HospitalInspections.org

Based on review of facility policies, review of medical records, video surveillance, and staff interviews it was determined that the facility failed to protect and promote each patient's rights as evidenced by failure to ensure that patients receive necessary levels of supervision (A0145).

Cross Reference:
482.13(c)(3) Patient Rights: Free from abuse/harassment

On January 24, 2024 at 10:48 AM, as a result of this failure, Immediate Jeopardy (IJ) was identified. The immediate interventions implemented by the facility included staff re-education, implementation of a zero tolerance policy, and an increase in leadership review and auditing. These interventions were implemented and verified by the State Agency, and the IJ was removed on January 25, 2024 at 12:41 PM.

Based on review of hospital policies, medical record review, video surveillance review, and interview with staff, it was determined that the facility failed to keep patients free from harm by failing to ensure that patient observations are conducted at indicated intervals consistent with facility policy, for 2 of 4 patients sampled (Patient #1 and Patient #2).


"Hospital policy titled "Patient's Rights" (last reviewed by facility 09/2023) stated, "...the patient has the right to be free from all forms of abuse, neglect, mistreatment, harm, or harassment..."

Hospital policy titled "Level of Observation/Rounds" (last reviewed by facility 2/2023) stated, "It is the policy of Dover Behavioral Health System that all patients will be routinely observed in compliance with physician orders and prescribed protocols...observe each patient, a minimum of every 15 minutes and/or according to precaution level and document observation on the patient form...whenever possible, staff should make informal, verbal contact with assigned patients to ascertain safety and well being...the assigned RN [Registered Nurse] will accompany the MHT [Mental Health Technician] or other assigned staff making rounds on 11-7 every 2 hours to ensure the patient is not in any distress, all doors remain open on 11-7 and there is a 'hall monitor' in place..."

Medical record review revealed:

Patient #1
- "Psychiatric Assesment" dated 01/20/24 stated, "...patient had increasing symptoms in the community leading to suicidal ideation and increased psychosis...patient will be placed on q [every] 15 minute checks to guard against harm to self and others..."
- No documented safety observation rounds after 5:15 AM on 1/21/24

Patient #2
- "Psychiatric Assessment" dated 01/18/24 stated, "...Q [every] 15- minute safety checks..."
- No documented safety observation rounds after 5:15 AM on 1/21/24


Video surveillance on 1/21/24 indicated that at 6:11 AM Patient #1 and Patient #2 entered their room. At 6:12:43 the door to the patients' room was closed from the inside. At 6:25:39 AM, Employee #7 opens the patients' door.
No interactions or patient observations by staff were visible between 5:59 AM and 6:25 AM (26 minutes without a safety observation). No hallway monitor was present during this time.

Employee #7, in a written statement provided by hospital administration, indicated "...I walked into one patient room to do rounds and found one patient [Patient #1] over another patient [Patient #2] over the floor, face down. Roommate [Patient #1] was over him with a towel around the patient's [Patient #2's] neck. The patient [Patient #2] was not moving. I told [Patient #1] to get off [Patient #2] and the patient [Patient #1] let go... I went to get the cart and we started CPR..."

During an interview with Employee #3, it was revealed that during the time of the missing safety observation, Patient #2 was assaulted by Patient #1 in their room utilizing a towel around Patient #2's neck, which resulted in the loss of pulses and respirations, requiring immediate life-saving measures including cardiopulmonary resuscitation (CPR).

These findings were confirmed during an interview on 01/23/24 at 09:24 AM with Employee #3.

Based on review of facility policies, review of medical records, and staff interviews, it was determined that the hospital nursing staff failed to properly supervise safety observations for 4 out of 4 patients (Patients #1, #2, #3, #4) sampled.


The hospital policy titled, "Level of Observation/Rounds", dated 02/23 stated, "...The Charge Nurse reviews and signs the Patient Observation Rounds Sheet a minimum of 2x per shift..."


The Patient Observation Rounds sheet, in each patient's medical record, contains a section for nursing to sign for their review and supervision of their observations in 4-hour slots (12:00 AM - 4:00 AM; 4:00 AM - 8:00 AM, etc.).


Medical record review for Patient #1 revealed:

Review of the Observation Record 24-Hour Inpatient Form showed there was no nursing signature to indicate a nurse reviewed and supervised the observation rounds on the following dates and times:

1/20/24: 12 AM-8 AM (8 hours)


Medical record review for Patient #2 revealed:

Review of the Observation Record 24-Hour Inpatient Form showed there was no nursing signature to indicate a nurse reviewed and supervised the observation rounds on the following dates and times:

1/18/24: 9 PM-12 AM (4 hours)

1/19/24: 8 AM-12 AM (20 hours)

1/20/24: 9 PM-12 AM (4 hours)

1/21/24: 12 AM-8 AM (8 hours)

Medical record review for Patient #3 revealed:

Review of the Observation Record 24-Hour Inpatient Form showed there was no nursing signature to indicate a nurse reviewed and supervised the observation rounds on the following dates and times:

1/13/24: 4 PM-4 PM (12 hours)

1/14/24: 4 AM-4 PM (12 hours)

1/15/24: 4 AM-12 AM (20 hours)

1/16/24: 12 AM-4 PM (16 hours)

1/18/24: 8 AM-12 AM (16 hours)

1/19/24: 4 AM-4 PM (12 hours)

1/20/24: 12 AM- 12 AM (24 hours)

1/21/24: 12 AM-8 AM; 4 PM-12 AM (16 hours)

1/22/24: 12 AM-8 AM; 4 PM-12 AM (16 hours)

Medical record review for Patient #4 revealed:

Review of the Observation Record 24-Hour Inpatient Form showed there was no nursing signature to indicate a nurse reviewed and supervised the observation rounds on the following dates and times:

1/5/24: 4 AM-8 AM; 4 PM-12 AM (12 hours)

1/6/24: 4 PM-12 AM (8 hours)

1/7/24: 12 AM-12 AM (24 hours)

1/8/24: 4 AM-8 AM; 4 PM-12 AM (12 hours)

1/9/24: 4 AM-8 AM; 4 PM-12 AM (12 hours)

1/10/24: 4 AM-8 AM; 12 PM-4 PM (8 hours)

1/11/24: 4 PM-12 AM (8 hours)

1/12/24: 12 AM-8 AM; 4 PM-12 AM (16 hours)

1/13/24: 4 AM-4 PM (12 hours)

1/14/24: 4 AM-4 PM (12 hours)

1/15/24: 4 AM-8 AM; 4 PM-12 AM (12 hours)

These findings were confirmed by Employee #3 on 1/23/24 at 2:43 PM.

Based on hospital policy review, medical record review, and interviews with staff, it was determined that for 4 out of 4 patients (Patient #1, 2, 3, and 4) the hospital failed to adhere to the policies and procedures of the hospital. Findings include:

1. Failure to document a code blue event.

Hospital policy titled "CPR" (last reviewed by facility 5/2022) stated, "...Documentation of Code Blue will include...time of cardiac, and/or respiratory arrest...how arrest was recognized...time CPR started...vital signs...procedures performed...time medical control relinquished to paramedic team...disposition of patient..."

Review of Patient #2's medical record revealed:

- No documented evidence of a Code Blue event occurring, or any of the required Code Blue documentation requirements.

It was confirmed during interviews on 1/23/24 between 2:10 PM and 2:40 PM with Employee #2 and Employee #3, Patient #2 received CPR on 1/21/24 from facility staff and that no documentation of the event took place.


2. Failure to document nursing assessments.

The hospital job description titled, "Registered Nurse" stated, "...Essential Job Duties ...Plan, provide, and evaluate patient care through quality nursing assessments..."

Review of the hospital policy titled, "Timeliness of Initial Assessments" (last reviewed by facility 3/2023) stated, "...Each staff member responsible for any document or entry in a patient medical record will follow the time frames listed ...Progress Note Entries ...Once per shift..."

Hospital policy titled "Chart Documentation Requirements" (last reviewed by facility 1/2022) stated, "...required documentation consists of the following...progress notes documented for each shift..."

Review of Patient #3's Medical record revealed:

No evidence that a nursing assessment was completed and no evidence of a "Daily Nurse Progress Note" in the medical record for the following dates and shifts:

- 1/17/24 from 3 PM to 11 PM
- 1/21/24 from 3 PM to 11 PM


Review of Patient #4's Medical record revealed:

No evidence that a nursing assessment was completed and no evidence of a "Daily Nurse Progress Note" in the medical record for the following dates and shifts:
- 1/7/24 from 7 AM to 3 PM
- 1/12/24 from 3 PM to 11 PM
- 1/16/24 from 3 PM to 11 PM

These findings were confirmed by Employee #3 on 1/23/24 at 2:47 PM.


3. Failure to document a patient's change in condition.

Hospital policy titled "Reporting Changes in Patient's Medical/Mental Condition" (last reviewed by facility 5/2022) stated, "...documentation in the record of change in condition will include any interventions..."

Hospital policy titled "Chart Documentation Requirements" (last reviewed by facility 1/2022) stated, "Documentation in the progress notes (using the narrative format) is performed by physician and nursing staff...incorporating the following circumstances...medical emergency and/or problem...events, which significantly impact patient's status whether positively or negatively...significant interactions with the patient..."

Review of records revealed:

Patient #1

- Patient with no documented history of violence or acting out per the medical record.
- On 01/21/24, Patient #1 assaulted Patient #2, the roommate, using a towel around Patient #2's neck, and causing severe harm as indicated in a written statement from Employee #7.
- No documentation of this change in behavior or interventions implemented for the patient was able to be located within the medical record.

This finding was confirmed during an interview on 1/22/24 at 3:27 PM with Employee # 2.

Patient # 2

- On 01/21/24, Patient #2 was assaulted by Patient #1 in their room and sustained serious harm as indicated in a written statement from Employee #7. No documentation of this change in patient's in medical condition was able to be located within the medical record.

This finding was confirmed during an interview on 1/22/24 at 3:27 PM with Employee #2.