HospitalInspections.org

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The findings were:

482.13 Tag A-0144
The information reviewed during the survey provided evidence the facility failed to ensure a one to one sitter provided continuous unobstructed observation for a suicidal patient.

A discussion took place with the survey team and the facility's administrative staff (EMP4 and EMP5) regarding the survey team's concerns related to Patient's Rights on August 25, 2020 at approximately 12:00 PM.

Based on review of facility documents, observation, medical record (MR) and staff interview (EMP), it was determined the facility failed to ensure a 1:1 sitter provided continuous unobstructed observation for a suicidal patient for one of one medical record (MR1) reviewed in the Emergency Department (ED).

Findings include:

Review on August 25, 2020, of the facility's "Notice of Patient Rights and Responsibilities" last reviewed June 2019, revealed "You have the right to: ... An environment that is safe, preserves dignity and contributes to a positive self-image. ..."

Review on August 25, 2020, of the facility's "Suicide Risk Assessment and Interventions: Columbia Protocol in Non-Behavioral Health Setting Policy," last revised January 10, 2020, revealed "I. Policy ... Based on the severity and immediacy of suicide risk assessed using the Columbia Protocol, patient safety measures and interventions will be implemented as a means to keep patients from inflicting harm to self. This policy is applicable to non-behavioral health settings including the Emergency Department ...III. Definitions A. Ligature Risk: a ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include shower rails, coat hooks, pipes, and radiators, bedsteads [sic], window and door frames, ceiling fittings, handles, hinges and closures. ... B. One to One (1:1) Observation: Intervention for high risk for suicide. Continuous observation and staff are able to see the patient in clear view and staff can respond immediately to intervene and assure safety at all times. ... E. Suicidal Ideation: Thought of harming or killing oneself. Intensity determined by assessing the frequency, duration and intensity of these thoughts; in addition to the presence of a plan. ... G. Suicide Attempt: A self-injurious act with at least some intent to die, as a result of the act. There does not need to be any injury or harm, just the potential for harm (e.g. gun failing to fire). ..."

Review on August 25, 2020, of the facility's "Table 1: Patient Safety measures and Interventions Based on Screening Responses" last revised January 10, 2020, revealed the following list of questions requiring a Yes or No response: 1. Have you wished you were dead or wished you could go to sleep and not wake up? 2. Have you actually had any thoughts of killing yourself? 3. Have you been thinking about how you might kill yourself? 4. Have you had thoughts and had some intention of acting on them? 5. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? 6. Have you ever done anything, started to do anything, or prepared to do anything to end your life? If the patient responds no to these questions, no ideation or behavior identified, no safety precautions or interventions. If the patient responds Yes, then 1:1 continuous observation is initiated. The RN assesses and completes a Safe Room Checklist ..."

Review on August 25, 2020, of the facility's "Trained Observers for Suicide Precautions Policy," last revised October 22, 2019, revealed "I. Purpose To provide guidelines for the use of a trained observer. II. Scope A. Trained Observer - This role is to provide continual observation for the patient with suicidal ideation and who may be considered a suicide risk. ..."

Review of MR1 on August 25, 2020, revealed this patient was admitted to the Emergency Department (ED) on August 24, 2020, at 1:39 PM on a 302 (Involuntary Commitment) due to an attempt to hang self at home. The facility assessed MR1 as a continued suicidal risk due to continued thoughts of killing self; had a history of suicidal thoughts and actions in the past and this patient had a plan for suicide. MR1 was ordered 1:1 continuous observation due to this patient's assessed risk for suicide.

Observation of EMP1 on August 25, 2020, at 8:50 AM revealed this employee sitting outside MR1's room, approximately four feet from the entry door, facing away from MR1.

Interview with EMP1 on August 25, 2020, at approximately 8:55 AM confirmed MR1 was ordered 1:1 continuous observation due to this patient's assessed risk for suicide. EMP1 did not have a continuous unobstructed view of MR1. EMP1 needed to turn self around in order to observe MR1 and that MR1 was not continuously observed by EMP1.

Interview with EMP4 and EMP5 on August 25, 2020, at the time of the observation confirmed MR1 was ordered 1:1 continuous observation due to this patient's assessed risk for suicide; EMP1 did not have a continuous unobstructed view of MR1; EMP1 needed to turn self around in order to observer MR1 and MR1 was not continuously observed by EMP1.

Observation on August 25, 2020, of MR1's patient room revealed oxygen, suction and air regulators; a clear plastic bag covering an intravenous (IV) pump and pole; this IV pump had a visible cord attached; there was a plastic bag hanging on the wall directly behind MR1's headboard and a green plastic linen bag in the dirty linen receptacle.

Interview with EMP4 and EMP5 on August 25, 2020, at the time of the observation confirmed MR1's patient room had oxygen, suction and air regulators; a clear plastic bag covering the IV pump and pole; the IV pump had a visible cord attached; the plastic bag hanging on the wall directly behind MR1's headboard and the green plastic linen bag in the dirty linen receptacle. EMP4 and EMP5 confirmed the regulators; clear plastic bag on covering the IV pump and pole; the IV cord; the plastic bag behind MR1's headboard and the green plastic linen bag in the dirty linen receptacle posed a safety risk to patients with suicidal thoughts.

Interview with EMP3 on August 25, 2020, revealed MR1's ED patient room did not have a bathroom and EMP3 escorted MR1 to the bathroom next to this patient's ED room. EMP3 revealed this employee did not have a continuous unobstructed view of MR1 while this patient was using the bathroom; EMP3 stood outside the bathroom and kept checking MR1 and that MR1 was not continuously observed by EMP3.

Observation on August 25, 2020, of the ED bathroom utilized by MR1 revealed a metal hook secured to the wall with a nail alongside the commode, a rigid garbage can with a plastic garbage bag liner, two open metal handicap bars attached to the wall near the commode; and a plastic call bell cord. This bathroom also contained a shower with open metal handicap bars attached to the wall in the shower and a plastic call bell cord.

Interview with EMP4 and EMP5 on August 25, 2020, at the time of the observation confirmed the metal hook secured to the wall with a nail alongside the commode, the rigid garbage can with a plastic garbage bag liner, the two open metal handicap bars attached to the wall near the commode; the plastic call bell cord; the shower with open metal handicap bars attached to the wall in the shower and the plastic call bell cord. EMP4 and EMP5 confirmed the metal hook secured to the wall with a nail alongside the commode, the rigid garbage can with a plastic garbage bag liner, the two open metal handicap bars attached to the wall near the commode; the plastic call bell cord; the shower with open metal handicap bars attached to the wall in the shower and the plastic call bell cord posed a safety risk to patients with suicidal thoughts.

Cross reference
482.23 (b)(4) Nursing Care Plan

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to ensure the Quality Improvement monitoring was performed for all contracted services.

Findings include:

Review on August 26, 2020, of Moses Taylor Hospital Organization-wide Quality Assessment and Performance Improvement Program 2020" revealed "... III. Organization and Responsibilities of Leaders A. Responsibilities Participation in Quality Improvement activities are the responsibility of everyone employed by, on the medical staff of, or contracted with Moses Taylor Hospital .... Executive Leadership ... Perform evaluations of clinically contracted services in collaboration with the respective department director and reporting the results of the evaluation to the Quality Improvement Council, Medical Executive Committee and the Board. ... Hospital Departments ... Evaluate the performance of all clinically contracted services and report the results of the evaluation to the Quality Management Department for reporting in applicable committee(s). ... IV. Design - Quality Methodology ... B. Measure ... Annual Evaluation of Contracted Services. ..."

1. Review on August 26, 2020, of the facility's Contracted Services for 2020 revealed the facility listed the following patient services provided to the facility under contract: Vascular Ultrasound, Pathology and Laboratory, Auto-transfusion services, Neonatology, Lithotripsy, Laser Therapy and Neurophysical Monitoring.

Interview with EMP6 and EMP7 on August 26, 2020, at approximately 1:30 PM revealed Vascular Ultrasound is reported under the Imaging Department in January 2020 and Pathology and Laboratory, Auto-transfusion services, Neonatology, Lithotripsy, Laser Therapy and Neurophysical Monitoring are reported under the Operating Room in May 2020.

Review of the facility's Quality Assessment and Performance Improvement committee reporting schedule for July 2019 through August 2020 revealed Imaging was scheduled to report to this committee in January 2020 and the Operating room was scheduled to report to this committee in May 2020.

Review on August 26, 2020, of the facility's Quality Assessment and Performance Improvement committee meeting minutes for January 1, 2020 through August 26, 2020, revealed no documentation the facility reviewed ongoing monitoring, analysis of specific performance indicators and / or data elements related to patient services provided under contract with an outside company for Vascular Ultrasound, Pathology and Laboratory, Auto-transfusion services, Neonatology, Lithotripsy, Laser Therapy and Neurophysical Monitoring.

Interview with EMP6 and EMP7 on August 26, 2020, at approximately 1:30 PM confirmed there was no documentation in the facility's Quality Assessment and Performance Improvement committee meeting minutes for January 1, 2020 through August 26, 2020, of ongoing monitoring, analysis of specific performance indicators and / or data elements for Vascular Ultrasound, Pathology and Laboratory, Auto-transfusion services, Neonatology, Lithotripsy, Laser Therapy and Neurophysical Monitoring.

2. Review on August 26, 2020, of the facility's Contracted Services for 2020 revealed the facility listed Tele-Burn services as patient services provided to the facility under contract.

Review of the facility's Quality Assessment and Performance Improvement committee reporting schedule for July 2019 through August 2020 revealed no documentation Tele-Burn services was listed on this reporting schedule.

Interview with EMP6 and EMP7 on August 26, 2020, at approximately 1:35 PM confirmed the facility listed Tele-Burn services as patient services provided to the facility under contract and the facility's Quality Assessment and Performance Improvement committee reporting schedule for July 2019 through August 2020 revealed no documentation Tele-Burn services was listed on this reporting schedule.

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The findings were:

482.23 Tag A-0395
The information reviewed during the survey provided evidence the facility failed to ensure the registered nurse reviewed and documented the patient's heart rhythm every 4 hours.

482.23 Tag A-0396
The information reviewed during the survey provided evidence the facility failed to follow patient care plans for a safe environment by not ensuring items that pose a risk to a suicidal patient were removed from the patient room.

482.23 Tag A-397
The information reviewed during the survey provided evidence the facility failed to ensure a registered nurse (RN) that was floated to the telemetry unit as an assigned registered nurse had the required advanced cardiac life support (ACLS) certification and successfully completed a course in rhythm interpretation.

A discussion took place with the survey team and the facility's administrative staff (EMP4 and EMP5) regarding the survey team's concerns related to Nursing Services on August 27, 2020 at approximately 10:00 AM.

Based on review of facility documents, staff interview (EMP) and medical records (MR), it was determined the facility failed to ensure the registered nurse reviewed and documented the patient's heart rhythm every four hours in the medical record for four of four medical records reviewed (MR16, MR17, MR18, MR19.)

Findings include:

Review on August 26, 2020, of the facility policy, "Telemetry Policy," revised August 19, 2020, revealed " I. Purpose to provide a guide for the monitoring of patients and the transport of monitored patients within Moses Taylor Hospital. This policy will define training requirements for staff caring for cardiac monitored patients, monitoring requirements for patients being transported within the hospital, monitor alarm requirements, process for monitoring and responding to arrhythmias and documentation requirements of cardiac rhythms being monitored. ...B. RN is responsible to: 1. Interpret and document rhythms and ectopic beats 2. Document rhythm changes ...VII. Documentation ...A. The telemetry technician/RN will place monitor tracings in the chart upon admission, at least every 4 hours, and with any rhythm changes. B. RN and/or tele tech will verify and record the patients [sic] name, heart rate and rhythm. ..."

Review on August 27, 2020, of the facility, "Position Description/Competency Based Evaluation for a Registered Nurse-Medical Surgical/Telemetry " revised February 2020, revealed "Position Purpose: The primary focus of the RN is to be a professional caregiver who assumes responsibility and accountability for a group of patients. The RN collaborates with other care providers to assess, plan, implement, and evaluate patient care across the continuum. ... General Duties ...10. Reviews and documents patient rhythm every four (4) hours and with any rhythm change. ..."

Review on August 26, 2020, of MR16 revealed this patient was ordered cardiac monitoring on August 19, 2020, at 15:40 PM. There was no documentation in the medical record the RN reviewed and documented MR16's rhythm every four hours on August 19, 2020 from 15:40 to 23:59 ; August 20, 2020 from 00:00 to 20:00; August 21, 2020 from 00:00 to 08:00: August 21, 2020 from 11:00 until 20:00 ; August 22, 2020 from 00:00 to 08:00; August 22, 2020 at 12:00 until August 23, 2020 at 08:00.

Review on August 26, 2020, of MR17 revealed this patient was ordered cardiac monitoring on August 18, 2020, at 16:44. There was no documentation in the medical record the RN reviewed and documented MR17's rhythm every four hours on August 18, 2020 from 16:44 until August 22, 2020 at 04:00.

Review on August 26, 2020, of MR18 revealed this patient was ordered cardiac monitoring on August 14, 2020, at 15:27. No documentation in the medical record the RN reviewed and documented MR18's rhythm every four hours on August 14, 2020 from 16:00 until August 15, 2020 at 10:00; August 15, 2020 at 16:00 until August 16, 2020 at 08:00; August 16, 2020, at 20:00 until August 17, 2020 at 08:00.

Review on August 27, 2020, of MR19 revealed this patient was ordered cardiac monitoring on March 4, 2020, at 14:36. No documentation in the medical record the RN reviewed and documented in the MR19's rhythm every four hours on March 6, 2020 from 15:00 until 20:00.

Interview on August 27, 2020, with EMP7 confirmed the RN did not document in the medical record the patient's rhythm was reviewed every 4 hours for MR16, MR17, MR18, MR19.


Cross Reference
482.23 (b)(4) Nursing Care Plan
782.23 (b)(5) Patient Care Assignments

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to follow patient care plans for a safe environment by not ensuring items that pose a risk to a suicidal patient were removed from the patient room for seven of seven applicable ED medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6 and MR7).

Findings include:

Review on August 25, 2020, of the facility's "Interdisciplinary Plan of Care Policy," last revised December 30, 2019, revealed "I. Purpose to provide a brief, pertinent and individualized written plan of care for each patient. To document patient problems, outcomes, interventions and Plan of Care orders. To provide guidelines for documentation and education ... C. A Plan of Care will contain the following components: 1. Order. 2. Expected Outcomes/Interventions ..."

Review of MR1 on August 25, 2020, revealed this patient was admitted to the Emergency Department (ED) on August 24, 2020, with suicidal thoughts. Nursing documented MR1's Plan of Care was Safety by providing a safe environment free of any safety hazards and removal of all nonessential equipment from the room.

Observation on August 25, 2020, of MR1's patient room revealed oxygen, suction and air regulators, a clear plastic bag covering an intravenous (IV) pump and pole, a visible cord attached to the IV pump, a plastic bag hanging on the wall directly behind MR1's headboard and a green plastic linen bag in the dirty linen receptacle.

Interview with EMP4 and EMP5 on August 25, 2020, at the time of the observation confirmed the facility did not remove all safety hazards and all nonessential equipment from MR1's room as indicated on this patient's Plan of Care.

Review of MR2 on August 25, 2020, revealed this patient was admitted to the ED on August 25, 2020, with suicidal thoughts. Nursing documented MR2's Plan of Care was Safety by providing a safe environment free of any safety hazards and removal of all nonessential equipment from the room.

Observation on August 25, 2020, of MR2's patient room revealed oxygen, suction and air regulators, a clear plastic bag covering an intravenous (IV) pump and pole, a visible cord attached to the IV pump, a plastic bag hanging on the wall directly behind MR2's headboard and a green plastic linen bag in the dirty linen receptacle.

Interview with EMP4 and EMP5 on August 25, 2020, at approximately 4:45 PM confirmed the facility did not remove all safety hazards and all nonessential equipment from MR2's room as indicated on this patient's Plan of Care.

Review of MR3 on August 26, 2020, revealed this patient was admitted to the ED on July 13, 2020, with suicidal thoughts. The facility assessed MR3 as a moderate risk due to continued thoughts of killing self and had a history of suicidal thoughts and actions in the past. Nursing documented MR3's Plan of Care was Safety by providing a safe environment free of any safety hazards and removal of all nonessential equipment from the room.

Review of MR4 on August 26, 2020, revealed this patient was admitted to the ED on July 15, 2020, with suicidal thoughts. The facility assessed MR4 as a high risk for suicide due to continued thoughts of killing self; had a history of suicidal thoughts and actions in the past and this patient had a plan for suicide. Nursing documented MR4's Plan of Care was Safety by providing a safe environment free of any safety hazards and removal of all nonessential equipment from the room.

Review of MR5 on August 26, 2020, revealed this patient was admitted to the ED on July 18, 2020, with suicidal thoughts. The facility assessed MR5 as a moderate risk due to continued thoughts of killing self; had a history of suicidal thoughts and actions in the past. Nursing documented MR5's Plan of Care was Safety by providing a safe environment free of any safety hazards and removal of all nonessential equipment from the room.

Review of MR6 on August 26, 2020, revealed this patient was admitted to the ED on July 15, 2020, with suicidal thoughts. The facility assessed MR6 as a high risk for suicide due to continued thoughts of killing self; had a history of suicidal thoughts and actions in the past and this patient had a plan for suicide. Nursing documented MR6's Plan of Care was Safety by providing a safe environment free of any safety hazards and removal of all nonessential equipment from the room.

Review of MR7 on August 26, 2020, revealed this patient was admitted to the ED on July 25, 2020, with suicide thoughts. The facility assessed MR7 as a continued risk for suicide due thoughts of killing self; had a history of suicidal thoughts and actions in the past and this patient had a plan for suicide. Nursing documented MR7's Plan of Care was Safety by providing a safe environment free of any safety hazards and removal of all nonessential equipment from the room.

There was no documentation in MR3, MR4, MR5, MR6 and MR7 indicating nursing staff followed these patients' Plan of Care for a safe environment free of any safety hazards and removal of all nonessential equipment from the room.

Interview with EMP4 and EMP5 on August 26, 2020, approximately 2:00 PM confirmed there was no documentation in MR3, MR4, MR5, MR6 and MR7 indicating nursing staff followed these patients' Plan of Care for a safe environment free of any safety hazards and removal of all nonessential equipment from the room.

-Cross reference
482.13 (c)(2) Patient's Rights
482.23 (b)(3) Rn Supervision Of Nursing Care
782.23 (b)(5) Patient Care Assignments

Based on review of facility documents personnel files (PF) and staff interview (EMP), it was determined the facility failed to ensure a registered nurse (RN) that was floated to the telemetry unit as an assigned registered nurse had the required advanced cardiac life support (ACLS) certification and successfully completed a course in rhythm interpretation for one of one personnel files reviewed.

Findings include:

Review on August 26, 2020, of the facility policy, "Telemetry Policy," revised August 19, 2020, revealed "I. Purpose to provide a guide for the monitoring of patients and the transport of monitored patients within Moses Taylor Hospital. This policy will define training requirements for staff caring for cardiac monitored patients, monitoring requirements for patients being transported within the hospital, monitor alarm requirements, process for monitoring and responding to arrhythmias and documentation requirements of cardiac rhythms being monitored. ...B. RN is responsible to: 1. Interpret and document rhythms and ectopic beats ...III. Training A. RNs and telemetry technicians must have successfully completed a course in rhythm interpretation. RNs must have successfully completed 40 hours of observation by a competent technician or RN. ..."

Review on August 27, 2020, of the facility, "Position Description/Competency Based Evaluation for a Registered Nurse-Medical Surgical/Telemetry" revised February 2020, revealed "Position Purpose: The primary focus of the RN is to be a professional caregiver who assumes responsibility and accountability for a group of patients. The RN collaborates with other care providers to assess, plan, implement, and evaluate patient care across the continuum. Position Qualifications: ...ACLS within six (6) months of hire ..."

Review on August 27, 2020, of staffing schedules/assignment sheets for the telemetry unit dated March 6, 2020 for 3:00 PM to 7:00 PM revealed PF4, was floated to a telemetry unit and was assigned to patients that required telemetry monitoring.

Interview on August 27, 2020, with EMP8 confirmed PF4, was floated to a telemetry unit and assigned to patients that required telemetry monitoring.

Review on August 27, 2020, of PF4 revealed this RN did not have ACLS certification or documentation they successfully completed a course in rhythm interpretation.

Interview on August 27, 2020, with EMP11 confirmed PF4 did not have ACLS certification and did not successfully complete a course in rhythm interpretation.


Cross reference
482.23 (b)(4) Nursing Care Plan
482.23 (b)(5) Patient Care Assignments