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Based on observation, interview, record and document review, the facility failed to ensure accurate and consistent documentation in accordance with physician's orders and hospital policy, for one patient (Patient 1) who required routine observation and monitoring.

The medical record was reviewed with the DRA (Director of Regulatory Affairs) on 9/12/17. Patient 1 was brought in by medics to the ED (Emergency Department) on 8/2/17 after becoming combative at a construction site, per the admission History and Physical, dated 8/2/17. The patient had become more confused and paranoid over the previous week, and was psychotic in the ED. Patient 1 was admitted to the ICU (Intensive Care Unit) with diagnoses that included schizophrenia, and was placed on a 14 day hold for being gravely disabled.

Per physician order, dated 8/2/17 at 5:45 P.M., Patient 1 was placed on IMO (Increased Medical Observation) level of observation. According to the Patient Rounding Record, Patient 1 was to be routinely observed every 15 minutes for AR (Assault Risk) and IMO. The rounding record indicated, "Routine observation includes direct visualization of patient and verification of respirations whenever patient appears asleep regardless of location." The rounding record further indicated, "For patients on Detox and IMO status, assess respiratory rate every hour and document in patient's interactive view." The vital signs flowsheet indicated Patient 1's last documented respiration rate was 16 on 8/4/17 at 5 A.M. Furthermore, staff documented on the flowsheet on 8/4/17 at 6 A.M. that, "Pt. refused am vitals. Nurse notified." There was no documentation of Patient 1's respiration rate at 7 A.M.

According to the facility's policy & procedure, Levels of Patient Observation (in Behavioral Health Units), revised 11/2015, "Routine observation includes visualization of the patient by the responsible staff member validating the patient's immediate safety ...Routine levels of observation by unit include: Q [every] 15 minutes at ...Intensive Care Unit (ICU)." In addition, "Patients on routine levels of observation are documented on unit rounds sheets that are not part of the medical record."

The policy further indicates that patients on Assault Risk level of observation are " ...observed and documented at 15 minute intervals." In addition, "All patients on IMO status ...Respiration rate will be assessed and documented hourly while asleep."

On 11/9/17, security camera footage from 5:45 A.M. to 7:45 A.M. on 8/4/17 was jointly viewed with the DRA. While scanning the footage, there was no staff observed entering the patient's room during the two hour timeframe. The DRA stated she had also viewed footage from the same timeframe and did not see any staff go into the patient's room during that time.

During an interview on 11/17/17 at 2:35 P.M., the CNO (Chief Nursing Officer) stated she viewed the security camera footage from 8/4/17 night shift in its entirety. According to the CNO, the MHAs were not observed doing patient rounds. The CNO acknowledged the last time staff was seen checking on Patient 1 was around 1:30 A.M. The CNO further acknowledged there were no visual checks done by staff between 1:30 A.M. and 7:45 A.M. on 8/4/17, a period of six hours.

An interview and joint record review was conducted with Mental Health Assistant (MHA) 1 on 11/30/17 at 7:35 A.M. According to the Patient Rounding Record for night shift, dated 8/3/17 to 8/4/17, MHA 1 documented he performed 15 minute checks on Patient 1 from 1:30 A.M. to 3 A.M.; and at 5:30 A.M., 5:45 A.M., 6:30 A.M. and 6:45 A.M., however, he stated he does not always take the clipboard with the rounding sheet with him on rounds. MHA 1 was unable to provide a clear answer whether he actually performed the 15 minute checks on Patient 1 that he had documented. MHA 1 stated, "I think I rounded every 15 minutes, but sometimes distractions take from duties of rounding."

According to the vital signs record, which included documentation of respiratory rate, dated 8/4/17, MHA 1 documented at 6 A.M., "Patient refused am vitals. Nurse notified." MHA 1 stated he did not take Patient 1's vital signs at that time because the patient was asleep; however, MHA 1 could not verify if he actually observed Patient 1 sleeping at that time. MHA 1 further stated, "That's what I was taught, to document 'patient refused' if patient was asleep."

An interview and joint record review was conducted on 12/8/17 at 7:30 A.M. with MHA 2. According to the Patient Rounding Record for night shift, dated 8/3/17 to 8/4/17, MHA 2 documented he performed 15 minute checks on Patient 1 from 11:30 P.M. to 1:15 A.M., 3:15 A.M. to 5:15 A.M., and at 6 A.M., 6:15 A.M., 7 A.M. and 7:15 A.M. MHA 2 was unable to provide a clear answer whether he actually performed the 15 minute checks on Patient 1 that he had documented. MHA 2 further stated, "Maybe a couple of times I didn't round. Maybe I caught up later."

As a result, there was a disparity with MHA interviews, documentation, and observed video surveillance, which did not ensure quality patient care in a safe environment, in accordance with physician's orders and hospital policy.

Based on observation, interview, document and record reviews, the facility failed to ensure nursing staff provided complete oversight of patient rounds performed by the MHAs, for one patient (Patient 1).

A joint interview and record review was conducted with the DRA (Director of Regulatory Affairs) on 11/9/17 at 2:30 P.M. Patient 1 was brought in by medics to the ED (Emergency Department) on 8/2/17 after becoming combative at a construction site, per the admission History and Physical, dated 8/2/17. The patient had become more confused and paranoid over the previous week, and was psychotic in the ED. Patient 1 was admitted to the ICU (Intensive Care Unit) with diagnoses that included schizophrenia, and was placed on a 14 day hold for being gravely disabled.

Per physician order, dated 8/2/17 at 5:45 P.M., Patient 1 was placed on IMO (Increased Medical Observation) level of observation. According to the Patient Rounding Record, Patient 1 was to be routinely observed every 15 minutes for AR (Assault Risk) and IMO. The rounding record indicated, "Routine observation includes direct visualization of patient ..."

According to the Patient Rounding Record, dated 8/3/17 at 11:30 P.M. through 8/4/17 at 7:45 A.M., MHA staff documented Patient 1's whereabouts every 15 minutes. In addition, the night shift Patient Rounding Record was validated for completion by RN 1.

The DRA stated that the Charge Nurse rounds with the MHA at least once per eight hour shift to ensure rounds were conducted.

A Nursing Interdisciplinary Note dated 8/4/17 was reviewed. In the note, nursing staff documented, "Approximately 7:44 A.M., MHA doing rounds and calls for help. RNs respond and arrive in room to find patient face down on the floor next to his bed. Not breathing. No pulse. Compressions initiated. Code Blue called."

MD 1 documented on 8/4/17 that he responded to Code Blue at 7:46 A.M. According to MD 1's progress note, "Patient found in supine position. CPR already underway by staff. Pt [patient] demonstrated lividity [areas of discoloration of skin and organs after death] and rigidity [rigor mortis; the stiffening of the body after death] of legs. Jaw could not be opened for airway...Death pronounced at 0757."

On 11/9/17, security camera footage from 5:45 A.M. to 7:45 A.M. on 8/4/17 was jointly viewed with the DRA. While scanning the footage, there was no staff observed entering the patient's room during the two hour timeframe that was viewed. The DRA stated she had also viewed footage from the same timeframe and did not see any staff go into the patient's room during that time.

During an interview on 11/17/17 at 2:35 P.M., the CNO (Chief Nursing Officer) stated she viewed the security camera footage from 8/4/17 night shift in its entirety. According to the CNO, the MHAs were not observed doing patient rounds. The CNO acknowledged the last time staff was seen checking on Patient 1 was around 1:30 A.M. The CNO further acknowledged there were no visual checks done by staff between 1:30 A.M. and 7:45 A.M. on 8/4/17, a period of six hours.

When interviewed on 11/30/17 at 7:20 A.M., MHA 3 stated she was doing a 15 minute check on Patient 1 around 7:44 A.M. on 8/4/17. According to MHA 3, she saw Patient 1 on the floor next to his bed, by the window and, "Found him cold, hard, with no pulse." MHA 3 stated she then immediately called for help.

An interview and joint record review was conducted with MHA 1 on 11/30/17 at 7:35 A.M. According to the Patient Rounding Record for night shift, dated 8/3/17 to 8/4/17, MHA 1 documented he performed 15 minute checks on Patient 1 from 1:30 A.M. to 3 A.M.; and at 5:30 A.M., 5:45 A.M., 6:30 A.M. and 6:45 A.M. MHA 1 was unable to provide a clear answer whether he actually performed the 15 minute checks on Patient 1 that he had documented. MHA 1 stated, "I think I rounded every 15 minutes, but sometimes distractions take from duties of rounding."

An interview and joint record review was conducted on 12/8/17 at 7:30 A.M. with MHA 2. According to the Patient Rounding Record for night shift, dated 8/3/17 to 8/4/17, MHA 2 documented he performed 15 minute checks on Patient 1 from 11:30 P.M. to 1:15 A.M., 3:15 A.M. to 5:15 A.M., and at 6 A.M., 6:15 A.M., 7 A.M. and 7:15 A.M. MHA 2 was unable to provide a clear answer whether he actually performed the 15 minute checks on Patient 1 that he had documented. MHA 2 further stated, "Maybe a couple of times I didn't round. Maybe I caught up later." According to MHA 2, he also did not round with the Charge Nurse during his shift on 8/4/17.

During an interview on 6/20/18 at 7:30 A.M. RN 1 stated she was Charge Nurse on night shift 8/3/17. According to RN 1, she did not do patient rounds as Charge Nurse that shift. RN 1 stated she signed the Charge Nurse Shift Verification section on the Patient Rounding Record at the end of her shift to confirm the form was filled out, but not that the rounding had been done. RN 1 acknowledged she did not verify whether the MHAs actually performed the rounding every 15 minutes during the shift. RN 1 stated, "I trust them that they're doing their work."

The cumulative effects of these deficient practices did not ensure nursing staff provided complete oversight of patient rounds performed by the MHAs.