HospitalInspections.org

Based on review of documentation and interview, it was determined that the facility failed to always provide a safe environment for its patients.

Findings were:

Facility policy entitled "Patient Rights and Responsibilities" stated in part "Each Seton patient receives a copy of the Seton Patient Rights and Responsibilities and Healthcare Choices sheet which defines their rights as defined below:

" Participate in the development and implementation of your plan of care and make decisions regarding your care including pain management.
" Make informed decisions regarding your care, including being informed of your health status, being involved in your care planning and treatment, and being able to request or refuse treatment ...
" Personal privacy.
" Receive care in a safe setting.
" Be free from all forms of abuse or harassment ...
" Care that is considerate and respectful of personal values and beliefs ...
" Have Seton use its best efforts to meet your special communications needs."

Facility Policy entitled "Precaution Levels-Assessment" stated under "Levels of Observation:
1. Routine Observation-this is the routine minimum patient observation of at least every 15 minutes.
2. Fifteen minute checks-for suicide/self-injurious behavior, assaultive/aggressive behavior, elopement risk, and/or sexual acting out.
3. Other precautions may include falls and seizure.
4. 1:1 Line of Sight-this is where the patient is visible to a staff person at all times. This may be done from a distance but the line of vision between the patient and staff person is kept clear. This level of observation can be ordered for a specific precaution.
5. 1:1 Observation-is where staff are to remain within arm's length except at night when patient is sleeping, staff may move to doorway in exceptional instances, as with a paranoid patient, the physician may expand the boundary to a specified number of feet ....

One-to-One (1:1) Arm's Length Observation
1. One-to-One (1:1) Arm's Length Observation is defined as staff remaining within arm's length of patient at all times including toileting and personal hygiene times.
2. The patient is restricted to the unit except to leave accompanied by staff for diagnostic tests. A specific physician order is necessary to leave the unit.
3. Check patient and patient's room for harmful objects at the time of initiating 1:1 arm's length observation.
4. Explain reason for monitoring to patient.
5. Observations regarding suicidal ideation or self-harm behaviors, aggressive or assaultive ideation/behaviors, arson or fire-related ideation/behaviors, sexual acting out ideation/behaviors, as applicable (and as related to the precautions established), shall be documented in the progress notes every shift.
6. Disposable razors and other sharp/flammable/potentially dangerous supplies may NOT be used by the patient.
7. A precautions checklist is maintained for the duration of 1:1 arm's length observation and becomes a permanent part of the patient's medical record."

Precaution Check Sheet dated 1/25/18 revealed that Patient # 1 was on 1:1 Arm's Length precautions for suicide and elopement. She was documented on every 15 minutes except for 1230 and 1300.

On 1/25/18, Patient # 1 was allowed to go into her room to nap. She was not observed per policy and attempted suicide by hanging. She was found unconscious by staff after ½ an hour of being alone in her room.

The above policies and scenario was confirmed in interviews with the Clinical Manager, the Social Worker and the Director of Nursing on 1/30/18.

Based on review of documentation and interview, it was determined that the facility did not follow its own policies which resulted in the neglect of a patient.

Findings were:

Facility policy entitled "Patient Rights and Responsibilities" stated in part "Each Seton patient receives a copy of the Seton Patient Rights and Responsibilities and Healthcare Choices sheet which defines their rights as defined below:

" Participate in the development and implementation of your plan of care and make decisions regarding your care including pain management.
" Make informed decisions regarding your care, including being informed of your health status, being involved in your care planning and treatment, and being able to request or refuse treatment ...
" Personal privacy.
" Receive care in a safe setting.
" Be free from all forms of abuse or harassment ...
" Care that is considerate and respectful of personal values and beliefs ...
" Have Seton use its best efforts to meet your special communications needs."

Facility Policy entitled "Precaution Levels-Assessment" stated under "Levels of Observation:
6. Routine Observation-this is the routine minimum patient observation of at least every 15 minutes.
7. Fifteen minute checks-for suicide/self-injurious behavior, assaultive/aggressive behavior, elopement risk, and/or sexual acting out.
8. Other precautions may include falls and seizure.
9. 1:1 Line of Sight-this is where the patient is visible to a staff person at all times. This may be done from a distance but the line of vision between the patient and staff person is kept clear. This level of observation can be ordered for a specific precaution.
10. 1:1 Observation-is where staff are to remain within arm's length except at night when patient is sleeping, staff may move to doorway in exceptional instances, as with a paranoid patient, the physician may expand the boundary to a specified number of feet ....

One-to-One (1:1) Arm's Length Observation
8. One-to-One (1:1) Arm's Length Observation is defined as staff remaining within arm's length of patient at all times including toileting and personal hygiene times.
9. The patient is restricted to the unit except to leave accompanied by staff for diagnostic tests. A specific physician order is necessary to leave the unit.
10. Check patient and patient's room for harmful objects at the time of initiating 1:1 arm's length observation.
11. Explain reason for monitoring to patient.
12. Observations regarding suicidal ideation or self-harm behaviors, aggressive or assaultive ideation/behaviors, arson or fire-related ideation/behaviors, sexual acting out ideation/behaviors, as applicable (and as related to the precautions established), shall be documented in the progress notes every shift.
13. Disposable razors and other sharp/flammable/potentially dangerous supplies may NOT be used by the patient.
14. A precautions checklist is maintained for the duration of 1:1 arm's length observation and becomes a permanent part of the patient's medical record."

Precaution Check Sheet dated 1/25/18 revealed that Patient # 1 was on 1:1 Arm's Length precautions for suicide and elopement. She was documented on every 15 minutes except for 1230 and 1300.

On 1/25/18, Patient # 1 was allowed to go into her room to nap. She was not observed per policy and attempted suicide by hanging. She was found unconscious by staff after ½ an hour of being alone in her room.

The above policies and scenario was confirmed in interviews with the Clinical Manager, the Social Worker and the Director of Nursing on 1/30/18.