HospitalInspections.org

Based on record review, observations and interviews, the hospital failed to provide care in a safe setting. This deficient practice is evidenced by failing to monitor the safety of patients for 3 (#1, R1, R2) of 10 patients observed out of a total population of 11 patients (#1, 2, 3, R1-R8).
Findings:

Review of the hospital's policy CS-23 titled, "Level of Observations" revealed in part: Purpose - Observation should be both safe and therapeutic. Respect should be shown for the patients' need for autonomy while ensuring safety.\
Policy - Three levels of observation are utilized: every 15-minute (Q-15 minute) observation; Line of Sight (Constant Observation); and one-to-one observation. The level of observation is determined by the individual needs of the patient and treatment team recommendation and ultimately requires a physician order.
Observation Levels: Every 15 minutes - staff will visually observe the patient Q15 to monitor location and activity, with emphasis on any noticeable behaviors of escalation, aggression and unsafe activities.
Line of Sight - staff will ensure patient is visually within sight at all times.
One-to-one (1:1) - staff will ensure patient is visually within sight and within arms-reach of a staff member at all times and in all circumstances. Procedure - Physician provides order for one-to-one. Charge nurse explains procedure to patient. 1:1 can be initiated by Director of Nursning (DON) or Administrator based on identified risk prior to physician order. Documents in chart and nurse report sheet/ the level of observation ordered and implemented. Reassesses patient every 4 hours for continued risk and need for 1:1. Registered Nurse (RN) will initial off on the observation sheet every 2 hours with our current model of RN availability. 1:1 staff is to be relieved at least every 4 hours for at least 15 minute periods.

Patient 1
Review of physician orders dated 03/14/2024 revealed 1:1 observation ordered for Patient #1.

Observation on 03/21/2024 at 12:10 p.m. revealed Patient #1 seated and eating lunch in bed and S3MHT seated in the vestibule adjoining Patient #1's bedroom. S3MHT was not in arms-length of Patient #1.

In an interview at this time, S2RN confirmed the finding and acknowledge S3MHT was not monitoring Patient #1 according to the patient's orders.

Patient R1
Review of the hospital's list of current patients with orders for Line of Sight monitoring revealed Patient R1.

Observations on 03/25/2024 at 12:45 revealed S3MHT open Patient R1's door, make an observation, close the door and return to the opposite end of the hall.

In an interview at this time, S1Administrator acknowledged Patient R1's door was closed and the patient was not being monitored as ordered.

Patient R2
Review of the hospital's list of current patients with orders for Line of Sight monitoring revealed Patient R2.

Observations on 03/25/2024 at 12:46 revealed S3MHT open Patient R2's door, make an observation, close the door and return to the opposite end of the hall.

In an interview at this time, S1Administrator acknowledged Patient R2's door was closed and the patient was not being monitored as ordered.