HospitalInspections.org

43881


Based on surveyor observation, record review, and staff interview, it has been determined that the hospital failed to maintain and provide care in a safe environment by ensuring adequate supervision of a patient at risk for self-injurious behaviors, who had an order for constant observation. The hospital failed to identify and prevent 1 of 4 patients reviewed who were on constant observation (Patient ID #1), from elopement. (Refer to A-144).

As a result of these findings, Immediate Jeopardy was identified on August 23, and removed on August 24, 2022, after the State Survey Agency verified that the hospital had implemented interventions to remove the immediate risk to the health and safety of patients.

Findings are as follows:

Based on record review, and staff interviews, it has been determined that the hospital failed to maintain and provide care in a safe environment by ensuring adequate supervision of a patient at risk for self-injurious behaviors. The hospital failed to prevent and identify an elopement had occurred for a patient who was on constant observation (ID #1). (Refer to A-144).

As a result of these findings, Immediate Jeopardy was identified on August 23, and removed on August 24, 2022, after the State Survey Agency verified that the hospital had implemented interventions to remove the immediate risk to the health and safety of patients.

Record review for Patient ID# 1 revealed an ongoing physician's order for constant observation due to his/her potential for self-injurious behaviors.

On 8/17/2022 Patient ID#1 eloped from his/her hospital room while under the constant observation of a Certified Nurse Assistant (CNA).

On 8/23/2022 the hospital provided a resolution plan which indicated all Hasbro unit 4 and 5 staff will be re-educated on the "Observation Levels" policy and expectations for staff to keep patients safe. Security Officers were also deployed to the units until the re-education of staff was completed and additional security measures developed.

Follow up on 8/24/2022 confirmed that the removal plan had been fully implemented.

Staff had completed the re-training process and review of the education provided to the employees revealed re-training in resident "Observation Levels" policy and hospital protocols. Security Officers deployed to units 4 and 5 for added security and presence.

Based on record review, policy review, and staff interviews, it has been determined that the hospital failed to ensure that patients receive care in an environment that a reasonable person would consider to be safe for 2 of 4 patients reviewed who were ordered to be under constant observation with a 1 patient to 1 staff observer (1:1), Patient ID #'s 1 and 2.

Findings are as follows:

On 8/18/2022, the hospital submitted a report to the Rhode Island Department of Health indicating that Patient ID #1 eloped from his/her room while on an inpatient unit the morning of 8/17/2022. The report then indicated that the patient presented to the emergency department approximately 45 minutes after eloping where she/he was assessed and escorted back to his/her room on the hospital unit 4.

Review of the hospital's policy titled, "Observation Levels" last revised on 9/2019 states in part,

" ...Constant Observation (CO): highest level of observation. CO is used when a patient is high risk for intentional self-harm, high risk for suicide or harm to others. This requires a 1:1 to one staff to patient ratio.

Patient up server: especially trained staff designated to provide observation of a patient at risk for safety .... General responsibilities include:

Being alert and aware of all patient activity and avoiding distraction ...

...No sleeping or "resting your eyes"...

...Facing the patient if 1:1 patient observation is ordered...

...IV. Procedure...
Constant Observation (CO) 1:1
Outside of Behavioral Health Settings

...patient observer with Life Chart access documents patient behavior and activity hourly in the Constant Observation Flowsheet, and a log is maintained providing evidence for every 15-minute observations....

...Patient observer is assigned to only one patient at all times..."

1. Record review revealed that Patient ID #1 presented to the hospital's emergency department on 8/12/2022. His/her past medical history includes, but is not limited to, suicidal ideation with attempts, self-mutilation via cutting, burning, hitting, and bipolar 1 disorder.

Review of the "ED Provider Note" For Patient ID #1 dated 8/12/2022 at 6:23 PM states in part,

"...Psychiatric History
...-Previous suicide attempts
-Endorses daily self-harm by cutting, burning, and hitting [himself/herself]
-Cuts [himself/herself] with a razor blade "on every surface but my stomach"
-Burns [himself/herself] with joints, heated up coins, pieces of metal..."

Review of an "ED Note" for Patient ID #1 dated 8/12/2022 at 9:15 PM states in part, "Per DCYF [Department of Children Youth and Families] pt. [patient] states...that [she/he] has a plan to run in front of a truck tonight if [she/he] leaves the hospital ...[she/he] has not been taking medications appropriately and that [she/he] has auditory/visual/tactile hallucinations..."

Review of the "H&P Notes" for Patient ID #1 dated 8/13/2022 at 5:09 AM states in part,

"Chief complaint: SI [suicidal ideation] with plan...
Assessment and Plan...the severity of [his/her] psychiatric symptoms make it unsafe for [him/her] to return home at this time. Will admit for further psychiatric assessment and monitoring while awaiting placement. [Patient ID #1] is not acutely psychotic however warrants constant observation..."

Record review revealed that on the date of the elopement, Patient ID #1 had an active physician's order for constant observation around the clock that was initiated on 8/15/2022 at 7:38 AM.

Review of a document titled, "Default Flowsheet Data" for "Constant Observation" revealed that on 8/17/2022 at 5:00 AM the patient was on "Constant Observation" while observed by a Patient Care Attendant, Employee A, who documented that the patient was in bed and cooperative.

Review of e-mail correspondence between Employee A and Employee B, 4th floor Clinical Manager, from 8/18/2022 at 6:34 AM, revealed a statement from Employee A which indicated that when she took her break "around 5:20 AM" the patient was still in the room.

During a surveyor interview with Employee C, Certified Nursing Assistant, on 8/23/2022 at 11:49 AM, she revealed that on the morning of 8/17/2022, she was assigned to observe Patient ID #2 who required 1:1 constant observation. Employee C was then asked to relieve Employee A for a break "around 5:15 AM or 5:20 AM" who was watching Patient ID #1 in the adjacent room. She indicated that since both rooms were next to each other, she sat "right outside" both rooms to observe both patients. She revealed that at approximately 5:38 AM or 5:39 AM, she last saw Patient ID #1 lying in bed on his/her stomach and stated that she "started to dose off." She acknowledged that she fell asleep until she felt a tap on her shoulder at approximately "6:00 AM" or "6:10 AM" from Employee A who questioned the whereabouts of Patient ID #1.

During a surveyor interview with Employee A on 8/23/22 at 9:25 AM, she revealed that when she returned from her break on 8/17/2022, she was speaking to a nurse when the unit received a phone call from the emergency department asking if the unit was missing a patient. She indicated that she went to Patient ID #1's room and saw Employee C sitting in front of Patient ID #1 and Patient ID #2's doorways. She stated that she tapped Employee C on the shoulder to tell her that Patient ID #1 was missing. Employee A stated that when Patient ID #1 arrived back on the unit following her elopement, she/he was escorted by staff and her left arm was "wrapped up and bleeding."

During a surveyor interview with Employee D, Emergency Department Triage Nurse, on 8/23/2022 at 12:23 PM, she indicated that she was working at the "triage booth area ambulance bay" on the morning of 8/17/2022 when security staff brought Patient ID #1 in front of her at approximately 6:00 AM. Employee D revealed that Patient ID #1 was wearing blue paper scrubs which are usually given to patients in the psychiatric unit and she/he was "soaking wet" from the rain that morning. Employee D revealed that she noticed approximately 20 to 30 recent, horizontal cuts on the Patient's arm that were "oozing blood" and Patient ID #1 revealed to her that she/he had cut himself/herself. She indicated that Patient ID #1's cuts were cleansed and dressed in the emergency department. Shortly after the unit was informed of the patient's return and Patient ID #1 was escorted back to the unit. Employee D stated that when she questioned Patient ID #1 about what happened, she/he said, "I was upstairs, no one was watching so I bolted." Employee D then revealed that according to Patient ID #1, she/he took the elevator to the second floor, pressed all the buttons, she/he then hid in a closet, went through a window, and then walked a gravel path and into a garage.

Additional record review revealed a physician's progress note dated 8/17/2022 at 7:15 AM written after the event which stated in part, "...numerous superficial lacerations on [his/her] left forearm which [she/he] explained to the provider had been self-inflicted with a shard of glass [she/he] found outside, before [she/he] went to the ED [emergency department]. Wounds were cleansed and bandaged by nursing.

During a surveyor interview on 8/22/2022 at 8:45 AM and at 12:10 PM with the Risk Manager, when asked if the hospital's elopement protocol was initiated on the morning of 8/17/2022, she indicated that it was not as no employees were aware that Patient ID #1 had eloped, nor had they seen where she/he exited from.

Based on record review, policy review and staff interview, it has been determined that the hospital failed to meet the Condition of Participation for Nursing Services for 4 of 4 Patients ID #'s 1, 2, 3, and 4, relative to providing care in accordance with hospital policy and accepted standards of nursing practice.

Findings are as follows:

1. The hospital failed to provide nursing care in accordance with the hospital policy related to "Observation Levels" for Patient ID#1, who eloped from the hospital while on physician ordered constant observation status. (Refer to A-0395)

2. The hospital failed to ensure that per hospital policy nursing staff complete the required 15-minute Constant Observation Log (This log is initialed by staff every 15 minutes in a 24 hour period and is used to represent constant observation of the patient) for 3 of 4 patients (ID #'s 1, 2, and 3) and the hourly Constant Observation Flow Sheet (The hourly assessment within this document indicates the level of observation of the patient, who is observing the patient, the nurse's assessment of the patient's affect and the patient's behavior and activity) for 2 of 4 patients, ID #'s 3 and 4. (Refer to A-0395)

3. The hospital failed to assign the nursing care for each patient to other nursing personnel in accordance with the patient's needs and specialized qualification and competence of the nursing staff available (refer to A 397).

4. The hospital failed to provide an adequate number of other personnel to provide patient observer care for 2 of 4 patients, Patient ID #'s 1 and 2 (refer to A-0392).

Based on record review and staff interview, it has been determined that the hospital failed to provide an adequate number of other personnel to provide patient observer care for 2 of 4 patients who had a physician's order for Constant Observation, Patient ID #'s 1 and 2.

Findings are as follows:

Review of the hospital's policy titled, "Observation Levels" last revised on 9/2019 states in part,

"...Constant Observation (CO): highest level of observation. CO is used when a patient is high risk for intentional self-harm, high risk for suicide or harm to others. This requires a 1:1 staff to patient ratio.

Patient observer: Specially trained staff designated to provide observation of a patient at risk for safety.... General responsibilities include:

...Facing the patient if 1:1 patient observation is ordered...

...IV. Procedure...
Constant Observation (CO) 1:1
Outside of Behavioral Health Settings
...Patient observer is assigned to only one patient at all times..."

1. Record review revealed that Patient ID #1 presented to the hospital's emergency department on 8/12/2022 after an altercation with his/her parent. His/her past medical history includes, but is not limited to, suicidal ideation with attempts, self-mutilation via cutting, burning, hitting, and bipolar 1 disorder.

Further review of the record for Patient ID #1 revealed that in the early morning of 8/17/2022, she/he eloped from the hospital after his/her observer at the time, Employee C, a Certified Nursing Assistant (CNA), fell asleep. Upon Patient ID #1's return to the hospital through the emergency department, she/he had approximately 20 to 30 self-inflicted superficial cuts to his/her left arm and 1 cut on his/her shin that she/he made with a shard of glass she/he found outside of the hospital.

Record review revealed that on the date of the elopement, Patient ID #1 had an active physician's order for Constant Observation around the clock that was initiated on 8/15/2022 at 7:38 AM.

2. Record review revealed that Patient ID #2 presented to the hospital's emergency department on 8/11/2022 after displaying physical aggression at school and at home. His/her medical history includes adjustment disorder with mixed disturbance of emotions and conduct, autism spectrum disorder, aggression, and obsessive-compulsive disorder.

Record review for Patient ID #2 revealed a physician's order for Constant Observation around the clock that was initiated on 8/15/2022 at 7:41 AM.

During a surveyor interview with Employee C, on 8/23/2022 at 11:49 AM, she revealed that on the morning of 8/17/2022, she was assigned to observe Patient ID #2 who required 1:1 constant observation. Employee C was then asked to relieve Employee A for a break "around 5:15 AM or 5:20 AM" who was watching Patient ID #1 in the adjacent room. She indicated that since both rooms were next to each other, she sat "right outside" both rooms to observe both patients. She indicated that per hospital policy, employees can only watch one patient at a time when the patient requires Constant Observation but at the time, there were no other staff available to sit with Patient ID #1.

During a surveyor interview with the Associate Chief Nursing Officer of Pediatrics on 8/23/2022 at 10:10 AM, she acknowledged that 1 employee observing 2 patients who require Constant Observation was a problem and indicated it should not have happened.








43881

Based on record review and staff interview, it has been determined that the facility has failed to provide nursing care in accordance with accepted standards of nursing practice and hospital policy for 4 of 4 patients reviewed, Patient ID #1, who had a physician's order for Constant Observation and eloped from the hospital and for Patient ID #s 2, 3, and 4 who had a physician's order for Constant Observation.

Findings are as follows:

Review of the hospital's policy titled, "Observation Levels" last revised on 9/2019 states in part,

"...Constant Observation (CO): highest level of observation. CO is used when a patient is high risk for intentional self-harm, high risk for suicide or harm to others. This requires a 1:1 staff to patient ratio.

Patient observer: Specially trained staff designated to provide observation of a patient at risk for safety. Staff member has completed required education to function as a patient observer...General responsibilities include:

Being alert and aware of all patient activity and avoiding distraction...

...No sleeping or "resting your eyes"...

...Facing the patient if 1:1 patient observation is ordered...

...IV. Procedure...
Constant Observation (CO) 1:1
Outside of Behavioral Health Settings
...Patient observer is assigned to only one patient at all times..."

1. Record review revealed that Patient ID #1 presented to the hospital's emergency department on 8/12/2022 after an altercation with his/her parent. His/her past medical history includes, but is not limited to, suicidal ideation with attempts, self-mutilation via cutting, burning, hitting, and bipolar 1 disorder.

Review of the "ED Provider Note" For Patient ID #1 dated 8/12/2022 at 6:23 PM states in part,

"...Psychiatric History
...-Previous suicide attempts
-Endorses daily self-harm by cutting, burning, and hitting [himself/herself]
-Cuts [himself/herself] with a razor blade "on every surface but my stomach"
-Burns [himself/herself] with joints, heated up coins, pieces of metal..."

Review of an "ED Note" for Patient ID #1 dated 8/12/2022 at 9:15 PM states in part, "Per DCYF [Department of Children Youth and Families] pt. [patient] states...that [she/he] has a plan to run in front of a truck tonight if [she/he] leaves the hospital ...[she/he] has not been taking medications appropriately and that [she/he] has auditory/visual/tactile hallucinations..."

Review of the History and Physical ("H&P Notes") for Patient ID #1 dated 8/13/2022 at 5:09 AM states in part,
"Chief complaint: SI [suicidal ideation] with plan...
Assessment and Plan...the severity of [his/her] psychiatric symptoms make it unsafe for [him/her] to return home at this time. Will admit...for further psychiatric assessment and monitoring while awaiting placement. [Patient ID #1] is not acutely psychotic however warrants constant observation..."

Record review revealed that on the date of the elopement, Patient ID #1 had an active physician's order for constant observation 1:1 around the clock that was initiated on 8/15/2022 at 7:38 AM.

Review of a document titled, "Default Flowsheet Data" for "Constant Observation" revealed that on 8/17/2022 at 5:00 AM Patient ID #1 was on "Constant Observation" while observed by a Patient Care Attendant, Employee A, who documented that the patient was in bed and cooperative.

Review of e-mail correspondence between Employee A and Employee B, Clinical Manager of the 4th floor, from 8/18/2022 at 6:34 AM, revealed a statement from Employee A which indicated that when she took her break "around 5:20 AM" the patient was still in the room.

During a surveyor interview with Employee C, Certified Nursing Assistant, on 8/23/2022 at 11:49 AM, she revealed that on the morning of 8/17/2022, she was assigned to observe Patient ID #2 who required 1:1 constant observation. Employee C was then asked to relieve Employee A for a break "around 5:15 AM or 5:20 AM" who was watching Patient ID #1 in the adjacent room. She indicated that since both rooms were next to each other, she sat "right outside" both rooms to observe both patients. She indicated that per hospital policy, employees can only watch one patient at a time when the patient requires 1:1 Constant Observation but at the time, there were no other staff available to sit with Patient ID #1. She revealed that at approximately "5:38 AM or 5:39 AM", she last saw Patient ID #1 lying in bed on his/her stomach and stated that she "started to dose off." She acknowledged that she fell asleep until she felt a tap on her shoulder at approximately "6:00 AM or 6:10 AM" from Employee A who questioned her about Patient ID #1's whereabouts.

During a surveyor interview with Employee A on 8/23/22 at 9:25 AM, she revealed that when she returned from her break, she was speaking to a nurse when the unit received a phone call from the emergency department asking if the unit was missing a patient. She indicated that she went to Patient ID #1's room and saw Employee C sitting in front of Patient ID #1 and Patient ID #2's doorways. She stated that she tapped Employee C on the shoulder, to tell her that Patient ID #1 was missing. Employee A stated when Patient ID #1 arrived back on the unit following her elopement, she/he was escorted by staff and her left arm was "wrapped up and bleeding."

During a surveyor interview with Employee D, Emergency Department Triage Nurse, on 8/23/2022 at 12:23 PM, she indicated that she was working at the "triage booth area ambulance bay" on the morning of 8/17/2022 when a security staff brought Patient ID #1 in front of her at approximately 6:00 AM. Employee D revealed that Patient ID #1 was wearing blue paper scrubs which are usually given to patients in the psychiatric unit and she/he was "soaking wet" from the rain that morning. Employee D revealed that she noticed approximately 20 to 30 recent, horizontal cuts on the Patient's arm that were "oozing blood" and Patient ID #1 revealed to her that she/he had cut himself/herself. She indicated that Patient ID #1's cuts were cleansed and dressed in the emergency department. Shortly after, the unit was informed of the patient's return and Patient ID #1 was escorted back to the unit. Employee D stated that when she questioned Patient ID #1 about what happened, she/he said, "I was upstairs, no one was watching so I bolted." Employee D then revealed that according to Patient ID #1, she/he took the elevator, pressed all the buttons, got off on the second floor, she/he then hid in a closet, went through a window, and then walked a gravel path into a garage.

Additional record review revealed a physician's progress note dated 8/17/2022 at 7:15 AM written after the event which stated in part, "...numerous superficial lacerations on [his/her] left forearm which [she/he] explained to the provider had been self-inflicted with a shard of glass [she/he] found outside, before [she/he] went to the ED [emergency department]. Wounds were cleansed and bandaged by nursing. Patient stated [his/her] reasoning for the elopement as being a lack of sleep and frustration with [his/her] hospital stay...Physical Exam...Skin: many superficial linear lacerations on bilateral upper extremities...most notably on left forearm...singular linear laceration on right lower leg..."

Further record review failed to reveal evidence that a 15-minute Constant Observation Log was completed for Patient ID #1 on 8/17/2022 per hospital policy. This log is initialed by staff every 15 minutes in a 24-hour period and is used to represent constant observation of the patient.

During a surveyor interview on 8/22/2022 at 8:45 AM and at 12:10 PM with the Risk Manager, she revealed that Employee C, who fell asleep, was placed on an administrative leave after the event occurred. When asked if the hospitals elopement protocol was initiated on the morning of 8/17/2022, she indicated that it was not as no employees were aware that Patient ID #1 had eloped, nor had they seen where she/he exited from. Additionally, she was unable to provide evidence that a 15-minute Constant Observation Log was completed for Patient ID #1 on 8/17/2022 per hospital policy.

2. Record review revealed that Patient ID #2 presented to the hospital's emergency department on 8/11/2022 after displaying physical aggression at school and at home. His/her medical history includes adjustment disorder with mixed disturbance of emotions and conduct, autism spectrum disorder, aggression, and obsessive-compulsive disorder.

Record review for Patient ID #2 revealed a physician's order for constant observation 1:1 around the clock that was initiated on 8/15/2022 at 7:41 AM.

Review of the 15-Minute Constant Observation Logs from 8/16/2022 through 8/21/2022 for Patient ID #2 revealed the following:

- For 8/18/2022, fourteen 15-minute blocks were not signed off by staff to represent the constant observation of Patient ID #2 between 3:30 AM and 6:45 AM.

- For 8/19/2022, ten 15-minute blocks were not signed off by staff to represent the constant observation of Patient ID #2 between 1:00 AM and 3:15 AM.

During a surveyor interview conducted via telephone with the Risk Manager on 8/25/2022 at 8:27 AM, she acknowledged that the above-mentioned information for Patient ID #2 was not complete.

3. Record review for Patient ID #3 revealed a physician's order for constant observation 1:1 around the clock that was entered on 8/16/2022 at 4:03 PM.

The record failed to reveal evidence that a 15-minute Constant Observation Log was completed for Patient ID #3 from 8:15 PM on 8/16/2022 throughout 8/17/2022 from 12:00 AM through 11:45 PM per hospital policy.

Additionally, the record for Patient ID #3 failed to reveal evidence of a completed hourly assessment for 8:00 AM on 8/17/2022 within the document titled, "Default Flowsheet Data" for "Constant Observation" per hospital policy. The hourly assessment within this document indicates the level of observation of the patient, who is observing the patient, the nurse's assessment of the patient's affect and the patient's behavior and activity.

During e-mail correspondence with the Risk Manager on 8/25/2022, she was unable to provide evidence for the above-mentioned missing documentation.

4. Record review for Patient ID #4 revealed a physician's order for constant observation 1:1 that was entered on 8/15/2022 at 9:46 PM.

Record review for Patient ID #4 failed to reveal evidence of completed hourly assessments within the document titled, "Default Flowsheet Data" for "Constant Observation" between 6:26 AM and 9:24 AM on 8/16/2022 and between 9:24 AM and 11:33 AM.

During e-mail correspondence with the Risk Manager on 8/24/2022 at 3:36 PM, she acknowledged the discrepancies identified in the "Default Flowsheet Data" for "Constant Observation" for Patient ID #4.


43881

Based on record review, and staff interview, the hospital failed to assign the nursing care for each patient to other nursing personnel in accordance with the patient's needs, and competence of the nursing staff available for 2 of 4 patients reviewed, Patient ID #1 and #2.

Findings are as follows:

Review of the hospital's policy titled, "Observation Levels" last revised on 9/2019 states in part,

"...Constant Observation (CO): highest level of observation. CO is used when a patient is high risk for intentional self-harm, high risk for suicide or harm to others. This requires a 1:1 staff to patient ratio.

Patient observer: Specially trained staff designated to provide observation of a patient at risk for safety. Staff member has completed required education to function as a patient observer...General responsibilities include:

Being alert and aware of all patient activity and avoiding distraction...

...No sleeping or "resting your eyes"...

...Facing the patient if 1:1 patient observation is ordered...

Review of the "Certified Nursing Assistant II" job description implemented since October of 2001 states in part,

...Responsible for Emergency and Safety Conduct:

...Maintains an environment conducive to patient comfort and safety..."

1. Record review revealed that Patient ID #1 presented to the hospital's emergency department on 8/12/2022 after an altercation with his/her parent. His/her past medical history includes, but is not limited to, suicidal ideation behavior via cutting, suicide attempts, and bipolar 1 disorder.

Further review of the record for Patient ID #1 revealed that in the early morning of 8/17/2022, she/he eloped from the hospital after his/her observer at the time, Employee C, a Certified Nursing Assistant (CNA), fell asleep. Upon Patient ID #1's return to the hospital through the emergency department, she/he had approximately 20 to 30 self-inflicted superficial cuts to his/her left arm and 1 cut on his/her shin that she/he made with a shard of glass she/he found outside of the hospital.

Record review revealed that on the date of the elopement, Patient ID #1 had an active physician's order for Constant Observation 1:1 around the clock that was initiated on 8/15/2022 at 7:38 AM.

During a surveyor interview with Employee C, Certified Nursing Assistant, on 8/22/2022 at 11:49 AM, she revealed that on the morning of 8/17/2022, she was assigned to observe Patient ID #1 during the primary observer, Employee A's break at approximately "5:15 AM or 5:20 AM". She revealed that at approximately "5:38 AM or 5:39 AM", she last saw Patient ID #1 lying in bed on his/her stomach and stated that she "started to dose off." She acknowledged that she fell asleep until she felt a tap on her shoulder at approximately "6:00 AM or 6:10 AM" from Employee A who questioned her about Patient ID #1's whereabouts.

2. Record review revealed that Patient ID #2 presented to the hospital's emergency department on 8/11/2022 after displaying physical aggression at school and at home. His/her medical history includes adjustment disorder with mixed disturbance of emotions and conduct, autism spectrum disorder, aggression, and obsessive-compulsive disorder.

Record review for Patient ID #2 revealed a physician's order for Constant Observation 1:1 around the clock that was initiated on 8/15/2022 at 7:41 AM.

During a surveyor interview with Employee C, on 8/23/2022 at 11:49 AM, she revealed that on the morning of 8/17/2022, she was assigned to observe Patient ID #2 who required 1:1 constant observation. According to Employee C she was asked by Patient ID# 1's assigned nurse, Employee E, to relieve Employee A for a break "around 5:15 AM or 5:20 AM" who was watching Patient ID #1 in the adjacent room. She indicated that since both rooms were next to each other, she sat "right outside" both rooms to observe both patients at the same time. When asked about the hospitals policy for constant observation of a patient, she indicated that per hospital policy, employees can only watch one patient at a time when the patient requires 1:1 Constant Observation but at the time, there were no other staff available to sit with Patient ID #1.

During a surveyor interview with Employee E, on 8/22/2022 at 1:19 PM, she revealed that neither Employee A nor Employee C informed her that coverage was needed during Employee A's break. She did state that when the hospital is short of staff, a staff member may be assigned to watch more than 1 patient who requires 1:1 constant observation. She did acknowledge that a patient observer can only have one patient assigned to one observer at a time.



43881