HospitalInspections.org

Based on a review of documentation and interview, the facility failed to ensure right to care in a safe setting by failing to monitor patients at the level of monitoring most recently specified in the patient's medical record.

Findings included:

Facility based policy entitled, "LEVEL OF OBSERVATIONS" stated in part,
"Observation Levels:..
o One-to-one observation - The staff should ensure the patient is visually within sight and within arms-reach of a staff member at all times and in all circumstances. See Appendix A for more information.
PROCEDURE:
I. The initial patient observation level is determined and ordered by the physician upon patient admission. The decision to utilize one of the observation levels is made based on the patient's needs and presenting symptomology. The following are considered when the decision for an observation level is made:
o Suicidal ideation
o Violence/ aggressive threats
o Poor judgment
o Poor impulse control
o Actively psychotic
o High Fall risk
o Manic behavior
o Intrusive behavior placing patient and peers ...

3. Close Observation Form:
Staff members utilize the close observation checklist form (QlS check sheet) to document the ongoing observation and location of the patient. · Additional information regarding, activities are included on the form when relevant, i.e. water offered, activities of daily living The form is initialized with the observing staffs initials to indicate the patient was observed. The staff member signs the signature line at the bottom of the form to validate their initials and credentials. The Registered Nurse (RN) must perform observations in addition to the other assigned staff.
The RN will initial their rounds in the column indicating RN rounds ...

6. One-to-one Observation:
Physician/NPP:
o Provides order for one-to-one observation based on assessed risk and individual needs.
o The physician/NPP must give the order to discontinue a one-to-one level of observation once it is begun.
Charge Nurse:
o Explains procedure to the patient. Provides for the respect of the patient.
o Implements one-to-one order/protocol when received.
o May invoke a one-to-one observation with approval of the DON or Administrator based on identified risk of patient pending notification of physician/ NPP for an order.
o Assesses patient's condition regarding danger to self, others, fall risk, psychological factors, elopement and psychosis which places the patient at risk.
o Reports assessment findings to physician/NPP and DON.
o Assigns a nursing staff to perform one-to-one and ensures staff have relief for all breaks.
o Documents the reason for the observation by circling on close observation form the precautions type, e.g., suicide, fall, etc.
o Documents in the patient's chart and nurse report sheet/ the level of observation ordered and implemented."

Review of medical records revealed patient observation forms did not reflect the correct level of monitoring per physician orders for 3 (#1,2, and 3) of 4 patients with 1:1 observation orders in place.

Review of observation status orders and Observation Check Sheet/Graphic Flowsheet for Patient #1 revealed the following:
* On 02/08/20 at 2200 the patient was placed on 1:1 observation "due to sexual behaviors". On 02/08/20 the Observation Check Sheet only had "Q15" indicated for the observation level. There was no change to the sheet to reflect the patient was being monitored 1:1 as ordered.
* On 02/10/20 at 0655 the patient remained on 1:1 observation "due to sexual behaviors". On 02/10/20 the Observation Check Sheet only had "Q15" indicated for the observation level. There was no change to the sheet to reflect the patient was being monitored 1:1 as ordered.
* On 02/11/20 at 0700 the patient remained on 1:1 observation "due to sexual behaviors". On 02/11/20 the Observation Check Sheet had nothing marked to indicate the observation level for this patient. There was no indication on the sheet to reflect the patient was being monitored 1:1 as ordered.
* On 02/14/20 at 0700 the patient remained on 1:1 observation "due to sexual behaviors". On 02/14/20 the Observation Check Sheet had nothing marked to indicate the observation level for this patient. There was no indication on the sheet to reflect the patient was being monitored 1:1 as ordered.
* On 02/15/20 at 0700 the patient remained on 1:1 observation "due to sexual behaviors". On 02/15/20 the Observation Check Sheet only had "Q15" indicated for the observation level. There was no change to the sheet to reflect the patient was being monitored 1:1 as ordered.

Review of observation status orders and Observation Check Sheet/Graphic Flowsheet for Patient #2 revealed the following:
* On 02/08/20 at 2200 the patient was placed on 1:1 observation "due to sexual behaviors". On 02/08/20 the Observation Check Sheet only had "Q15" indicated for the observation level. There was no change to the sheet to reflect the patient was being monitored 1:1 as ordered.
* On 02/10/20 at 0655 the patient remained on 1:1 observation "due to sexual behaviors". On 02/10/20 the Observation Check Sheet only had "Q15" indicated for the observation level. There was no change to the sheet to reflect the patient was being monitored 1:1 as ordered.
* On 02/13/20 the Observation Check Sheet only had "1:1 Observation" indicated for the observation level. There was no order for this patient to be on 1:1 on 02/13/20.
* On 02/14/20 the Observation Check Sheet had nothing marked to indicate the observation level for this patient. This checklist also had no observation noted from 0215 to 0545.
* On 02/18/20 at 2100 the patient remained on 1:1 observation "for safety". On 02/10/20 the Observation Check Sheet only had "Q15" indicated for the observation level. There was no change to the sheet to reflect the patient was being monitored 1:1 as ordered.

Review of observation status orders and Observation Check Sheet/Graphic Flowsheet for Patient #3 revealed the following:
* On 10/02/20 at 1327 the patient was placed on 1:1 observation "for safety". On 10/02/20 the Observation Check Sheet only had "Q15" indicated for the observation level. There was no change to the sheet to reflect the patient was being monitored 1:1 as ordered.
* On 10/03/20 at 2155 the patient remained on 1:1 observation. On 10/03/20 the Observation Check Sheet only had "Q15" indicated for the observation level. There was no change to the sheet to reflect the patient was being monitored 1:1 as ordered.
* On 10/05/20 at 1330 the patient was placed on 1:1 observation "for safety due to SI". There was no Observation Check Sheet dated 10/05/20. One Check Sheet with no date that was chronologically between 10/04/20 and 10/06/20 was in the medical file. This undated Check Sheet only had "Q15" indicated for the observation level. There was no change to the sheet to reflect the patient was being monitored 1:1 as ordered.

The above findings were verified with staff member #2 in an interview on 10/22/20.