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Based on record review, interviews and observations, the hospital failed to protect and promote the patient rights of Patient #1.

See tag 0144.

Based on record review and interviews, the hospital failed to appropriately document the invocation of Patient #7's health care proxy (HCP) in the medical record.

Findings include:

The surveyor interviewed Nurse #2 at 09/14/21 at 4:30 P.M. Nurse #2 was overseeing the care of Patient #7. It was Nurse #2's understanding that the HCP was conducting the medical decision making on behalf of Patient #7.

The Director of Quality spoke to the Nursing Director of the Intensive Care Unit (ICU) on 09/14/21 at approximately 6:00 P.M. The Nursing Director of the ICU spoke to the attending provider overseeing the care of Patient #7. The attending provider acknowledged that the HCP on file is making the medical decisions on behalf of Patient #7.

The policy titled Advance Directive Health Care Proxy, last effective date 05/21/2018, states under item #6: "If the attending invokes the proxy, it is his/her responsibility to notify the patient's health care proxy, and immediately document in the medical chart that proxy was invoked."

The surveyor conducted record review on Patient #7 and although a HCP was identified, documentation that the HCP was indeed invoked could not be found.

The surveyor interviewed the Director of Quality on 09/14/2021 @ 4:35 P.M. The Director of Quality confirmed that there was no invocation of health care proxy (HCP) order nor documentation in the medical record of Patient #7.

Based on record review, interviews and observations, the hospital failed to protect and promote the patient rights of Patient #1. The hospital's constant observation (CO) program (in which hospital staff, upon a medical order for CO, are responsible for maintaining CO on a given patient) failed to identify a sexual interaction (kissing incident) between two patients, Patient #1 and Patient #2, who both were under medical orders to be constantly observed by two separate constant observers.

Findings include:

The policy titled Constant Observer Assessment, Implementation, And Discontinuation states, under the definitions section that: One to One observation is "one competent constant observer to one patient within line of sight, in close proximity with no physical barriers in the same room/area. Close proximity is determined by the physician, mid-level provider, registered nurse or qualified mental health professional." Line of Sight observation is defined as: "one competent constant observer in direct line of sight with one or more patients."

Patient #1 and Patient #2 where both located in the Behavioral Health Unit (BHU) of the Emergency Department (ED). The BHU spans across one hallway.

Medical record review identified that Patient #1 had an order for a Line of Sight Constant Observer during the time of this event, 08/24/21 into 08/25/21. Patient #1's room was located at the end of the hallway from the perspective of the BHU main entry.

Medical record review identified that Patient #2 had an order for a 1:1 CO for the duration of Patient #2's stay in the BHU. Patient #2 was located at the beginning of the hallway of the BHU, 2nd room from the main entry. (2 rooms span between Patient #1 and Patient #2's rooms).

The Surveyor interviewed Public Safety Officer (PSO) #1 on 09/07/2021 at 09:45 A.M. The PSO #1 stated that PSO #1 was sitting at the dispatch room of the hospital, monitoring the hallway camera of the BHU as well as the unrecorded cameras that are located in each individual patient room of the BHU. PSO #1 stated that her shift in the dispatch room started on 08/25/2021 at 01:00 A.M. PSO#1 stated the responsibility of the dispatch officer is to monitor the cameras and await for any potential PSO calls for help.

During the overnight on 08/25/2021, PSO #1 stated that Patient #1 was talking to Patient #2 in the hallway of the BHU. PSO #1 stated that a little bit before either 2:00 A.M. or 3:00 A.M., PSO #1 observed Patient #2 starting to kiss Patient #1 on the neck. PSO#1 called down to the BHU public safety officer (PSO #2) and relayed to PSO #2 the situation. PSO#1 states that immediately, PSO #2 went to Patient #1's room and split the patients up, at which point Patient #2 went back to Patient #2's room and Patient #1 stayed in Patient #1's room and went to sleep.

PSO#1 stated that during the kissing incident between Patient #1 and Patient #2, Constant Observer (CO) #3's head was facing down and it appeared that CO#3 wasn't paying attention.

The Surveyor interviewed the Director of Public Safety (DPS) on 09/03/2021 at 2:15 P.M. The DPS interviewed PSO #1 and stated that PSO #1 told the DPS that PSO#1 saw Patient #2 standing over Patient #1 and kissing Patient #1.

The hospital report to the Department of Public Health (DPH), submitted on 08/27/2021, states that an officer (PSO #1) witnessed the kissing (between Patient #1 and Patient #2) on the in-room unrecorded video camera.

The surveyor interviewed PSO #2 on 09/07/2021 at 1:35 P.M. During the nightshift of 08/24/2021 into 08/25/2021 shift "around 2:00ish," PSO #2 stated that PSO #2 received a call from PSO #1 (dispatch) who said that PSO #1 thinks that "something could be going on" in Patient #1's room. PSO #2 stated that by the time PSO #2 arrived to Patient #1's room, PSO #2 did not encounter any sexual interaction. PSO #2 stated that Patient #1 and Patient #2 were talking. PSO #2 told Patient #2 that you've been here (Patient #1's room) long enough and that it was time for you to go back to your room, at which point Patient #2 goes back to Patient #2's room. PSO #2 also acknowledged that there was a blindspot in the doorjamb area as well as the left corner of Patient #1's room.

The surveyor interviewed CO #3 on 09/07/2021 at 11:20 A.M. The CO #3 stated that at no time during CO #3's shift, did CO #3 observe any sexual interaction between Patient #1 and Patient #2. CO #3 observed only talking between Patient #1 and Patient #2. CO #3 stated that at approximately 2:30 A.M. on 08/25/2021, based on where CO #3 was sitting and where Patient #1 and Patient #2 were located within Patient #1's room, CO #3 could not visualize Patient #1 nor knew what section of the room Patient #1 was in. CO#3 said that from the desk area where CO#3 sits, and having to watch two patient rooms, CO#3 acknowledged that there are blind spots in the rooms. CO #3 said that one cannot see the entire room, while sitting at their given desk area.

The Director of Public Safety (DPS) stated that based on the angle of where CO#3 was sitting, one could see roughly 90% of the room, and indicated that there is a blindspot from the CO location to Patient #1's room.

The surveyor toured the BHU on 09/03/2021 at approximately 2:00 P.M. The surveyor sat and stood at the location of CO#3 desk area in front of Patient #1's room and the surveyor identified that from that spot, one could not observe the entire room. The left side of the room was not visible from the desk positioning of CO#3 location.

Medical record review identified that Patient #2 had an order for a 1:1 CO for the duration of Patient #2 stay in the BHU.

The surveyor reviewed video observation of the hallway camera of the BHU, made available from the Manager of Public Safety (MPS) on 09/14/2021 at 2:10 P.M. The video observation was a recording between 2:00 A.M. and 3:00 A.M. on 08/25/2021, during the time period of the kissing event between Patient #1 and Patient #2. The video identified that the CO #4 failed to follow the Constant Observer Policy for 1:1 constant observation of Patient #2. Video observation identified that on 08/25/2021 at 2:03 A.M., the CO #4 leaves CO #4's post without finding coverage and leaves the BHU entirely. CO #4 returns to the BHU at 2:08 A.M. The surveyor further identified that around 2:10 A.M. CO #4 is continuously looking down at CO #4's mobile device. At 2:36 A.M., it is observed that moving images appear on the mobile device. CO#4 puts the device away at 2:50 A.M.

Video observation identifies that on 08/25/2021, between the time period of 2:29 A.M. and 2:50 A.M., Patient #2 (who is supposed to be under 1:1 constant observation by CO #4) is either mostly in the room or completely in the room of Patient #1. Patient #1's room is located at the end of the hallway of BHU, and CO #4 remains stationed at the entry of the BHU, located on the other end of the BHU.

Constant Observer Flowsheets for Patient #2 and Patient #11 (eleven) indicate that both of these patients (Patient#2 and Patient#11 had adjacent rooms) were being observed by the same constant observer #4, (also known as a 1:2 constant observation), despite medical record review indicating that Patient #2 had an order for a 1:1 constant observation during the event time period of 08/25/21.

Based on interviews and observations, the hospital failed to identify that the existing constant observer (CO) practice failed to identify a sexual interaction (kissing incident) between two patients, Patient #1 and Patient #2, both of who were under a constant observation order in the BHU. As a result of the hospital not identifying the failure in CO practice during the hospital's internal investigation, the hospital subsequently failed to implement any system-wide corrective actions to address extremely poor CO practice.

See tag 0286.

Based on interviews and observations, the hospital failed to identify that the existing constant observer practice did not identify a sexual interaction (kissing incident) between two patients, Patient #1 and Patient #2, both of who were under a constant observation order in the BHU. As a result of the hospital not identifying the failure in CO practice during the hospital's internal investigation, the hospital subsequently failed to implement any system-wide corrective actions to address poor CO practice.

Findings include:

Record review of the Constant Observer flow sheet for Patient #1 identified that CO #3 was responsible for observing Patient #1 during the sexual interaction (kissing incident) that occurred between Patient #1 and Patient #2.

The surveyor interviewed Constant Observer #3 on 09/07/2021 at 11:20 A.M. The CO #3 stated that at no time during CO #3 shift, did CO #3 observe any sexual interaction between Patient #1 and Patient #2. CO #3 observed only talking between Patient #1 and Patient #2. CO #3 stated that at approximately 2:30 A.M. on 08/25/2021, based on where CO #3 was sitting and where Patient #1 and Patient #2 were located within Patient #1's room, CO #3 could not visualize Patient #1 nor knew what section of the room Patient #1 was in. CO #3 said that based on the desk location of CO #3 and the additional requirement of watching a 2nd patient room simultaneously with Patient #1's room, CO #3 acknowledged that there are blind spots in the rooms. CO #3 said that one cannot see the entire room while sitting at their given desk area.

Record review of the Constant Observer flow sheet for Patient #2 and Patient #11 (eleven), dated 08/24 into 08/25, identified that CO#4 was responsible for observing Patient #2 and Patient #11.

Video observation conducted on 09/14/2021 at 2:10 P.M. identified that CO #4 failed to adhere to the hospital policy, "Constant Observer Assessment, Implementation, and Discontinuation," as indicated during the video in which CO #4 left the BHU entirely for five minutes, between 2:03 A.M. and 2:08 A.M. Subsequently upon return to the BHU, CO #4 utilized CO #4's mobile device for an additional 40 minutes from 2:10 A.M. until 2:50 A.M. During this entire time period, CO #4 was responsible for constant monitoring between Patient #2 and Patient #11.

The surveyor interviewed the Director of Quality on 09/14/2021 at 4:00 P.M. The Director of Quality confirmed that no one from administration interviewed CO #4 after the sexual interaction (kissing incident) between Patient #1 and Patient #2.

The surveyor interviewed the Director of Risk on 09/03/2021 at 9:10 A.M. The Director of Risk confirmed that corrective measures implemented were concentrated towards Patient #1's safety and removal from the BHU.

The surveyor identified that no corrective actions were implemented in regards to the deficient practice of the constant observers in the BHU at the time survey commenced.