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Based on record reviews and interviews, the hospital failed to ensure patients received care in a safe setting free from neglect when the hospital staff failed to accurately complete and monitor the observation rounds on 5 (Patient #1-#5) of the 5 (Patient #1 - #5) records reviewed.
Findings:

Review of the policy and procedure titled, "Patient Rights" effective 1/11/2016 revealed, in part, the facility supports the patient's right to care, treatment and services within its mission and applicability to law and regulation, and to support and protect the fundamental human, civil, constitutional and statutory rights of each patient. You have the right to medically appropriate treatment. Individual Client Rights read, in part, 8. Patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect and/or exploitation.

Review of the policy and procedure titled, "Level of Observations" effective date 01/11/2016 and last revised on 11/16/2022 revealed, in part, the purpose is to provide staff with a framework for monitoring patients to ensure safety. There are three levels of observation including every 15 minutes where the staff member will visually observe the patient every 15 minutes to monitor the location and activity, with an emphasis on any noticeable behaviors of escalation, and unsafe activities. The procedures includes, in part, staff members utilize the close observation checklist form to document the ongoing observation and location of the patient. The observing staff initials the 15-minute increments on the form to indicate the patient was observes. The Registered Nurse will conduct routine rounds to visually observe each patient for safety at least once every 2 hours and will validate rounds by initialing in the appropriate section of the form. The staff physically walks to find each patient on every 15 minute observation, documents patient's location and reports identified risk to RN when indicated.

Review of the job description/performance review for a Mental Health Technician revealed, in part, implements patient care activities under the direction and supervision of licensed nursing personnel; documents significant occurrences, observed behavior, vital signs, nutrition intake and patient observation findings on assigned patients and as requested by the registered nurse, with 100% accuracy and within defined time frames; assumes the responsibility for the safety of patients; completes duties during the shift with few exceptions and coordinates work to achieve maximum productivity; complies with safety policies and procedures and reports safety hazards and initiates appropriate action.

Patient #1
Review of Patient #1's medical record revealed, in part, on 11/12/2022 at 4:32 p.m. he was placed on a Physician's Emergency Certificate (PEC) after he threatened to shoot and stab family members. Patient #1 was admitted to the facility on 11/13/2022 at 12:45 a.m. On 11/14/2022 at 4:43 p.m. the Coroner's Emergency Certificate (CEC) indicated Patient #1 was homicidal, a danger to others and unable to seek voluntary admission. Patient #1 was diagnosed with Bipolar disorder single episode, Oppositional defiant disorder and placed on every 15 minute observation rounds.

Review of the Observation Check Sheet/Graphic Flowsheet dated 11/13/2022 revealed S6RN initialed blank 15 minute observation rounds on the third row of an incorrect checklist where the times were not legible. Further review revealed, on 11/13/2022, S6RN initialed another incorrect form with inaccurate observation rounds beginning at 1:00 a.m. through 5:00 a.m.

In interview on 12/28/22 at 3:25 p.m., S2ADON indicated S6RN should not have initialed a blank 15 minute observation rounds sheet. S2DON further indicated an incorrect form was used and could not determine why two observation sheets were completed for 11/13/2022.

Patient #2
Review of Patient #2's medical record revealed, in part, on 11/29/2022 at 1:47 a.m. he was placed on a PEC for danger to self and unwilling to sign himself into a facility. Patient #2 was admitted to the facility on 11/30/2022 at 4:15 p.m. Patient #2 was diagnosed with Major depressive disorder, Oppositional defiant disorder and placed on every 15 minute observation rounds.

Review of the Observation Check Sheet/Graphic Flowsheet dated 12/02/2022 revealed, in part, an incomplete document where S7MHT failed to initial the form for 8 increments of time. The times on the observation check sheet were not legible. Further review revealed S5RN initialed the incomplete document.

Patient #3
Review of Patient #3's medical record revealed, in part, on 11/15/2022 at 2:08 p.m. he was placed on a PEC for making suicidal statements and violence towards others. Patient #3 was admitted to the facility on 11/16/2022 at 4:35 p.m. On 11/17/2022 at 1:33 p.m. Patient #3 was placed on a CEC for danger to self and others. Patient #3 was diagnosed with Major depressive disorder, Autistic disorder, Attention deficit hyperactivity and placed on every 15 minute observation rounds.

Review of the undated Observation Check Sheet/Graphic Flowsheet revealed, in part, an inaccurate document where S8MHT failed to initial on the correct line and initialed on the line to reposition patient every 2 hours. Further review revealed S6RN initialed the inaccurate document.

Patient #4
Review of Patient #4'smedical record revealed, in part, on 11/16/2022 at 2:00 p.m. Patient #4 was placed on a PEC related to being suicidal. Patient #4 was admitted to the facility on 11/16/2022 at 11:45 p.m. On 11/18/2022 at 1:54 p.m., Patient #4 was placed on a CEC related to being suicidal and unwilling to voluntarily sign in. Patient #4 was diagnosed with Major depressive disorder, Attention deficit hyperactivity, Anxiety disorder and placed on every 15 minute observation rounds.

Review of the Observation Check Sheet/Graphic Flowsheet for Patient #4 revealed an incomplete, inaccurate and use of an incorrect form in that there was no date recorded and S9MHT initialed on the line to reposition every 2 hours. Further review revealed, S6RN initialed the incomplete and inaccurate form.

Patient #5
Review of Patient #5's medical record revealed, in part, on 11/09/2022 at 10:54 p.m., Patient #5 was placed on a PEC for being suicidal and danger to self. On 11/10/2022 at 4:30 p.m., Patient #5 was placed on a CEC. On 11/10/2022 at 10:00 p.m. Patient #5 was admitted to the facility with diagnoses including Oppositional defiant disorder, Attention deficit hyperactivity, Bipolar disorder and was placed on every 15 minute observation rounds.

Review of the LDH Licensed Provider Abuse/Neglect Initial Report related to Patient #4 and Patient #5 submitted on 11/21/2022 revealed, in part, surveillance video revealed on 11/18/2022 at 9:35 p.m. both patients were observed to be in the room together from 9:39 p.m. to 9:58 p.m.

Review of the Observation Check Sheet/Graphic Flowsheet for Patient #5 dated 11/18/2022 revealed, in part, incomplete observation rounds by S5MHT with no documentation of the behavior or location of Patient #5 between 8:30 p.m. and 10:45 p.m. Further review revealed at 9:00 p.m. and 11:00 p.m.S4RN initialed the incomplete observation rounds

In interview on 12/28/2022 at 2:53 p.m., S2ADON indicated the rounds on Patient #5 should have been completely documented. In addition, S2ADON indicated S4RN should have identified the incomplete rounds upon initialing the form.

In interview on 01/03/2022 at 1:15 p.m., S4DON reviewed the Observation Check Sheets/Graphic Flowsheets for Patients #1 - #5 and verified the findings listed above for each patient.

Based on record review and interviews, the hospital failed to ensure the Registered Nurse (RN) supervised the care of each patient as evidenced by failure to ensure the correct implementation and documentation of the levels of observation policy and procedure for 5 (Patient #1 - #5) of 5 (Patient #1 - #5) records reviewed.
Findings:

Review of the policy and procedure titled, "Level of Observations" effective date 01/11/2016 and last revised on 11/16/2022 revealed, in part, the purpose is to provide staff with a framework for monitoring patients to ensure safety. The Registered Nurse will conduct routine rounds to visually observe each patient for safety at least once every 2 hours and will validate rounds by initialing in the appropriate section of the form. The staff physically walks to find each patient on every 15 minute observation, documents patient's location and reports identified risk to RN when indicated.

Review of the job description/performance review for an RN revealed, in part, evaluates the effectiveness of interventions in relation to expected outcomes; provides structure and maintains a therapeutic milieu in collaboration with the patient and other health care providers; adheres to established nursing practices and standards of care; demonstrates professionalism, accountability, and responsibility for decision making, quality nursing care and knowledge base of psychiatric nursing care; documents care, progress, response to intervention in medical record in an accurate, thorough and concise manner; follows up on client care responsibilities, communicates incomplete assignments and current client needs to staff to assure continuity of care; implements staff assignments and delegation of duties using appropriate judgment and knowledge; assumes the responsibility for the safety of patients; complies and adheres to all hospital policies; complies with safety policies and procedures and reports safety hazards and initiates appropriate action.

Patient #1
Review of Patient #1's medical record revealed, in part, on 11/12/2022 at 4:32 p.m. he was placed on a Physician's Emergency Certificate (PEC) after he threatened to shoot and stab family members. Patient #1 was admitted to the facility on 11/13/2022 at 12:45 a.m. On 11/14/2022 at 4:43 p.m. the Coroner's Emergency Certificate (CEC) indicated Patient #1 was homicidal, a danger to others and unable to seek voluntary admission. Patient #1 was diagnosed with Bipolar disorder single episode, Oppositional defiant disorder and placed on every 15 minute observation rounds.

Review of the Observation Check Sheet/Graphic Flowsheet dated 11/13/2022 revealed S6RN initialed blank 15 minute observation rounds on the third row of an incorrect checklist where the times were not legible. Further review revealed, on 11/13/2022, S6RN initialed another incorrect form with inaccurate observation rounds beginning at 1:00 a.m. through 5:00 a.m.

In interview on 12/28/22 at 3:25 p.m., S2ADON indicated S6RN should not have initialed a blank 15 minute observation rounds sheet. S2DON further indicated an incorrect form was used and could not determine why two observation sheets were completed for 11/13/2022.

Patient #2
Review of Patient #2's medical record revealed, in part, on 11/29/2022 at 1:47 a.m. he was placed on a PEC for danger to self and unwilling to sign himself into a facility. Patient #2 was admitted to the facility on 11/30/2022 at 4:15 p.m. Patient #2 was diagnosed with Major depressive disorder, Oppositional defiant disorder and placed on every 15 minute observation rounds.

Review of the Observation Check Sheet/Graphic Flowsheet dated 12/02/2022 revealed, in part, an incomplete document where S7MHT failed to initial the form for 8 increments of time. The times on the observation check sheet were not legible. Further review revealed S5RN initialed the incomplete document.

Patient #3
Review of Patient #3's medical record revealed, in part, on 11/15/2022 at 2:08 p.m. he was placed on a PEC for making suicidal statements and violence towards others. Patient #3 was admitted to the facility on 11/16/2022 at 4:35 p.m. On 11/17/2022 at 1:33 p.m. Patient #3 was placed on a CEC for danger to self and others. Patient #3 was diagnosed with Major depressive disorder, Autistic disorder, Attention deficit hyperactivity and placed on every 15 minute observation rounds.

Review of the undated Observation Check Sheet/Graphic Flowsheet revealed, in part, an inaccurate document where S8MHT failed to initial on the correct line and initialed on the line to reposition patient every 2 hours. Further review revealed S6RN initialed the inaccurate document.

Patient #4
Review of Patient #4'smedical record revealed, in part, on 11/16/2022 at 2:00 p.m. Patient #4 was placed on a PEC related to being suicidal. Patient #4 was admitted to the facility on 11/16/2022 at 11:45 p.m. On 11/18/2022 at 1:54 p.m., Patient #4 was placed on a CEC related to being suicidal and unwilling to voluntarily sign in. Patient #4 was diagnosed with Major depressive disorder, Attention deficit hyperactivity, Anxiety disorder and placed on every 15 minute observation rounds.

Review of the Observation Check Sheet/Graphic Flowsheet for Patient #4 revealed an incomplete, inaccurate and use of an incorrect form in that there was no date recorded and S9MHT initialed on the line to reposition every 2 hours. Further review revealed, S6RN initialed the incomplete and inaccurate form.

Patient #5
Review of Patient #5's medical record revealed, in part, on 11/09/2022 at 10:54 p.m., Patient #5 was placed on a PEC for being suicidal and danger to self. On 11/10/2022 at 4:30 p.m., Patient #5 was placed on a CEC. On 11/10/2022 at 10:00 p.m. Patient #5 was admitted to the facility with diagnoses including Oppositional defiant disorder, Attention deficit hyperactivity, Bipolar disorder and was placed on every 15 minute observation rounds.

Review of the LDH Licensed Provider Abuse/Neglect Initial Report related to Patient #4 and Patient #5 submitted on 11/21/2022 revealed, in part, surveillance video revealed on 11/18/2022 at 9:35 p.m. both patients were observed to be in the room together from 9:39 p.m. to 9:58 p.m.

Review of the Observation Check Sheet/Graphic Flowsheet for Patient #5 dated 11/18/2022 revealed, in part, incomplete observation rounds by S5MHT with no documentation of the behavior or location of Patient #5 between 8:30 p.m. and 10:45 p.m. Further review revealed at 9:00 p.m. and 11:00 p.m.S4RN initialed the incomplete observation rounds

In interview on 12/28/2022 at 2:53 p.m., S2ADON indicated the rounds on Patient #5 should have been completely documented. In addition, S2ADON indicated S4RN should have identified the incomplete rounds upon initialing the form.

In interview on 01/03/2022 at 1:15 p.m., S4DON reviewed the Observation Check Sheets/Graphic Flowsheets for Patients #1 - #5 and verified the findings listed above for each patient.