HospitalInspections.org

Based on review of medical records and staff interview, the facility failed to ensure patients received care in a safe setting for 1 out of 4 patients reviewed, when Patient #1's "Patient Observation Record (Q5 and Q15)" sheets did not accurately reflect the physician's current observation order.

Findings were:

Review of the medical record for Patient #1 was transferred on 12/14/24 to the facility Residential Treatment Center for an attempted suicide. On 12/17/24 the patient was moved to the acute unit due to suicidal gestures. She was initially placed on 1;1 monitoring for Suicidal Ideations. Further review revealed she was placed on Q5minute checks on 12/18/24 at 15:20 pm. Patient #1's Patient Observation Record sheets for 12/18/24 from 19:15-2015 revealed 5-minute checks reporting the patient was "(A) in the activity room, (5) calm, and (h) sitting/lying" at each check documented by Staff #3. Further review of Patient #1's nursing notes reflected:
"1940 BHA found the patient on the floor of her room with a pair of jeans around her neck. Patient was breathing but unresponsive after sternal rubs ... 2004 EMS arrives on scene and assumes care of patient ... 2008 EMS out of building with staff {sic patient}to McClain's Hospital ..."
During a telephone interview, on 12/23/24 at 1:40 pm, Staff # 2 reported that she was not assigned the patient. She continued that she was with the patients on the hall for showers at the time of the incident. She stated "I talked to the patient after her shower. She was sitting on her bed. I asked her if she needed anything, and she said she was feeling anxious. I asked if she wanted to talk to the nurse and she refused. I went to check on another patient. When I was walking down the hall, I saw the blue jeans hanging on the door. I ran in and found her with the jeans around her neck." When asked how long she was away from the patient she replied, "about 10 or 15 minutes."
During a telephone interview, on 12/23/24 at 3:15 pm, Staff # 3 reported that she "had been documenting her 5-minute checks on the patient she thought was Patient #1." She continued that "when I called out Patient #1's name another patient answered. I documented on her." When asked the process she reported that the tablets were down, so we were documenting on paper. When we use the tablets there is a picture of the patients for us to look at.
Review of the facility policy titled "Observations, Patient, Last revised 7/2021, reflected " ...
8. Q 5 Minute Rounds ...
b. Patient is monitored at minimum once in every 5-minute block of time.
c. During times of personal hygiene, toileting and other self-care needs, the staff should be in visual and hearing range of the bathroom door ..."
During an interview, on the afternoon of 12/20/24, Staff #6 reported that on the day of the incident the tablets used for patient monitoring were out for an update. Typically, the tablets are linked to the patient wrist monitor. The staff must be in a proximity for the tablet to allow them to document. A picture of each patient is on the screen for patient identification. If the staff miss a scheduled check the tablet alerts the assigned staff as well as the administrative staff of the late or missed check.
The above information was verified by Staff #6.