HospitalInspections.org

Based on review of policy, medical record, surveillance video and staff interviews, the facility failed to provide a safe environment for psychiatric patients for 3 out of 4 sampled psychiatric patients by failing to follow policy for observation of psychiatric patients. (#11, #23, and #37).

The findings include:

Review of the facility's policy titled "Routine Patient Rounds (Checks), Behavioral Health" with revision date 04/19, revealed "General Policy Statement: It is the policy of (Named Facility) that rounds will be made by nursing staff on a regular basis to ensure that the patients and environment are safe. The purpose of this policy is to ensure that patients are and remain safe in the milieu....Policy Guidelines: A. A nursing staff member performs, and documents rounds at a minimum of every 15 minutes including change of shift. The exact times of rounds varies slightly so patients cannot predict when they will be made. B. Staff should locate each patient and insure (sic) that the patient is safe. Staff must see each patient on the unit. Staff will not accept voice contact (i.e. patient in bedroom stating he/she is fine) as a substitute for visualizing the patient. C. Staff will knock on the patient's bedroom door before entering but will pause only for a few seconds before opening the door. It is not acceptable for staff to wait for the patient to open the door. D. The staff member rounding on nights must use a flashlight if unable to visualize patient and observe a patient's respiratory effort....When the staff member is assured of the patient's safety and location, this information is documented on the rounds board...."

1. Closed medical record review of Patient #11 revealed an 18 year old female admitted voluntarily on 09/09/2022 to the psychiatric facility. Patient #11 had a past psychiatric history of bipolar disorder (mental disorder with periods of depression and abnormally elevated moods), mixed anxiety disorder (unexplained worry) and bulimia nervosa (an eating disorder in which a large quantity of food is consumed in a short period of time, often followed by feelings of guilt or shame), and who presented to the ED (emergency department) for suicidal ideation (ideas of harming self or taking one's own life). Review of rounding sheets dated 09/10/2022 at 0137 revealed Patient #11 was in the bedroom; in bedroom at 0150; asleep at 0211; asleep at 0227; asleep at 0246; asleep at 0314; asleep at 0334; asleep at 0358; asleep at 0423; asleep at 0509; asleep at 0548; asleep at 0616; asleep at 0640; in bedroom at 0647; and in bedroom at 0659.

Review on 11/02/2022 and 11/03/2022 of video surveillance dated 09/10/2022 revealed Patient #11 was escorted to her room (#114) at 0031 by staff. Nurse exited room at 0032. At 0111, Patient #11 opened room door and MHT entered. At 0113, MHT exited room. Review of video revealed no other staff appeared at Patient #11's door until 0201. At 0226, MHT opened Patient #11's door; MHT opened door at 0314; RN entered room at 0353; MHT entered room at 0357 and exited; MHT opened and exited at 0509; MHT entered and exited door at 0611. Patient #11 exited room at 0705.

Review revealed video did not support staff documentation of patient rounding on Patient #11. Documentation revealed patient rounding was performed at approximately every 15 minutes following policy; however video footage did not reveal staff conducting the patient rounds according to policy.

Phone interview on 11/02/2022 at 1410 with RN #1 revealed patients are on every 15 minutes checks. Interview revealed documentation of the rounding is written on the log.

Interview on 11/03/2022 at 0900 with Psychiatric floor manager #1 revealed staff performed every 15 minutes checks. Interview revealed the videos had not been viewed until this morning. Interview revealed there were differences in the documentation and the video.

2. Closed record review of Patient #23 revealed a 30 year old male admitted on 09/01/2022 under involuntary commitment for aggression. Patient #23 has a past psychiatric history of schizoaffective disorder (mental disorder characterized by abnormal thought processes and an unstable mood), cannabis and cocaine use disorder. Review of rounding sheets dated 09/10/2022 at 0134 revealed Patient # 23 was in the bedroom. At 0151, in his bedroom; At 0212, asleep in bedroom; Asleep at 0228; Asleep at 0246; Asleep at 0315; Asleep at 0335; Asleep at 0359; Asleep at 0424; Asleep at 0509; Asleep at 0549; Asleep at 0617; Asleep at 0640; In bedroom at 0647; In bedroom at 0701; In bedroom at 0715; In bedroom at 0731; In bedroom at 0752; In bedroom at 0804; In bedroom at 0816; In bedroom at 0830; In bedroom at 0848; and in bedroom at 0902.

Review on 11/02/2022 and 11/03/2022 of video surveillance dated 09/10/2022 revealed Patient #23 entered his room (#112) at 0128. At 0201, staff entered Patient #23's room. At 0314, MHT opened Patient #23's door. At 0718, CNA opened Patient #23's door. At 0753, MHT opened Patient #23's door. At 0917, Patient #23 exited room.

Review revealed video did not support staff documentation of patient rounding on Patient #23. Documentation revealed patient rounding was performed at approximately every 15 minutes following policy; however video footage did not reveal staff conducting the patient rounds according to policy.

Phone interview on 11/02/2022 at 1410 with an assigned RN, RN #1, revealed patients are on every 15 minutes checks. Interview revealed documentation of the rounding is written on the log.

Interview on 11/03/2022 at 0900 with Psychiatric floor manager #1 revealed staff performed every 15 minutes checks. Interview revealed the videos had not been viewed until this morning. Interview revealed there were differences in the documentation and the video.

3. Closed medical record of Patient #37 revealed a 39 year old male admitted on 10/26/2022 under involuntary commitment with acute decompensation of his psychiatric illness. Patient #37 has a past medical history of schizophrenia who recently was living in a new assisted living facility and began refusing medication and acting out. Review of the rounding sheets dated 10/30/2022 revealed at 0748, Patient #37 was asleep in bedroom. At 0811, asleep in bedroom. At 0826 and 0843, in dayroom. At 0858 and 0913, asleep in bedroom. At 0931, asleep in bedroom. At 0945, in bedroom. At 1000, in hall.

Review on 11/4/2022 of the video surveillance dated 10/30/2022 revealed Patient #37 walked out of his room at 0813. At 0835, Patient #37 entered his room. At 0911, Patient #37 exited room and returned at 0912. At 0924, physician entered patient's room and exited at 0926. At 0935, Patient #37 exited room and returned at 0937. At 1000, Patient #37 exited his room.

Review revealed video did not support staff documentation of patient rounding on Patient #37. Documentation revealed patient rounding was performed at approximately every 15 minutes following policy; however video footage did not reveal staff conducting the patient rounds according to policy.

Phone interview on 11/02/2022 at 1410 with RN #1 revealed patients are on every 15 minutes checks. Interview revealed documentation of the rounding is written on the log.

Interview on 11/03/2022 at 0900 with Psychiatric floor manager #1 revealed staff performed every 15 minutes checks. Interview revealed the videos had not been viewed until this morning. Interview revealed there were differences in the documentation and the video of patient rounding.


NC00194183; NC001911632; NC00191015; NC00193808; NC00193226; NC00193120; NC00184978