HospitalInspections.org

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Based on Medical Record review, document review, observation and interview, the facility failed to: a) follow the facility's Policy for Constant Observation for one (1) of one (1) patient, and b) implement the Occurrence Reporting Policy for one (1) of one (1) patient.

These failures potentially place vulnerable patients at increased risk for harm and prevent the facility from identifying and implementing needed changes.

Findings:

a) Medical Record review revealed that Patient #6 presented to the Emergency Room (ER) on 05/17/15 for a Mental Health Evaluation after an episode of agitation and behavioral outbursts at her psychiatric group home, and making suicidal statements to Police. Patient #6 had a documented history of Pica (ingestion of non-food items). The patient was accompanied to the ER by an Aide from her residence. A Physician's Order for Constant Observation (CO) was entered on 05/17/15 at 5:15PM. No documentation of CO monitoring was found in the patient's Medical Record.

The facility's Policy titled "Constant Observation and Occurrence Reporting", effective 09/5/13, defined CO as "continuous, unbroken observation of a single patient by an appropriate, competent staff member from a distance of not more than one arm's length;" and "Patients at risk for self-injurious or violent behavior must have their hands in view at all times." The Policy further stated "Only staff with validated competency can perform Constant Observation."

Review of video footage and interview on 10/20/15 at 2:30PM with Staff Members A, B, C & D revealed that Patient #6's CO was not performed by Behavioral Health (BH) ER / Facility Staff, but instead, was performed by Patient #6's Group Residence Aides.

When asked if the BH ER utilizes external Residential Aides to perform CO, Staff Members B and C replied "Yes". Both staff members also stated the Residential Aides are not facility employees, therefore their CO competency could not be validated.

Video observation also revealed that Patient #6 was left unobserved for approximately two (2) minutes on 05/17/15, between 5:08PM and 5:10PM, while two (2) Residential Aides had a discussion outside of the patient's room and halfway up the hallway. During that time, Patient #6 was observed on video, raising her gown sleeves to her mouth multiple times and attempting to bite off her hospital gown snap closures. Patient #6 was not in the Aides' view during this time.

Staff B stated "All our patients are on constant observation; we have cameras throughout the Unit". On further interview it was discovered there are no dedicated staff assigned to monitor the cameras, and Staff B stated "No, we do not have anyone dedicated to watch the monitors".

Staff D stated the facility-wide CO Policy is "acceptable for the large majority of patients, but it is not tailored to this [BH ER] specific area". Staff Member C stated "In our area, a Doctor will order CO for a patient, and depending on how well known the patient is, or what is known about the patient, observation from a distance may be acceptable". Staff B stated "This is what we need to do, we need to delineate and define this [CO] Policy for our specific area".

b) On 10/20/15 at 3:00PM, video observation with Staff Members A and D revealed Patient #6 raising her gown sleeves to her mouth multiple times and attempting to bite off her bilateral hospital gown snap closures.

An ER Provider Note dated 05/17/15 at 8:16PM states "Progress: Stable. Patient was witnessed by our ED (Emergency Department) Staff to tear a snap button off the hospital gown and swallow it ... ".

The facility's Policy titled "Occurrence Reporting" implemented 12/15/14, defines an Occurrence as an "unusual event involving a patient, employee or visitor ... ". The Policy further states "All Occurrences shall be promptly reported on an applicable Occurrence Report Form or on the Electronic Tracking and Trending Software. It is the responsibility of every employee / volunteer to immediately report to his / her Supervisor any Occurrence."

No Occurrence Report was completed for this Incident. On interview with Staff Members A, B, C and D on 10/20/15 at 3:26PM, Staff B stated "I was not informed the patient had swallowed gown snaps". Staff D confirmed "An Occurrence Report should have been filled out".