HospitalInspections.org

Based on observation, record review, and interview, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient's rights as evidenced by:
Failure of the hospital to provide supervision as ordered by the physician for 2 patients on LOS observation levels (Patient #3 and #4) and 16 of 30 total patients on every 15 minute routine observation levels (Patients #R1-R16).

This resulted in an Immediate Jeopardy Situation. S1Administrator was notified on 9/25/2024 at 2:30 p.m.
The hospital provided the following plan of removal for the Immediate Jeopardy situation:
1. The MHT that clearly displayed incompetence of patient observations will be immediately removed from providing care with disciplinary actions per Human Resource and Code of Conduct Guidelines.
2. Each RN and MHT that did not complete duties previously trained on as required while being observed today by State Surveyor will have a written disciplinary action completed and put in their HR record within the next 2 hours.
3. Hospital Leadership team members will meet with each individual staff member presently on duty, and on the next scheduled shifts for the next 48 hours, to review/educate on the requirements and importance of patient observations.
4. A Training & Acknowledgement form will be signed by all staff members and placed in their HR record stating that they understood the requirement/importance of patient observations being performed accurately and appropriately. Each staff member will also be provided with corresponding policies for review.
5. All full time and prn nursing department staff will complete this training EOD Friday, September 27, 2024 or they will not be scheduled to work.
6. A separate Training & Acknowledgement form will be completed with all RNs on staff today and the rest by EOD, September 27, 2024, indicating their understanding of RN duties related to safety rounds and signing off on observation sheets completed by the MHTs.
7. Ongoing, monitoring will be established and completed on each shift effective 09/25/2024.


On 09/25/2024 at 14:20 p.m., the Immediate Jeopardy Situation was lifted but there was not enough evidence to determine sustainability of compliance for the Condition of Patient Rights to be cleared therefore the deficiency remains at a Condition level (See findings in A0144).

Based on observation, record review, and interview, the hospital failed to ensure patients receive care in a safe setting as evidenced by failure of the hospital to provide supervision as ordered by the physician for 2 patients on LOS observation levels (Patient #3 and #4) and 16 of 30 total patients on every 15 minute routine observation levels (Patients #R1-R16).
Findings:

Review of the hospital policy titled, Suicide Precautions (dated 10/24/2019) revealed in part that Line of Sight observation is very restrictive towards the patient and involves continuous visual monitoring at all times. Staff must be within visual contact at all times with the exception of toileting and showering. A staff member may observe more than one patient on LOS observations only while those patients remain in an area for a scheduled activity. If a staff member is observing more than one patient and one or more of the patients go to separate areas, the staff must transfer responsibility for LOS to other staff members so that there is continuous observation of all patients on line of sight. Nursing staff must maintain a continuous log which indicates the patient's location every 15 minutes and documents the patient's behaviors throughout each shift.

Review of the hospital policy titled, Admission/Assessment - Close Observation (dated 10/24/2019) revealed in part that patients on regular precautions or close observations must be seen by a staff member every 15 minutes, or more frequently as needed, and checked off on the Close Observation Sheet as present. A staff member will be assigned by the Charge Nurse each shift to be responsible for monitoring the Close Observation Sheet.

On 09/25/2024 at 9:35 a.m., observation revealed S2MHT sitting in a chair in the hallway. The surveyor requested to review the tech's Close Observation sheets but he stated they were in the nurses station. S2MHT obtained the sheets and review revealed the last documented evidence of an observation of the 4 geri-psych patients (Patients #R1-R4) assigned to the MHT were at 9:00 a.m. The patients were on routine every 15 minute observations. S2MHT was asked why the Close Observation sheets were not current and S2MHT stated there was an incident earlier that he was dealing with. S2MHT confirmed he was behind on his observations.

On 09/25/2024 at 9:45 a.m., observation revealed S5MHT was in the nurses station talking to S4MHT. At that time, the surveyor asked the techs for their Close Observation sheets. They both stated that their sheets were on a clipboard on the top of the refrigerator in the day room. The surveyor obtained the sheets from the top of the refrigerator and review of S5MHTs Close Observation sheets, for geri-psych patients #R5-R8, revealed the last documented observation was at 8:15 a.m. (1 ½ hours earlier). Review of S4MHT's (orientee) Close Observation sheet for Patient #R9 revealed the last observation was at 8:30 a.m. (1 hour, 15 minutes earlier).

On 09/25/2024 at 9:50 a.m., interview with S5MHT revealed that she was training S4MHT and that she had not had time to observe her assigned patients. S5MHT stated that all of her assigned patients were on routine, every 15 minute observations, and confirmed she was late performing the observations. At that time, interview with S5MHT confirmed that she was in orientation and that she was late performing observations for her only assigned patient, Patient #R9, who was also on a routine observation level.

On 09/25/2024 at 9:52 a.m., upon entering the adult psychiatric unit, observation revealed S6MHT sitting in a chair near the door. Interview with S6MHT revealed that there was an issue with the door lock, so she was having to sit near the door to make sure patients did not attempt to exit. Further interview with S6MHT revealed that she was currently assigned seven patients and two were on LOS observation level, with the other patients being routine, every 15 minute observation levels. The surveyor asked where the LOS patients were currently and S6MHT pointed out one patient that was walking down the hall (Patient #4) and stated the other patient was in her room (Patient #3). Observation revealed Patient #3's room door was closed. When the surveyor asked S6MHT what LOS observation level meant, she stated that they must be checked on every 10-15 minutes and you must "keep your eye on them a little more". S6MHT then stated that she actually checks on Patient #3 about every 10 minutes because she was suicidal and may wrap a blanket around her neck. When asked if Patient #3 was allowed to keep her door shut, S6MHT stated yes, but it must be cracked. When asked if Patient #3 was in constant visual sight, S6MHT stated no. During this interview, Patient #4 was observed to walk on the other side of the unit, out of sight from S6MHT. S6MHT stated that the staff on the other side watch the patient when she is over there.

On 09/25/2024 at 9:56 a.m., observation revealed S7MHT was sitting in the hallway on the adult unit with two stacks of Close Observation sheets in front of her. Review of the sheets revealed one stack was S7MHT's assigned patients and the other stack was S8MHT's assigned patient sheets. Review of S8MHT's Close Observation sheets revealed the last documented observation of Patients #R10-R16 were at 9:15 a.m. (45 minutes earlier). S7MHT stated that S8MHT was making coffee in the nurses station. When S7MHT was asked if she was responsible for observing S8MHT's assigned patients, she stated no.

On 09/25/2024 at 10:10 a.m., S8MHT was observed in the nurses station handing out snacks to patients.

On 09/25/2024 at 10:25 a.m., interview with S8MHT confirmed that she had not observed her assigned patients since 9:15 a.m. (almost one hour earlier). S8MHT stated she was busy making coffee, handing out snacks and getting the discharges ready to go home. When asked who was observing her assigned patients as she was doing these tasks, she shrugged her shoulders.

On 09/25/2024 at 12:15 p.m., interview with S1ADM revealed that all patient Close Observation sheets should be current and the nurses should be ensuring that the patient observations are performed as ordered. S1ADM further stated that S6MHT should not have been assigned to watch two LOS patients as well as five other routine observation patients. S1ADM confirmed the lack of patient observations put the patients at risk for serious injury, serious harm, serious impairment or even death.