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Based on a review of clinical records, facility documentation, a tour of the unit, and interviews with staff, the facility failed to protect and promote each patient's rights.

Findings:

1. By the staff failing to monitor patients effectively at the level ordered, patients were at risk of increased opportunities for aggression and self-injurious behavior during lapses in monitoring. The facility was failing to protect the patient's right to care in a safe setting by not monitoring the patient at the appropriate level ordered, increasing the risk for potential harm to patients

Based on a review of clinical records, facility documentation, a tour of the unit, and interviews with staff, the facility failed to ensure patient's right to receive care in a safe setting, as evidence by failing to appropriately monitor patients.

Findings:

Facility policy #200.88, entitled "AGGRESSION/ASSAULT PRECAUTIONS" stated in part,

"II. Procedure ...

5. Aggression I Assault precautions will be communicated to team members responsible for the patient's safety during shift report, documented on the Patient Observation Form & Daily Nursing Assessment."


On 09/20/19 Patient #1 was assaulted by Patients #2 and Patient #3.

* On 09/20/19 at 4:25 PM - Patient #1 used profanity towards peer Patient #2 who punched Patient #1. The two patients fought and were separated by staff.

* On 09/20/19 at 6:45 PM - Patient #3 entered Patient #1's room and attacked patient, causing injuries that necessitated transfer to the ER at [another facility].

* On 09/20/19 at 7:00 PM - Patient #1 was in the dayroom, awaiting transfer to [another facility] when Patient #3 ran up to Patient #1 and punched patient in the face.


Review of the observation sheets for Patients #1, 2, and 3 revealed the following:

* Patient #1 was monitored appropriately every 15 minutes per review of their observation record for 09/20/19.

* Patient #2 was placed on q 5 minute checks on 09/20/19 at 1630 related to aggression. Review of the Observation record on 09/20/19 revealed that the patient was documented as being monitored only every 15 minutes the entire day, not q 5 minutes (starting at 1630) as ordered. Then the patient was placed on 1:1 observation on 09/20/19 at 1940 related to aggression and impulsivity. A nursing note at 1845 stated in part, "Placed on 1:1 on top of q5/AP". Review of the observation record on 09/20/19 revealed that the patient was documented as being monitored only every 15 minutes the entire day, not 1:1 (starting at 1940) as ordered.

* Patient #3 was placed on q 5 minute checks on 09/20/19 at 1940 related to aggression and impulsivity. Review of the Observation record on 09/20/19 revealed that the patient was documented as being monitored only every 15 minutes the entire day, not q 5 minutes (starting at 1940) as ordered. Q 5-minute monitoring as ordered was not documented until 0000 on 09/22/19.


The facility completed an internal investigation of the incidents on 09/20/19 involving these three patients. The facility identified there was an established issue with physician orders and observation levels being communicated effectively to staff, leading to gaps in patient monitoring. However, based on interviews with staff members #1 and 2 on 10/01/19, no immediate re-training had been initiated/completed with direct care staff regarding appropriate monitoring of patients. The plan for education and changing the system for completing the Observation Record was not due to take effect until 10/24/19.

A tour of the Brazos unit (child and adolescent) on 10/01/19 at approximately 4 PM revealed that patients were still not being observed properly at the most current ordered observation level. All patient records were checked for the most recent observation order and this was compared to the observation record for these patients. 5 out of 18 patients were being monitored incorrectly based on their most recent physician order.


The following patients were being monitored incorrectly:

* Patient #4 was placed on q 5 minute checks on 09/30/19 at 1445. Review of the Observation Record for 09/30/19 revealed the patient was only monitored every 15 minutes from 1445 through midnight, not every 5 minutes as ordered. The q 5-minute monitoring was not started until 0000 on 10/01/19.

* Patient #5 was on q 15 minute checks from admission on 09/28/19. However, review of the observation record for this patient revealed they had been monitored q 5 minutes, not q 15 as order from midnight onward throughout 10/01/19. There was no physician order present to monitor the patient q 5 minutes at any point while inpatient.

* Patient #6 was placed on q 5 minute checks on 09/28/19 at 0745. The q 5 minute checks were discontinued and the patient was placed on q 15 minute checks on 10/01/19 at 0830. The observation records for this patient revealed that patient was not being monitored q 5 on 09/28/19 properly. On 09/28/19 from 0745 until midnight the patient was only monitored every 15 minutes. On 09/29/19 at 0000 q 5 minute checks were documented, then suddenly at 1200 the patient was monitored every 15 minutes, not every 5 minutes as ordered. Then on 10/01/19 the observation sheet noted that staff stopped monitoring the patient every 5 minutes as ordered at 0715 (prior to the discontinuation of the order at 0830). This meant the patient was not monitored as ordered multiple times over these 3 dates.

* Patient #7 was on q 15 minute checks from admission on 09/30/19. However, review of the observation records for this patient revealed they had been monitored q 5 minutes, not q 15 as order from 1145 through midnight on 09/30/19. On 10/01/19 the q 5-minute monitoring continued from midnight through 0230. There was no physician order present to monitor the patient q 5 minutes at any point while inpatient.

* Patient #8 was placed on q 5 minute checks on 09/30/19 at 0745. On 10/01/19 at 0830 the q 5 checks were discontinued and he was placed on q 15 minute checks. Review of the observation records revealed that the patient was observed every 15 minutes not every 5 minutes for all of 08/30/19. The patient was not observed every 5 minutes as ordered starting at 0000 on 10/01/19. Then on 10/01/19 the observation sheet noted that staff stopped monitoring the patient every 5 minutes as ordered at 0735 (prior to the discontinuation of the order at 0830). This meant the patient was not monitored as ordered multiple times over these 2 dates.


Review of facility incident reports revealed that Patient # 4 had incidents of aggression on 09/30/19 and 10/01/19 requiring restraints. These were dates this patient was not being properly monitored at the level ordered. These incidents of aggression potentially could have been prevented if the patient had been monitored appropriately.


The immediate jeopardy was determined and continued to exist due to patient's not being properly monitored. By the staff failing to monitor patients effectively at the level ordered, patients were at risk of increased opportunities for aggression and self-injurious behavior during lapses in monitoring. The facility was failing to protect the patient's right to care in a safe setting by not monitoring the patient at the appropriate level ordered, increasing the risk for potential harm to patients. Review of facility based incident reports reveal that there had been several incidents of aggression between patients on the unit since 09/20/19.


The facility was notified that the immediate jeopardy was still in place and asked for a remediation plan.

On 10/01/19 the facility provided the following plan to abate the immediate jeopardy.

"The following immediate steps will be taken to mitigate the risk associated with the discrepancies between ordered and documented levels of observation.

A. SHORT TERM PLAN: TIMELINE: This process will begin 10/01/2019

o All staff on shift currently will be trained on the following:

o Verification of ordered observation level

o Documentation of observation level on Nursing Daily Shift Assessment Notes consistent with orders

o Documentation of observation level on Patient Board

o Notification of changes in observation level to MHTs

o Documentation of observation level on MHTs' Observation Rounds form consistent with orders

o RN assigned to each unit will round twice per shift to ensure consistency and accuracy of observation level

o Members of the leadership team (Nursing Supervisors and Senior Leadership) will conduct unit rounds every 6 hours, around the clock, to ensure that the documentation and carrying out of observation level correspond to orders and are documented on the on the abovementioned documents/patient board. Rounding will continue until all staff have been trained. Target Date: 10/08/2019

o Staff not able to receive training and education will have badges inactivated prior to assuming next scheduled shift.


B. SUSTAINABILITY:

o Starting 10/09/2019, Senior Leadership will conduct twice-daily rounds of all units to ensure that documentation is consistent with provider orders on the Nursing Daily Shift Assessment, Observation Rounds and Patient Board, until 100% compliance is met for 30 consecutive days."


With this plan in place the immediate jeopardy was abated by initiating training of all staff and monitoring audits in place to ensure patients were appropriately being monitored at the level most recently ordered by the physician. Monitoring patients effectively at the level most recently ordered will likely increase patient safety. However due to the immediate jeopardy being substantiated the facility is out of compliance with the Condition of Participation for Patient Rights.