HospitalInspections.org

Based on surveyor review of records and staff interviews, the facility failed to ensure that each patient received observation safety checks according to the level ordered by the physician (refer to A 144). The cumulative effects of this systemic issue failed to provide a safe environment for each patient and permitted patient #1 the necessary time to harm himself successfully.

Based on surveyor review of records and interviews, the facility failed to provide care to each patient in an environment that a reasonable person would consider safe and failed to ensure each patient received the level of observation and monitoring according to physician orders and the standard set by the facility's policy.

The findings include:

On 4/22/22, Patient #1 was voluntarily admitted to the facility for suicidal ideation. The physician placed patient #1 on suicide precautions with the observation monitoring level of close observation Q-15 checks [every 15 minutes checks].

On 5/5/22 at 0420, Staff #12 documented in part, "At approximately 0340, myself and staff were alerted by this pt's [patient #1's] roommate that 'My roommate hung himself.' Myself [staff #12] and [staff #7] entered the room and noted the pt [patient #1] hanging by a bedsheet tied around his neck and wedged in the bathroom door."

The staff performed cardiopulmonary resuscitation [CPR] on patient #1 and called 911. Waco emergency medical service [EMS] and police department [PD] responded. Nursing documentation revealed CPR efforts continued on patient #1 until 0407 am, at which time the patient was pronounced dead by EMS. Waco PD initiated an investigation; results are pending.

A review of patient #1's observation monitoring flowsheet revealed all entries completed, as ordered, except the charge nurse's every 2-hour check due on 5/5/2022 at 3:00 am. All "every 15-minute checks" were initial as completed, indicating the checks were conducted by staff #7.

During a personal interview on 5/5/2022 at 0930, in room 113 [room where the incident occurred], The Plant Operations Director, Staff #3, stated, "These are the bathroom doors that were approved during our life-safety inspection. They are ligature resistant and are slanted at a 90-degree angle to prevent knots being able to rest on the edges. From what I hear, the knot was pretty big."

The facility's root cause analysis [RCA] findings stated in part, "The cameras on the hallways were reviewed by the administrator. The findings were that the staff did not round [perform observation checks] from 12 am to 3 am. No Q15 [every 15 minutes] observation or Q2 [every 2-hour check] charge nurse check."

The facility's policy titled "Level of Observations" stated in part, "The staff member will visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities. Staff members utilize the close observation checklist form (Q15 check sheet) to document the ongoing observation and location of the patient. The observing staff initials the 15-minute increments on the form to indicate the patient was observed. The staff member signs the signature line at the bottom of the form to validate their initials and credentials. The registered nurse (RN) will conduct routine patient safety and observation rounds at least once every 2 hours (unless more often is warranted) and will validate rounds by initialing in the appropriate section(s) of the form."

The findings were validated on 5/5/2022 at 1:31 pm in the facility conference room by staff #2. Staff #2 stated, "I reviewed the camera footage and found that there had not been rounding on the patient [patient #1] for 3 hours. The staff just signed the rounding log as if it was performed. All staff members have been re-educated on observation policies. I will replace the doors on the adult side with a magnetic door that will collapse with bodyweight or prolonged pressure."