of eyesight when sitting 1:1. She stated she went back to the 1:1 observation of Patient #1 after Registered Nurse (RN) #1 had told her that during 1:1 her eyes must always be on the patient. She also stated she told RN #1 she knew she had made a mistake.

Interview with Licensed Practical Nurse (LPN) #1, on 07/21/16 at approximately 9:30 AM, revealed she assigned PA #1 to sit on 1:1 with Patient #1 and then she went into the office. LPN #1 stated when she came out of the office at approximately 2:35 AM she found Patient #1 out of his/her room, out of the restraint, and did not see PA #1 who should have been sitting 1:1 with the patient. LPN #1 revealed she was the first to see Patient #1 out of his/her room and the patient was acting in an aggressive manner. LPN #1 stated her and LPN #2 got the patient calmed and back in the restraint and another patient aide was sitting with the patient. She reported she did not know where PA #1 was at this point but when she saw PA #1 she told PA #1 "you left the patient you were assigned to sit 1:1. When sitting 1:1 with a patient you have to keep your eyes on the patient at all times." She stated PA #1 said she was going for the 1:1 paperwork. LPN #1 revealed she reported this to RN #1, and they completed the LPN #1 stated RN #4 did not pull PA #1 from direct patient care.

Interview with RN #1, on 07/21/16 at approximately 10:00 AM, revealed she was in the nurse's office doing the restraint paperwork for Patient #1 when LPN #1 came in and told her Patient #1 got out of the restraint, was found in the hallway, and PA #1 was not sitting 1:1 with the patient. RN #1 reported she called the coordinator's office and was told by RN #4 to come to her office. She stated she talked to PA #1 and PA #1 stated she did step away, approximately 12 feet with her back turned to Patient #1 while she was sitting 1:1 with the patient. RN #1 revealed she told PA #1 you could never take your eyes off a patient when sitting 1:1. She stated she did not pull PA #1 from direct patient care and when she and LPN #1 went to the coordinator's office, the coordinator did not pull PA #1 from direct patient care.

Interview with RN #4, on 07/21/16 at approximately 2:20 PM, revealed she was the coordinator on duty on 07/17/16 at 4:00 AM when RN #1 and LPN #1 came to the coordinator's office and brought her the restraint paperwork. She stated she did not tell RN #1 and LPN #1 to pull PA #1 from direct patient care and did not report the incident to Risk Management.

Interview with RN #2, on 07/21/16 at approximately 1:30 PM, revealed PA #1's shift ended at 7:00 AM on 07/17/16, and she called Risk Management to report the incident and then called PA #1 to let her know she had been pulled from patient care.

Interview with Risk Management Investigator (RMI) #2, on 07/21/16 at approximately 12:30 PM, revealed incidents should be reported to risk management within one (1) hour and their policy defines immediate as without delay.