HospitalInspections.org

Based on review of medical records and interviews, it was determined the facility failed to ensure:

1. There was a policy or procedure related to levels of care to be provided for the patients.

2. The Registered Nurse (RN) supervised the care provided by the Mental Health Technicians (MHT) to ensure 1 to 1 (1:1) patient observations were conducted by the MHT.

This affected 1 of 6 medical records reviewed for observations, including Patient Identifier (PI) # 2 and had the potential to negatively affect all patients admitted to the facility's Senior Care Unit (SCU).

Findings include:

1. PI # 2 was admitted to the facility on 11/10/17 with diagnoses including major depression, generalized anxiety disorder and severe psychosocial stressors.

Review of the Patient Progress Notes dated 11/12/17 revealed the nurse documented the following:

At 7:09 PM (amended on 11/13/17 at 12:39 AM), the RN documented, "... Patient (pt) cursing at staff... became hostile, argumentative and disruptive... Patient is verbally aggressive and difficult to redirect. Patient went to (his/her) room and slammed the door. Approached patient in a calm manner and allowed... verbalize... feeling. Patient advised that... can not have the door closed but... can pull curtain for privacy. Patient yelling and cursing at this nurse..."

At 7:10 PM (amended on 11/13/17 at 12:40 AM and at 3:46 AM), the RN documented, "... Patient noted trying to climb over the rail of the bed. Patient angry that this nurse let the rail down. Told patient it is for... safety so... doesn't fall... advised will let the rail up when... gets in the bed. Patient refused for this nurse to let the rail up after... (he/she) got in the bed. Patient threatening this nurse that no one better come in... (his/her) room tonight. Explained to patient that staff has to do safety rounds Q (every) 15 mins (minutes). Bed locked and in low position. Bed alarm on. Safety monitoring in progress. Patient refused shower and evening medication..."

At 8:00 PM (amended on 11/13/17 at 1:39 AM and 1:44 AM), the RN documented, "... 1930 (7:30 PM) Called to patients room per MHT. Was advised that she heard patient yell went in patients room and found (him/her) on the floor, Patient assessed... able to move bil (bilateral) lower extremities. Patient kicking... legs when this nurse assessed (him/her)... holding right arm straight. Will not let nurse move it... had a previous right shoulder injury and is scheduled for rotator cuff repair this Friday. No injury noted at this time. Patient refusing to get up off the floor. Staff assisted patient back in bed..."

At 10:10 PM (amended on 11/13/17 at 2:46 PM), the RN documented, "... Patient resting in bed with eyes closed... reassessed. Patient able to move bil arms and legs without difficulty or S/S (sign/symptoms) of discomfort. No redness, bruising, edema or displacement noted. Patient changed clothes and put on a gown... was able to use both hands and arms to unbutton and take of (off) shirt with minimal assistance. Patient lying in bed, used bil legs and lifted buttocks up and took off... pants. Bed locked and in low position. Bed and tabs alarm on. Staff implementing one on one observation and care..."

On 11/13/17 at 12:15 AM, the RN documented, "... Patient up to bathroom... with stand by assist... ambulating in dayroom... No complaints of pain or discomfort... Staff continues to implement one on one observation and care..."

Review of the medical record revealed an unnamed document dated 11/12/17 (6:15 PM ) to 11/13/17 (6:00 AM) revealed this document was separated into 15 minute increments with the Patient's Location, Staff Action, Patient Action/Behavior and initials of the staff member who completed the documentation. This document was completed and signed by Employee Identifier (EI) # 2, MHT.

A review of the above document revealed EI # 2 documented the patient was in the Dining/Group room at 7:15 PM and was disruptive, uncooperative, yelling and had cursing / verbal threats. At 7:30 PM and 7:45 PM, EI # 2 documented the patient was in his/her room and continued to be uncooperative, disruptive, cursing /verbal threats and yelling.

From 8:00 PM until 5:30 AM, the patient was documented as having been in the hallway, in bed with Tab (bed) alarm on. During that time, the patient was documented as having been asleep or napping with the total hours of sleep being documented as 8 hours.


There was no documentation in the medical record of a reason for the patient to be in bed in the hallway.

A review of the medical record revealed no documentation the patient was on 1:1 observation.

The surveyor requested a copy of the policy related to levels of observations for the patients admitted to the SCU.

An interview was conducted on 5/17/18 at 10:15 AM with EI # 1, Director of Nursing, Senior Care Unit; who verified the above findings. During this interview, EI # 1 stated she was unable to locate a policy related to levels of care and had been working on getting one updated.

Based on review of medical records and interviews, it was determined the facility failed to ensure the medical record contained complete and accurate documentation of all events and observations, including patient behaviors and actions requiring the patient to be placed in the hallway during the evening shift.


This affected 2 of 6 medical records reviewed, including Patient Identifier (PI) # 1, PI # 2 and had the potential to negatively affect all patients admitted to the facility's Senior Care Unit (SCU).

Findings include:

1. PI # 1 was admitted to the facility on 11/7/17 with diagnoses including Alzheimer's dementia and Psychosis due to organic brain disease.

Review of the medical record revealed unnamed documents which were separated into 15 minute increments with the Patient's Location, Staff Action, Patient Action/Behavior and initials of the staff member who completed the documentation. These documents were completed and signed by a Mental Health Technician (MHT).

A review of the document dated 11/10/17 to 11/11/17, revealed the MHT documented the patient was in the hallway from 10:45 PM until 11/11/17 at 1:30 AM, then from 2:15 AM to 4:00 AM and 4:30 AM to 6:00 AM. The patient was documented as having been sleeping/napping or sitting quietly. The patient's total hours of sleep was 1 hour and 30 minutes. The surveyor was unable to determine through review of this document if the patient was in bed or sitting in a chair in the hallway.

A review of the document dated 11/12/17 to 11/13/17 revealed the MHT documented the patient was in bed in the hallway on 11/12/17 from 8:30 PM to 9:45 PM, then the patient was "sitting quietly" in the hallway from 10:00 PM until 11/13/17 at 1:00 AM. The MHT further documented the patient was either sitting quietly or sleeping/napping in the hallway from 1:15 AM until 6:00 AM. The patient's total hours of sleep was 3 hours.

A review of the document dated 11/13/17 to 11/14/17 revealed the MHT documented the patient was in the hallway on 11/13/17 from 8:00 PM until 11/14/17 at 3:30 AM. The MHT further documented the patient was either sitting quietly or sleeping/napping in the hallway during that time. The patient's total hours of sleep was 3 hours and 15 minutes. The surveyor was unable to determine through review of this document if the patient was in bed or sitting in a chair in the hallway.

A review of the document dated 11/15/17 to 11/16/17 revealed the MHT documented the patient was in the hallway on 11/15/17 from 8:15 PM until 11/16/17 at 1:30 AM, then from 2:30 AM until 6:00 AM. The MHT further documented the patient was either sitting quietly or sleeping or napping in the hallway during that time. The surveyor was unable to determine through review of this document if the patient was in bed or sitting in a chair in the hallway.

A review of the document dated 11/16/17 to 11/17/17 revealed the MHT documented the patient was in the hallway on 11/16/17 from 8:15 PM until 11/17/17 at 6:00 AM. The MHT further documented the patient was either sitting quietly or sleeping/napping in the hallway during that time.

A review of the document dated 11/25/17 to 11/26/17 revealed the MHT documented the patient was in the hallway on 11/25/17 from 9:00 PM until 11/26/17 at 2:15 AM, then from 4:45 AM until 6:00 AM. The MHT further documented the patient was either sitting quietly or sleeping/napping in the hallway during that time. The patient's total hours of sleep was 2 hours. The surveyor was unable to determine through review of this document if the patient was in bed or sitting in a chair in the hallway.

A review of the document dated 11/26/17 to 11/27/17 revealed the MHT documented the patient was in the hallway on 11/27/17 from 4:30 AM until 6:00 AM. The MHT further documented the patient was either sitting quietly or sleeping/napping in the hallway during that time.

There was no documentation of a reason for the patient to be sitting / in bed in the hallway or if the patient was encouraged to go to bed in the bed room. There was no documentation of special risk precautions that were implemented, or behaviors that put the patient at risk for injury or fall that would require the patient to be placed in the hallway for his/her safety. There was no documentation the patient required 1:1 observation by a staff member.

An interview was conducted on 5/17/18 at 10:15 AM with Employee Identifier (EI) # 1, Director of Nursing, Senior Care Unit who verified there was no documentation of a reason for the patient to be in the hallway at night.

2. PI # 2 was admitted to the facility on 11/10/17 with diagnoses including major depression, generalized anxiety disorder and severe psychosocial stressors.

Review of the Patient Progress Notes dated 11/12/17 revealed the nurse documented the following:

At 7:09 PM (amended on 11/13/17 at 12:39 AM), the RN documented, "... Patient (pt) cursing at staff... became hostile, argumentative and disruptive... Patient is verbally aggressive and difficult to redirect. Patient went to (his/her) room and slammed the door. Approached patient in a calm manner and allowed... verbalize... feeling. Patient advised that... can not have the door closed but... can pull curtain for privacy. Patient yelling and cursing at this nurse..."

At 7:10 PM (amended on 11/13/17 at 12:40 AM and at 3:46 AM), the RN documented, "... Patient noted trying to climb over the rail of the bed. Patient angry that this nurse let the rail down. Told patient it is for... safety so... doesn't fall... advised will let the rail up when... gets in the bed. Patient refused for this nurse to let the rail up after... (he/she) got in the bed. Patient threatening this nurse that no one better come in... (his/her) room tonight. Explained to patient that staff has to de safety rounds Q (every) 15 mins (minutes). Bed locked and in low position. Bed alarm on. Safety monitoring in progress. Patient refused shower and evening medication..."

At 8:00 PM (amended on 11/13/17 at 1:39 AM and 1:44 AM), the RN documented, "... 1930 (7:30 PM) Called to patients room per MHT. Was advised that she heard patient yell went in patients room and found (him/her) on the floor, Patient assessed... able to move bil (bilateral) lower extremities. Patient kicking... legs when this nurse assessed (him/her)... holding right arm straight. Will not let nurse move it... had a previous right shoulder injury and is scheduled for rotator cuff repair this Friday. No injury noted at this time. Patient refusing to get up off the floor. Staff assisted patient back in bed..."

At 10:10 PM (amended on 11/13/17 at 2:46 PM), the RN documented, "... Patient resting in bed with eyes closed... reassessed. Patient able to move bil arms and legs without difficulty or S/S (sign/symptoms) of discomfort. No redness, bruising, edema or displacement noted. Patient changed clothes and put on a gown... was able to use both hands and arms to unbutton and take of (off) shirt with minimal assistance. Patient lying in bed, used bil legs and lifted buttocks up and took off... pants. Bed locked and in low position. Bed and tabs alarm on. Staff implementing one on one observation and care..."

On 11/13/17 at 12:15 AM, the RN documented, "... Patient up to bathroom... with stand by assist... ambulating in dayroom... No complaints of pain or discomfort... Staff continues to implement one on one observation and care..."

A review of the document dated 11/12/17 to 11/13/17 revealed the MHT documented the patient was in the Dining/Group room at 7:15 PM and was disruptive, uncooperative, yelling and had cursing / verbal threats. At 7:30 PM and 7:45 PM, EI # 2 MHT documented the patient was in his/her room and continued to be uncooperative, disruptive, cursing /verbal threats and yelling.

On 11/12/17 to 11/13/17 from 8:00 PM until 5:30 AM, EI # 2 documented the patient was in the hallway, in bed with Tab (bed) alarm on. During that time, the patient was documented as having been asleep or napping with the total hours of sleep being documented as 8 hours.

There was no documentation in the medical record of a reason for the patient to be in bed in the hallway. There was no documentation the patient was moved back into his/her room once the patient calmed down, nor was there documentation the patient was on 1:1 observation.

An interview was conducted on 5/17/18 at 10:15 AM with EI # 1, Director of Nursing, Senior Care Unit; who verified the above findings.