HospitalInspections.org

Based on document review and interview, the hospital failed to ensure staff ability to demonstrate competency in the levels of observations for 3 of 3 staff members (N1, N2, and N3).

Findings include:

1. Review of policy/procedure titled, "Orientation and Continuing Education" Policy No: EC 14, Issued: 09/2014 indicated all new employees will receive general hospital safety training within 30-60 days of employment.

2. Review of N1-MHT (Mental Health Technician), N2-CNA (Certified Nursing Assistant) and N3 (Registered Nurse) personnel file lacked training on the level of observations including line of sight and one on one completed.

3. In interview on 10/11/2023 at 1647 hours A2 (Assistant Director of Nurses) acknowledged that he/she was unable to provide this surveyor with the training on the level of observations for N1, N2, and N3.

Based on document review and interview, the registered nurse failed to ensure staff followed physician orders for level of observation (1:1) in one (1) instance. (P8)

Findings include:

1. The hospital policy titled, "PATIENT ROUNDS", Policy No: NU 60, indicated to provide guidelines for insuring a safe and therapeutic environment by accounting for all patients. Rounds are to be made on the unit on all patients by the assigned nursing staff at a minimum of every 15 minutes or more frequently as ordered for each 24-hour period.. The purpose of rounds is to check all aspects of security and safety while monitoring patient behavior and location. H. All rounds must be maintained as part the medical record. This policy was last reviewed on 09/2020.

2. Review of the policy titled, "Aggressive Behaviors", Policy No: CC80 , last reviewed 06/2022, indicates the purpose to ensure a safe environment from patients that may exhibit aggressive behaviors. Page 2: One on one (1:1) order the patient receives continuous monitoring and physical proximity to the patient by a staff member. Staff must always be within arm's reach, including toileting and showering.

3. Review of P8 MR indicated an order for level of observation as a 1:1 with Staff dated 09/12/2023 at 1500 hours for P8.

4. Reviewed the "AM and PM Patient Monitoring Round" every 15 (fifteen) minutes observation for 09/15/2023 through 10/10/2023. The MR of P8 lacked documentation the patient was on the 1:1 and checked every 15 minutes on 09/15/2023, 09/27/2023, 09/30/2023, 10/04/2023, and 10/09/2023.

5. On tour on 10/11/2023 at approximately 1515 hours with A2 (Assistant Director of Nurses) observed P8 alone in his/her bedroom with the door closed. N1 (Mental Health Technician) was assigned to P8 as a 1:1 level of observation. N1 was sitting outside of the room facing out towards the milieu reviewing a computer.

6. In interview on 10/11/2023 at approximately 1600 hours with staff member A2 (Assistant Director of Nurses), confirmed that when a patient has a 1:1 level of observation. The AM and PM Patient Monitoring Round form is documented on every 15 minutes. Also confirmed there should be documentation on the AM and PM Patient Monitoring Round indicating the patient should be was observed every 15 minutes without any missing documentation.