HospitalInspections.org

Based on medical record review, policy review, document review, observation, video surveillance review, and staff interview, it was determined that the facility failed to provide care in a safe setting for 1 of 4 patients (Patient #1) in the sample by not performing safety observations per hospital policy. These findings have the potential to negatively impact all 96 patients at the facility. Findings include:


Hospital policy "Level of Observation/Rounds" stated, "...Observe each patient, a minimum of every 15 minutes and/or according to precaution level and document observation on the patient form...Observe patients on bed rest or when sleeping by...Looking for the rise and fall of the chest...Counting at least three respirations...Making sure that the patient has moved from his/her previous sleeping position...Observations may not be completed standing in the doorway, or at a distance...It is expected that staff conducting 15 minute observations will enter the room, approach the patient...3 sets of respirations, and to ensure that they are not in any distress...Visually observe patient when behind closed doors by...Announce that they are stepping into the room for rounds...Open door and visually observe the safety of the patient..."

Hospital document "Patient Rights and Responsibilities" stated, "...Personal Safety - The patient can expect a reasonable safety [sic] in so far as hospital practices and environment are concerned to include protective precautions when indicated..."

Patient #1 was admitted to Dover Behavioral Health System (DBHS) on 3/8/24 at 2:44 PM with a diagnosis of opioid dependence, uncomplicated. Physician orders, initiated on 3/8/24 at 10:00 PM, included routine every 15-minute (Q15) safety rounding.

Patient #1's "Observation Record" for 3/9/24 lists that the patient was awake, agitated, and bizarre from 4:45 to 7:00 AM. At 8:15, 8:30, 8:45, 9:00, 9:15, and 9:30 AM, the patient was documented as in the patient room and with eyes closed.

Video surveillance review from 3/9/24 revealed:
- 8:15:06 Employee #11, Mental Health Technician (MHT), delivers food items to Patient #1 in room
- 8:16:18 Employee #9, MHT, closes the patient's door
- 8:45 Employees #11 and 12, MHTs, at the doorway of Patient #1
- 8:59 Employee #11 performs every 15-minute safety check from the door
- 9:24 Employee #12 walks past Patient #1's door without stopping
- 9:38 Employee #9 performs every 15-minute safety check
- 9:56:04 Employee #9 enters the patient's room for the safety check
- 9:56:20 Employee #9 runs out of the room
- 9:56:38 Employees #9, 11, and 13 (RN) enter the patient's room
- 9:58:46 The code cart and additional staff arrive at room
- 10:06:49 Emergency Medical Services (EMS) arrives

"Observation Record" listed the 8:15 AM and 8:30 AM observations were performed by Employee #9, however, based on video surveillance review, Employee #9 was at Patient #1's door at 8:16:18. The next MHT was at the patient's door at 8:45. Therefore, the 8:30 AM observation was not completed at documented. Also, at 9:15 AM, the patient was documented as being in the room with eyes closed. However, on video review, Employee #11 was visualized at the patient's door, at 9:24 AM, Employee #12 walks past the patient door without stopping to visualize, and at 9:38 AM, Employee #9 was visualized at the patient's door, therefore the 9:30 AM observation was not performed as documented.

In an interview statement conducted on 3/9/24 by Employee #1, Director of Risk Management, Employee #11, MHT, was questioned regarding performing safety checks from the doorway. Employee #11 stated this was done for multiple safety checks as Patient #1 was undressed during multiple safety checks. On one safety check, the patient was visualized standing up. Yet, on the Observation Record, the patient was charted as lying down with eyes closed. The patient was provided a pair of scrubs, however, the patient only donned the top and not the bottoms.

In an interview statement conducted on 3/9/24 by Employee #1, Director of Risk Management, Employee #9 stated that on the 9:45 AM safety check, the patient was visualized lying down, with eyes open. At the 10:00 AM rounds, Patient #1 was visualized with eyes open, and mouth open, but Employee #9 stated something "didn't look right". Employee #9 stated an attempt was made to arouse the patient, but was unsuccessful. Employee #9 then ran down the hallway to retrieve the nurse.

Employee #1, Director of Risk, stated in an interview on 3/13/23 from 9:25 to 9:37 AM, that, after video surveillance review, the administration identified observations were not being conducted for Patient #1 per policy, and did not align to what was documented on the Observation Record for Patient #1.

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 2 out of 4 (50%) patients (Patients #2 & #3) sampled. Findings include:

The hospital job description title, "Charge Nurse (RNIII)" 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" revised 1/24 stated, "...The Charge Nurse reviews and signs the Patient Observation Rounds sheet a minimum of 2x per shift."

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..."


I. Nursing Assessments

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:

3/9/24: 3 PM-11 PM

3/10/24: 3 PM-11 PM

3/11/24: 3 PM-11 PM

8/23/23: 3 PM-11 PM

These findings were confirmed by Employee # 1 on 3/13/24 at 2:30 PM.


Medical record review for Patient #3 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:

2/4/24: 3 PM-11 PM

2/6/24: 3 PM-11 PM

These findings were confirmed by Employee #1 on 3/13/24 at 2:30 PM.


II. Nursing Supervision of Patient Safety Observations

The Patient Observation Rounds sheet contains a section for registered nurses 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 #2, admitted with Bipolar Disorder and history of suicide attempt at last hospitalization in January (1/30/24), revealed:

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

3/8/24 (admission date): 9 PM-12 AM (3 hours)

3/10/24: 12 PM-4 PM (4 hours)

3/11/24: 8 AM-1:45 PM (5.75 hours - patient sent to local Emergency Department)

3/21/24: 4 PM-12 AM (8 hours)

These findings were confirmed by Employee # 1 on 3/13/24 at 2:30 PM.


Medical record review for Patient #3, admitted with Major Depressive Disorder and placed on suicide precautions revealed:

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

2/1/24: 4 PM-12 AM (8 hours)

2/3/24: 12 AM-8 AM; 9 PM-12 AM (12 hours)

2/4/24: 4 PM-12 AM (8 hours)

2/6/24: 12 PM-12 AM (12 hours)


These findings were confirmed by Employee #1 on 3/13/24 at 2:30 PM.