HospitalInspections.org

Based on observations, document review, and staff interviews it was determined that the facility failed to provide care in a safe setting for patients (refer to tag A 0144) as evidenced by the significant injuries of a patient. The severity of the injuries sustained in the incident, coupled with short staffing as a potential contributing factor, and ongoing short staffing (refer to tag A 0392) indicate Condition level non-compliance for Patient Rights.

Based on medical record review, policy review and hospital documentation review along with staff interview, it was determined that the facility failed to provide care in a safe setting, with the potential to negatively impact all 89 patients at the facility. Findings include:

Facility document "Patient Rights and Responsibilities" stated, " ...The patient can expect a reasonable safety in so far as hospital practices and environment are concerned to include protective precautions when indicated ..."


Review of hospital policy titled "Suicidal/Homicidal Patient Management Risk Reduction Guidelines "dated 2/23 stated, "...Patients demonstrating...behaviors that they are...danger to.... others should be managed in such a way as to minimize the threat of injury or harm...If at any time the Charge RN determines that a patient may need increased staff supervision to prevent harm to...others. The RN will take action to provide the additional supervision, contact the Director of Nursing/Clinical Services or designee to inform of patient condition and contact the attending physician...for appropriate orders..."


Review of hospital policy titled "Level of Observation/Rounds" dated 2/23 stated, "...If the patient is on a Q15 minute observation level, the patient's condition changes, and the Charge Nurse's clinical assessment indicates the patient requires a higher level of observation, the RN may implement, and then call the primary physician to obtain an order to place the patient on a 1:1..."



1) Patient #6

A) Medical record reviewed for Patient #6 revealed:

-Patient #6 was admitted on 8/28/2023 at 7:31 PM.

-Medication Administration Record stated, "Admit Date 8/28/2023...Unit 2 North...Age 15 years...Observations 15-minute checks...Self Harm..."

-Psychiatric Assessment dated 8/28/2023 stated, "...Justification for Hospitalization: Danger to self, others...with need for a controlled environment...Patient has a history of aggression towards animals...Upon discharge from last hospitalization, mom was unable to care for [his/her] increasing out of control behaviors...mom feels that she is unable to manage patient's behavior...patient started becoming increasingly aggressive...mom reports frequent fights, property destruction at school, and multiple suspensions...Patient admitted for alleged suicidal ideations..."

-Standardized Intake Assessment dated 8/28/2023 stated, "...Patient has a history of obtaining a BB gun to kill [himself/herself]. Patient reported ramming [his /her] head into a brick wall to kill [himself/herself]. Patient has self-injurious behavior, stabbing self with pencils/sharp objects. Patient hears voices telling [him/her] to harm animals..."

-Medical Consultation dated 8/29/2023 at 7:09 AM stated, "...Suicidal/homicidal thoughts..."

-Social Service Progress Note dated 8/30/2023 at 9:43 AM stated, "...admitted for SI (suicidal ideation) and aggression..."


Review of incidents for Patient #6 revealed the following:

9/10/2023 at 6:45 PM - Punched another patient.
9/11/2023 at 10:20 AM - Held pencil to [his/her] chest and stated [he /she] wanted to kill [himself/herself].
9/17/2023 at 8:10 AM - Hit peer.
9/22/2023 at 4:20 PM - Attempted to attack staff and tried to stuff toilet paper down [his/her] throat. Stated "I want to die."
9/25/2023 at 1:00 PM - Punched walls, punched nursing station window, made verbal threats to staff, and physically attacking staff.


Review of restraint packets for Patient #6 revealed the following:

9/11/2023 at 10:20 AM - Attempted to stab self with a pencil.
9/17/2023 at 8:10 AM - Punched peer in the head.
9/17/2023 at 1:15 PM - Punched wall.
9/20/2023 at 1:30 PM - Attempted to attack female staff and male peer.
9/22/2023 at 4:20 PM - Attempted to hit female staff.
9/25/2023 at 1:00 PM - Punched walls, punched nursing station window, made verbal threats to staff, and physically attacking staff.


-Physician's Orders dated 9/25/2023 at 3:22 PM stated, "...1:1 WA (while awake) and sleep out in dayroom..."


Patient admitted on August 28, 2023, with routine, every 15-minute checks. Between admission on August 28, 2023, and September 25, 2023, patient had numerous incidents of attempted self-harm and aggression towards peers and staff. There is no evidence that the facility implemented additional measures to address this patient's behavior, or to protect this patient and others from harm in response to the patient's aggressive behavior, until September 25, 2023.


This finding was confirmed by Employee #1 on 10/20/2023 at 12:25 PM.


B) Review of the hospital policy titled "Suicidal/Homicidal Patient Management Risk Reduction Guidelines" dated 2/23 stated, "...Orders (whether written or verbal) for a decrease in levels of observation/supervision...must be accompanied by a physician note providing clinical justification within 24 hours of writing the order.... can be documented in the Rationale section of the physician's order sheet..."


Medical record reviewed for Patient #6 revealed:

-Physician's Orders dated 9/28/2023 at 11:15 AM stated, "D/C (discontinue) 1:1 WA (while awake), resume Q (every) 15-minute checks."

-Incident Report for Patient #6 dated 9/30/2023 at 8:45 AM stated, "...Patient had taken a metal piece of the desk chair in the hall. Patient had the piece and wouldn't give it up willingly to staff, patient was on the floor spitting on staff trying to bite them."


Review of restraint packets for Patient #6 revealed the following:

9/30/2023 at 2:35 PM - Elopement attempt.


-Physician's Orders dated 9/30/2023 at 3:25 PM stated, "1 to 1 while awake."


No physician notes or rationale provided on the physician's order sheet for the clinical justification of decreasing Patient #6's level of observation on 9/28/2023. When asked to provide documentation of physician rationale to decrease level of observation, Employee #1 was unable to locate in the medical record.


This finding was confirmed by Employee #1 on 10/20/2023 at 12:27 PM.


C) Review of the hospital policy titled "Healthcare Peer Review (HPR) Occurrence Reporting System" dated 3/23 stated, "... of a patient...AWOL (absent from where one should be, missing) ...Any facility employee or occurrence (incident type): that which is not consistent with the routine care staff member who discovers, is directly involved in or is responding to an event/occurrence is to complete ...a Healthcare Peer Review Form...The event is documented in the medical record...and includes...clinical condition of the patient...names, times of notification of physician, supervisory personnel, family members..."


Medical record reviewed for Patient #6 revealed:

-Progress Note dated 10/2/2023 at 10:40 AM stated, "Patient wanted to go for a walk outside but ended up running down the hall. Code Orange (Elopement) was called and eventually got patient back on the unit, Patient was PRT (physically restrained) and brought into quiet room where [he/she] continued to fight with staff. Staff eventually got patient to calm down, patient was asking to be given shot to calm [him/her] down."

-Interview conducted with Employee #2 on 10/19/2023 at 2 PM. No Healthcare Peer Review Form found for Patient #6's 10/2/2023 elopement from the unit. Employee #2 stated, "No incident was reported to me."


No incident report found for this event. No documentation found in Patient #6's medical record indicating the notification of the physician, patient's family, or hospital supervisory personnel of this elopement incident. No detailed documentation found in the medical record regarding the patient's condition when [he/she] returned to the unit, along with the duration the patient was off the unit, and how the patient returned to the unit.


These findings were confirmed by Employee #1 on 10/20/2023 at 12:35 PM.



2) Patient #4

A) Medical record reviewed for Patient #4 revealed:

- Patient #4 admitted on 8/23/2023 at 10:05 PM. Psychiatric Assessment stated, "Justification for Hospitalization: Acutely psychotic and is a danger to self and others...Apparently, the patient lives in the group home.... while in the group home, was aggressive with bizarre behavior... [He/she] was exhibiting sexually inappropriate behavior and was physically aggressive towards [his/her] peer...deemed a danger.... therefore, was sent to the hospital for evaluation...[his/her] longitudinal psychiatric history is unknown because [he/she] has never been to Dover Behavioral Health..."

- Patient Care Orders, dated 8/24/2023 at 2:00 PM stated, "...Observations-15 Minute Checks...Precautions: Sexually Acting Out-History Sexual Perpetration Precautions...Aggression/Homicide Precaution...Psychosis Precaution."

- Psychiatric Progress note dated 8/25/2023 at 11:00 AM stated, "...Bizarre, irritable, isolated...inappropriate behavior at times..."

- Social Services Progress Note dated 8/25/2023 at 12:20 PM stated, "Pt [patient]was unable to be assessed due to agitation..."

- Daily Nursing Progress Note dated 8/25/2023 at 1:15 PM stated, ".... looking at females inappropriately, bizarre, no AM meds ordered..."

- Daily Nursing Progress Note dated 8/26/2023 at 1:45 PM stated, "Pt bizarre, pt kept attacking [his/her] peer [roommate] by punching [his/her] head while [he/she] was sleeping, wanting to get into bed with [him/her]. Roommate transferred to a different room-room now blocked. Pt started on Abilify this AM. Pt still delusional..."

- No evidence of physician notification of the 8/26/2023 incident of Patient #4 punching his/her roommate in the head found in the medical record.

- Physician's Orders dated 8/26/2023 at 6:10 PM stated, "Block room related to sexually inappropriate behavior. Sexual Precautions..."

-No evidence of interventions to address Patient #4 assaulting his/her roommate on 8/26/2023 found in the medical record.

- Daily Nursing Progress Note dated 8/27/2023 at 1:15 PM stated, "Pt sexually inappropriate, kept going in and out of a female peer's room. Pt temporarily removed from wing..."

- Daily Nursing Progress Note dated 8/27/2023 at 9:00 PM stated, "Pt was bizarre isolative and pacing in [his/her] room..."


Daily Nursing Progress Note dated 8/28/2023 at 11:53AM stated, "Pt physically attacked... patient in dayroom. Pt picked [him/her] up and threw [him/her] on the floor, started to bang [his/her] head then kept punching [him/her]. All unprovoked. Staff intervened. This writer was in treatment team at the time. Pt escorted to [his/her] room where [he/she] stayed until EMS arrived due to delirium..."

-Physician's Orders dated 8/28/2023 at 5:05 PM stated, "Pt needs to be a 1:1 at all times."


Review of Incident Reports for 8/28/2023 revealed on 8/28/2023 at 10:12 AM, an incident between Patient #3 and Patient #4 on Unit 5 West. Incident report for Patient #3 stated, "Around 10:12 AM, staff responded to code in dayroom. Another...pt (patient) entered dayroom and physically attacked [Patient 3]. [Patient 4] picked [him/her] up and threw [him/her] down, banged [his/her] head and started punching [his/her] face. Staff arrived at this time. Pt bleeding right side of face laying in fetal position on right side in floor. Pt at first unresponsive then opened eyes responding to [his/her] name. First aid applied. Applied pressure to facial area to stop bleeding. Initial VS (vital signs) 193/105 107 28 98.6 PO 95%. 911 arrived. Report given to ER (emergency room) nurse at [acute care hospital]. Husband notified. Police notified."

The "Rapid Response Code Form" dated 8/28/2023 for Patient #3 stated, "Assault by... peer...Pt has an open head wound...Observed on video peer slammed head on floor 6-7 times...awaiting 911...pressure to head wound..."

The "Inter-Facility Transfer After Visit Summary" for an admission on 8/28/2023 for Patient #3 from [acute care hospital] stated, "Reason for Hospitalization...Traumatic Subarachnoid Hemorrhage with unknown loss of consciousness...Subdural Hematoma [brain bleed] ..."


B) Review of the hospital policy titled "Appropriate Staffing Levels "dated 5/22 stated, "...It is the policy of Dover Behavioral Health System (DBHS) to ensure that the appropriate numbers and qualifications of nursing staff are available at all times for the care of patients. The Director of Nursing (DON) is responsible for the development and ongoing review of staffing requirements..."

Review of staffing for the unit and shift the incident occurred on revealed:

On 8/28/23 from 7:00 AM - 3:00 PM:

-West Unit had 1 patient on a 1:1 assignment and was short staffed by 1 staff member.


Patient #4 was admitted on 8/23/2023 with precautions for sexual perpetration and aggression. After incidents of sexually acting out along with aggression towards his/her roommate on 8/26/2023, there was no evidence of provider notification or interventions being implemented to address Patient #4's assaultive behaviors to protect the patient and others from harm. In addition, the facility failed to provide the appropriate number of staff on the West Unit on 8/28/2023. Patient #4 demonstrated further assaultive behaviors towards a peer on 8/28/2023 which resulted in that peer, Patient #3, sustaining a serious injury. These findings were confirmed by Employee #1 on 9/8/2023 at 2:36 PM.

Based on medical record review, document review and staff interviews, it was determined that the facility did not enforce its medical staff bylaws. Findings include:

Facility document titled "Medical Staff Rules & Regulations" stated, "...Progress notes for inpatients shall be written by the Attending or designee daily, Monday through Friday..."


Medical record reviewed for Patient #6 revealed:

-No evidence of a Psychiatric Progress Note for Thursday 8/31/2023 and Monday 9/28/2023.
-No evidence that Patient #6 was seen by the physician on Thursday 8/31/2023 and Monday 9/28/2023.

This finding was confirmed by Employee #1 on 10/20/2023 at 12:31 PM.

Based on medical record review, staff interview, review of policies and other hospital documents, it was determined that the hospital failed to: ensure adequate numbers of nursing staff (refer to A 392); ensure the registered nurse supervised and evaluated the nursing care (refer to A 395); and failed to revise the interdisciplinary care plan to reflect current patient care needs (refer to A 396). The cumulative effect of these systemic problems resulted in the hospital nursing service's inability to provide quality patient care.

Based on facility document review, and staff interview it was determined that the facility failed to provide adequate numbers of nursing staff to provide care to all patients on 4 out of 4 Units included in the review (North, South, East and West). Findings include:

Review of the hospital policy titled "Appropriate Staffing Levels" dated 5/22 stated, "...It is the policy of Dover Behavioral Health System (DBHS) to ensure that the appropriate numbers and qualifications of nursing staff are available at all times for the care of patients. The Director of Nursing (DON) is responsible for the development and ongoing review of staffing requirements..."


In an interview on 9/6/2023 with Employee #1, CNO, the following staffing ratios were confirmed:


For East, North, and South Units:

-1 staff member per 5 patients on day and evening shifts

-1 staff member per 9 patients on overnight shifts


For West Unit:

-1 staff member per 4 patients on day and evening shifts

-1 staff member per 7 patients on overnight shifts


Additionally, it was confirmed that staff members and patients in 1:1 assignment would not be counted toward the staffing ratios. Patient Experience Coordinators and Peer Support staff do not count toward patient ratios.

When a policy containing these staffing details was requested, Employee #1, CNO stated that they were unsure if there was a policy that contained these staffing expectations and indicated that "this is how it's always been done."



Review of Nursing Supervisor Reports for the week of 8/27/2023 - 9/2/2023 with Employee #1, CNO on 9/6/2023 showed:

8/27/23 from 7:00 AM - 3:00 PM: (3 patients on 1:1)
-North Unit was short staffed by 2 staff members
-West Unit was short staffed by 1 staff member

8/27/23 from 3:00 PM - 11:00 PM: (3 patients on 1:1)
-West Unit was short staffed by 1 staff member

8/27/23 from 11:00 PM - 7:00 AM: (3 patients on 1:1)
-East Unit was short staffed by 1 staff member
-North Unit was short staffed by 1 staff member
-West Unit was short staffed by 1 staff member

8/28/23 from 7:00 AM - 3:00 PM: (3 patients on 1:1)
-East Unit was short staffed by 1 staff member
-North Unit was short staffed by 1 staff member
-West Unit was short staffed by 1 staff member

8/28/23 from 3:00 PM - 11:00 PM: (4 patients on 1:1)
-West Unit was short staffed by 1 staff member

8/29/23 from 7:00 AM - 3:00 PM: (4 patients on 1:1)
-South Unit was short staffed by 1 staff member

8/29/23 from 3:00 PM - 11:00 PM: (6 patients on 1:1)
-South Unit was short staffed by 1 staff member
-West Unit was short staffed by 1 staff member

8/30/23 from 7:00 AM - 3:00 PM: (7 patients on 1:1)
-East Unit was short staffed by 2 staff members
-West Unit was short staffed by 1 staff member


Nursing Schedules and Supervisor Reports reviewed with Employee #1, CNO on 10/17/2023, 10/18/2023, and 10/19/2023 showed:

8/30/2023 from 7:00 AM to 3:00 PM: (3 patients on 1:1)
-North Unit was short 1 staff member from 7:00 AM to 8:30 AM

8/30/2023 from 3:00 PM to 11:00 PM: (2 patients on 1:1)
-North Unit was short 1 staff member from 7:00 PM to 9:00 PM

9/01/2023 from 7:00 AM to 3:00 PM: (1 patient on 1:1)
-North Unit was short 1 staff member from 7:00 AM to 8:00 AM

9/05/2023 from 7:00 AM to 3:00 PM: (1 patient on 1:1)
-North Unit was short 1 staff member

9/07/2023 from 7:00 AM to 3:00 PM: (1 patient on 1:1)
-North Unit was short 1 staff member from 7:00 AM to 10:30 AM

9/07/2023 from 3:00 PM to 11:00 PM: (1 patient on 1:1)
-North Unit was short 1 staff member from 3:00 PM to 4:30 PM, 1 staff member from 8:00 PM to 9:30 PM and 1 staff member from 9:30 PM to 11:00 PM

9/10/2023 from 7:00 AM to 3:00 PM: (2 patients on 1:1)
-East Unit was short by 1 staff member
-South Unit was short by 1 staff member from 7:00 AM to 11:00 AM

9/10/2023 from 3:00 PM to 11:00 PM: (2 patients on 1:1)
-East Unit was short by 1 staff member
-South Unit was short by 1 staff member 7:00 PM to 11:00 PM
-West Unit was short by 1 staff member 8:00 PM to 11:00 PM

9/11/2023 from 3:00 PM to 11:00 PM: (2 patients on 1:1)
-North Unit was short 2 staff members from 3:00 PM to 4:00 PM and 1 staff member from 9:30 PM to 11:00 PM

9/12/2023 from 7:00 AM to 3:00 PM: (2 patients on 1:1)
-North Unit was short 1 staff member from 7:00 AM to 10:00 AM

9/14/2023 from 3:00 PM to 11:00 PM: (1 patient on 1:1)
-North Unit was short 1 staff member from 3:00 Pm to 4:30 PM

9/15/2023 from 3:00 PM to 11:00 PM: (1 patient on 1:1)
-North Unit was short 1 staff member from 3:00 PM to 4:00 PM

9/16/2023 from 3:00 PM to 11:00 PM: (1 patient on 1:1)
-South Unit was short by 1 staff member from 9:00 PM to 11:00 PM

9/17/2023 from 7:00 AM to 3:00 PM: (1 patient on 1:1)
-East Unit was short 1 staff member from 7:00 AM to 9:00 AM

9/17/2023 from 3:00 PM to 11:00 PM: (1 patient on 1:1)
-West Unit was short 1 staff member from 9:00 PM to 11:00 PM

9/19/2023 from 3:00 PM to 11:00 PM: (2 patients on 1:1)
-North Unit was short 1 staff member from 3:00 PM to 4:00 PM and 1 staff member from 5:00 PM to 9:00 PM

9/23/2023 from 7:00 AM to 3:00 PM: (2 patients on 1:1)
-South Unit was short 1 staff member

9/23/2023 from 3:00 PM to 11:00 PM: (2 patients on 1:1)
-East Unit was short 1 staff member from 3:00 PM to 7:00 PM
-South Unit was short 1 staff member from 10:00 PM to 11:00 PM

9/23/2023 from 11:00 PM to 7:00 AM: (2 patients on 1:1)
-East Unit was short 1 staff member

9/24/2023 from 7:00 AM to 3:00 PM: (2 patients on 1:1)
-East Unit was short 1 staff member
-West Unit was short 1 staff member

9/24/2023 from 3:00 PM to 11:00 PM: (2 patients on 1:1)
-East Unit was short 2 staff members from 3:00 PM to 7:00 PM and 1 staff member from 7:00 PM to 11:00 PM
-West Unit was short 2 staff members from 3:00 PM to 5:00 PM and 1 staff member from 5:00 PM to 11:00 PM

9/24/2023 from 11:00 PM to 7:00 AM: (2 patients on 1:1)
-East Unit was short 1 staff member
-West Unit was short 1 staff member from 5:00 AM to 7:00 AM

9/27/2023 from 11:00 PM to 7:00 AM:
-West Unit was short 1 staff member

9/30/2023 from 3:00 PM to 11:00 PM: (1 patient on 1:1)
-East Unit was short 1 staff member from 3:00 PM to 5:00 PM
-North Unit was short 1 staff member from 7:00 PM to 11:00 PM

10/01/2023 from 7:00 AM to 3:00 PM: (2 patients on 1:1)
-South Unit was short 1 staff member

10/01/2023 from 3:00 PM to 11:00 PM: (2 patients on 1:1)
-East Unit was short 1 staff member from 10:00 PM to 11:00 PM

10/01/2023 from 11:00 PM to 7:00 AM: (2 patients on 1:1)
-East Unit was short 1 staff member

10/03/2023 from 3:00 PM to 11:00 PM: (2 patients on 1:1)
-North Unit was short 1 staff member from 3:00 PM to 7:00 PM

10/07/2023 from 3:00 PM to 11:00 PM: (2 patients on 1:1)
-North Unit was short 1 staff member from 7:00 PM to 9:00 PM

10/07/2023 from 11:00 PM to 7:00 AM: (1 patient on 1:1)
-West Unit was short 1 staff member from 11:00 PM to 1:00 AM

10/08/2023 from 11:00 PM to 7:00 AM:
-West Unit was short 1 staff member from 11:00 PM to 7:00 AM

10/15/2023 from 7:00 AM to 3:00 PM: (2 patients on 1:1)
-South Unit was short 1 staff member from 7:00 AM to 9:00 AM


Inadequate staffing has the potential to negatively impact patient care and staff safety (see tag A 144).

Based on medical record review, policy review and staff interview it was determined that the facility failed to supervise and evaluate the nursing care for 7 out of 9 patients (Patient's #1, #2, #4, #6, #7, #8, and #10) sampled. Findings include:


I. Nursing Assessments

The hospital job description titled, "Registered Nurse (Level 1)" stated, ".... Essential Job Duties...Plan, provide, and evaluate patient care through quality Nursing Assessments..."

Review of the hospital policy titled, "Timeliness of Initial Assessments "dated 3/23 stated, "...Each staff member responsible for any document or entry in a patient's medical record will follow the time frames listed...Progress Note Entries...Once per shift..."



Medical record review for Patient #1 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:

8/20/23: 7 AM-3 PM

8/20/23: 3 PM-11 PM

8/22/23: 3 PM-11 PM

8/23/23: 3 PM-11 PM

These findings were confirmed by Employee #1 on 9/7/2023 at 1:15 PM.



Medical record review for Patient #2 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:

8/25/23: 3 PM-11 PM

8/31/23: 3 PM-11 PM

9/5/23: 3 PM-11 PM

9/5/23: 11 PM-7 AM

These findings were confirmed on 9/7/2023 at 12:09 PM by Employee #1.



Medical record review for Patient #6 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:

9/25/2023: 7 AM-3 PM

9/25/2023: 3 PM-11 PM

9/25/2023: 11 PM-7 AM

These findings were confirmed by Employee #1 on 10/20/2023 at 12:31 PM.



Medical record review for Patient #7 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:

9/1/2023: 3 PM-11 PM

9/15/2023: 3 PM-11 PM

These findings were confirmed by Employee #1 on 10/18/2023 at 2:23 PM.



Medical record review for Patient #8 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:

9/8/2023: 7 AM-3 PM

9/9/2023: 7 AM-3 PM

9/9/2023: 3 PM-11 PM

These findings were confirmed by Employee #1 on 10/18/2023 at 2:23 PM.



Medical record review for Patient #10 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:

10/14/2023: 3 PM-11 PM

These findings were confirmed by Employee #1 on 10/19/2023 at 5:00 PM.




II. Patient Safety Observations

Review of the hospital policy titled, "Level of Observation/Rounds" dated 2/23 stated, "It is the policy...that all patients will be routinely observed in compliance with physician orders and prescribed protocols...Staff will observe patients and document on the Patient Observation Record Q15 minutes when the observation occurs..."



Medical record review for Patient #1 who was admitted with Major Depressive Disorder and placed on suicide precautions revealed:

No evidence of a 15-minute observation being completed as ordered and documented on the Observation Record 24-Hour Inpatient Form for the dates and times listed below:

8/18/2023: From 4:45 PM -7 PM (8 observations missed).

These findings were confirmed by Employee #21 and #1 on 9/7/2023 at 1:15 PM.



Medical record review for Patient #2 who was admitted with Major Depressive Disorder and placed on suicide precautions revealed:

No evidence of a 15-minute observation being completed as ordered and documented on the Observation Record 24-Hour Inpatient Form for the dates and times listed below:

8/22/2023: From 8:45 PM - 9:00 PM (2 missed observations).

These findings were confirmed by Employee #1 on 9/7/2023 at 12:13 PM.



Medical record review for Patient #4 who was admitted with Major Depressive Disorder, severe, recurrent with psychotic features and placed on sexually acting out, aggression/homicide, and psychosis precautions revealed:

No evidence of a 15-minute observation being completed as ordered and documented on the Observation Record 24-Hour Inpatient Form for the dates and times listed below:

8/24/2023: From 4:30 PM - 4:45 PM (2 observations missed).

These findings were confirmed by Employee #1 on 9/8/2023 at 2:13 PM.



III. Nursing Supervision of Patient Safety Observations

The hospital job description titled, "Charge Nurse (RN III)" stated, "...Timely review the Patient Observation Round sheets...and sign and date round sheets twice per shift..."

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

The Patient Observation Rounds sheet contains a section for nursing to sign for their review of the observations in 4-hour slots (12:00 AM - 4:00 AM; 4:00 AM - 8:00 AM, etc.).



Medical record review for Patient #1 who was admitted with Major Depressive Disorder and placed on suicide precautions revealed:

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

8/18/23: 8 PM-11:45 PM (4 hours)

8/19/23: 12 AM-11:45 PM (24 hours)

8/20/23: 8 AM-11:45 PM (16 hours)

8/21/23: 8 AM-11:45 PM (16 hours)

8/22/23: 12 AM-11:45 PM (24 hours)

8/23/23: 12 AM-11:45 PM (24 hours)

8/24/23: 12 AM-11:30 AM (11 hours and 30 minutes)

These findings were confirmed by Employee #19 and #1 on 9/7/2023 at 1:15 PM.



Medical record review for Patient #2 who was admitted with Major Depressive Disorder and placed on suicide precautions revealed:

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

8/23/2023: 12 AM-11:45 PM (24 hours)

8/24/2023: 12 AM-11:45 PM (24 hours)

8/25/2023: 4 AM-11:45 PM (20 hours)

8/26/2023: 12 AM-4 PM (16 hours)

8 PM-11:45 PM (4 hours)

8/27/2023: 8 AM-11:45 PM (16 hours)

8/28/2023: 4 AM-11:45 PM (20 hours)

8/29/2023: 4 AM-11:45 PM (20 hours)

8/30/2023: 12 AM-11:45 PM (24 hours)

8/31/2023: 12 PM-11:45 PM (12 hours)

9/1/2023: 8 AM-11:45 PM (16 hours)

9/2/2023: 12 AM-11:45 PM (24 hours)

9/3/2023: 12 AM-4 PM (16 hours)

8 PM-11:45 PM (4 hours)

9/4/2023: 8 AM-11:45 PM (16 hours)

9/5/2023: 8 AM-11:45 PM (16 hours)

9/6/2023: 12 AM-11:45 PM (24 hours)

These findings were confirmed by Employee #1 on 9/7/2023 at 12:13 PM.



Medical record review for Patient #4 who was admitted with Major Depressive Disorder, severe, recurrent with psychotic features and placed on sexually acting out, aggression/homicide, and psychosis precautions revealed:

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

8/24/2023: 12 AM-11:45 PM (24 hours)

8/25/2023: 12 AM-11:45 PM (24 hours)

8/26/2023: 4 AM-11:45 PM (20 hours)

8/27/2023: 4 AM-11:45 PM (20 hours)

8/28/2023: 12 PM-11:45 PM (12 hours)

8/29/2023: 12 AM-4 AM (4 hours)

12 PM-11:45 PM (12 hours)

8/30/2023: 12 AM-11:45 PM (24 hours)

8/31/2023: 12 AM-11:45 PM (24 hours)

9/1/2023: 12 AM-11:45 PM (24 hours)

9/2/2023: 12 AM-11:45 PM (24 hours)

9/3/2023: 12 AM-11:45 PM (24 hours)

9/4/2023: 12 AM-11:45 PM (24 hours)

9/5/2023: 12 AM-11:45 PM (24 hours)

These findings were confirmed by Employee #1 on 9/8/2023 at 2:13 PM.



Medical record review for Patient #7 revealed:

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

9/30/23: 8 AM-4 PM (8 hours)

10/1/23: 4 AM-11:45 PM (20 hours)

10/2/23: 4 AM-11:45 PM (20 hours)

10/3/23: 8 AM-4 PM (8 hours)

10/4/23: 4 AM-4 PM (12 hours)

10/5/23: 8 AM-11:45 PM (16 hours)

10/6/23: 8 AM-12 PM (4 hours)

10/8/23: 8 AM-11:45 PM (16 hours)

10/9/23: 8 AM-11:45 PM (16 hours)

10/10/23: 8 AM-11:45 PM (16 hours)

10/11/23: 12 AM-11:45 PM (24 hours)

10/12/23: 4 AM-11:45 PM (20 hours)

10/16/23: 8 AM-11:45 PM (16 hours)

These findings were confirmed by Employee #1 on 10/18/2023 at 2:23 PM.



Medical record review for Patient #8 revealed:

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

9/7/23: 12 AM-12 PM (12 hours)

8 PM-11:45 PM (4 hours)

9/10/23: 8 AM-11:45 PM (16 hours)

9/11/23: 12 AM-12 PM (12 hours)

4 PM-8 PM (4 hours)

9/12/23: 12 AM-4 PM (16 hours)

8 PM-11:45 PM (4 hours)

9/13/23: 12 AM-11:45 PM (24 hours)

9/14/23: 8 AM-12 PM (4 hours)

8 PM-11:45 PM (4 hours)

9/15/23: 12 AM-4 PM (16 hours)

9/16/23: 4 AM-11:45 PM (20 hours)

9/17/23: 12 AM-11:45 PM (12 hours)

9/18/23: 4 AM-12 PM (8 hours)

9/19/23: 12 AM-12 PM (12 hours)

9/20/23: 12 AM-11:45 PM (24 hours)

9/21/23: 12 AM-11:45 PM (24 hours)

9/22/23: 8 AM-4 PM (8 hours)

9/23/23: 12 AM-4 PM (16 hours)

8 PM-11:45 PM (4 hours)

9/24/23: 12 AM-12 PM (12 hours)

4 PM-11:45 PM (8 hours)

9/25/23: 12 AM-11:45 PM (24 hours)

These findings were confirmed by Employee #1 on 10/18/2023 at 2:23 PM.



Medical record review for Patient #10 revealed:

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

10/12/23: 12 AM-8 AM (8 hours)

8 PM-11:45 PM (4 hours)

10/13/23: 4 AM-8 AM (4 hours)

8 PM-11:45 PM (4 hours)

10/14/23: 4 AM-8 AM (4 hours)

12 PM-11:45 PM (12 hours)

10/15/23: 4 AM-8 AM (4 hours)

12 PM-11:45 AM (12 hours)

10/16/23: 12 AM-4 PM (16 hours)

8 PM-11:45 PM (4 hours)

10/17/23: 4 AM-8 AM (4 hours)

8 PM-11:45 PM (4 hours)

10/18/23: 12 PM-11:45 PM (12 hours)

These findings were confirmed by Employee #1 on 10/19/2023 at 5:00 PM

Based on medical record review, policy review and staff interview, it was determined that for 1 out of 9 patients (Patient #6) in the sample, nursing staff failed to revise the interdisciplinary care plan to reflect current patient care needs. Findings include:

The hospital policy titled "Interdisciplinary Patient-Centered Care Planning" dated 3/23 stated, "...It is the policy...to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist...works with the patient and family...to identify the patient's assessed needs to be addressed during treatment and develop appropriate goals and interventions.... must include...Identification of problems to be treated and the specific behavioral manifestations of those problems in the patient. Short-term and long-term goals for each active problem...The specific treatment modalities with individualized patient focus...A treatment plan revision can be completed at any time the treatment team decides to alter the proposed strategies based upon the patient's needs. Reviews of the treatment plan are documented on the appropriate treatment plan forms in the medical record..."


Medical record reviewed for Patient #6 revealed:

-Interdisciplinary Master Treatment stated, "Date of Admission: 8/28/2023...North Unit...Psychiatric Diagnosis: GAD (generalized anxiety disorder). ODD (oppositional defiant disorder), ADHD (attention deficit hyperactivity disorder), R/O (rule out) conduct disorder, R/O disruptive mood dysregulation disorder, R/O PTSD (post-traumatic stress disorder) ....8/28/23 Risky behaviors/opposition....9/25/2023 Aggression..."


-Review of incidents for Patient #6 revealed the following:

9/10/2023 at 6:45 PM -Punched another patient.
9/11/2023 at 10:20 AM-Held pencil to [his/her] chest and stated [ he/she] wanted to kill [ himself/herself].
9/17/2023 at 8:10 AM-Hit peer.
9/22/2023 at 4:20 PM-Attempted to attack staff and tried to stuff toilet paper down [his/her] throat. Stated "I want to die."


-On 9/25/2023 at 1:00 PM-Punched walls, punched nursing station window, made verbal threats to staff, and physically attacking staff.


-Review of Master Treatment Plan Update/Clinical Staffing Worksheet dated 9/14/2023 stated, "...Number of psychotropic Stat (immediately) Medications given since admission/last update: 0...Number of non-psychotropic PRN (as needed) or Stat Medications given since admission/last update:19...Medication changes...Yes: Abilify increased...Problem 1: Risky Behavior...Long-term Goal: Decrease risky behavior...prior to discharge...Progress still being made..."


-Review of Master Treatment Plan Update/Clinical Staffing Worksheet dated 9/21/2023 stated, "...Number of psychotropic Stat Medications given since admission/last update: 3....Number of non-psychotropic PRN (as needed) or Stat Medications given since admission/last update: 16...Medication changes...Yes: Zoloft increased.... Problem 1: Risky Behavior...Long-term Goal: Decrease risky behavior...prior to discharge...Progress still being made...Identify 3 factors that contribute to risky behaviors...Patient identified mom as a factor to risky behaviors..."


Except for the medication adjustments, there were no other updates noted to Patient #6's treatment plan that reflect the above incidents from 9/10/2023 to 9/22/2023. Patient #6 physically attacking peers and staff not addressed. Patient #6's statements of self-harm and attempts to harm [ himself/herself] not addressed. No evidence of the treatment plan being reviewed and revised. Goals were not adjusted. No interventions or strategies documented or initiated to address Patient #6's continued behavioral manifestations. The treatment plan did not reflect this patient's individualized needs.



This finding was confirmed by Employee #1 on 10/20/2023 at 12:26 PM.