HospitalInspections.org

Based on documentation review, clinical record reviews and interviews it was determined the Behavioral Health (BH) Unit Nurse Manager failed to monitor and ensure BH patient care assistants/BH nurse technicians complete patient safety checks every fifteen (15) minutes to protect and promote each patient's right for care in a safe setting. (See Tag A 144). This failure has the potential to place all patients at risk for serious harm.

A. Noncompliance: The nurse manager failed to monitor the fifteen (15) minute safety checks on (3) out of twelve (12) behavioral health patient records (patient's #2, #3 and #8). Review of the patient room safety checks for ligatures revealed a failure to check hinges for risk of ligatures.

B. Serious Adverse Outcome or Likely Serious Adverse Outcome: This failure has the potential for all patients admitted to the unit to be at risk for adverse harm to self or others.

C. Need for Immediate Action: An immediate plan of correction was received and sent to the State agency program Directors. It was accepted and the facility abated the immediate jeopardy on 11/21/19 at 12:10 p.m.

A. Based on document review, clinical record reviews and interview it revealed the Behavioral Health Unit Nurse Manager failed to ensure patient safety checks are completed every fifteen (15) minutes to provide patient care in a safe setting. This failure was identified in three (3) out of twelve (12) behavioral health patient records (patient's #2, #3 and #8). This failure has the potential to place all patients at risk for harm.

Findings include:

1. A review of policy, "Patient Checks and Suicide Precautions" revision date 09/18, states in part, "It is the responsibility of the Nurse Manager or RN staff, in the absence of the Nurse Manager, to assure that all patients are monitored as per unit policy or physician order. ... There will be a staff member dedicated exclusively to conducting fifteen (15) minute safety checks twenty-four (24) hours a day. ... These checks will include a review of patient rooms for elements of harm. It is the responsibility of the Nurse Manager to regularly review nursing documentation to assure that unit standards for patient checks and physician orders pertaining to suicide precautions are met at the one hundred (100) percent level."

2. A review of the job description for the Behavioral Health Nurse Manager states in part, "Plans, directs, supervises and monitors the activities of psychiatric nursing unit to achieve optimum patient care by meeting established goals and objectives. ... Accountable for the following activities of the nursing unit on a twenty-four (24) hour basis. ... Supervises the implementation of patient care. Evaluates the effectiveness of care delivered."

3. A review of patient #2's clinical record of the "Behavioral Health (BH) Close Observations" fifteen (15) minute checks, dated 11/14/19 revealed staff failed to record observing the patient between 9:45 a.m. and 10:00 a.m.

4. A review of patient #3's clinical record of the "Behavioral Health (BH) Close Observations" fifteen (15) minute checks, dated 11/15/19 revealed staff failed to record observing the patient between 10:30 a.m. and 10:45 a.m. and between 10:45 p.m. and 11:00 p.m.

5. A review of patient #8's clinical record of the "Behavioral Health (BH) Close Observations" fifteen (15) minute checks, dated 10/19/19 revealed staff failed to record observing the patient between 2:45 p.m. and 3:00 p.m.

6. An interview was conducted with the Regulatory and Patient Safety Manager was on 11/21/19 at approximately 9:30 a.m. When asked if staff should complete all fifteen (15) minute patient safety checks on each patient as per the BH Close Observations on the unit, she concurred with the above findings.

B. Based on observation and the hospital's patient room ligature safety risk assessment the hospital failed to ensure sixteen (16) of sixteen (16) patient doors were free from ligatures. This failure has the potential for all patients admitted to the behavior health unit to be at risk for death.

1. Observation of the behavior health unit in the presence of supervisor #1 on 11/20/19 at 3:45 p.m. revealed all patient rooms have a hinge the length of the door inside the patient's room.

2. A review of the ligature patient room risk assessment completed by the hospital revealed no risk assessment of the hinges on the behavior health unit was completed.

3. An interview was conducted with supervisor #1 during the observation and she concurred the internal hinge poses a ligature where a patient could hang themselves.

4. A joint interview was conducted on 11/21/19 at 7:25 a.m. with the Vice President of Support Services and the Facility Manager. When asked if they agreed the hinges on the doors were a ligature risk for patients to cause self-harm, they both stated, "Yes."

Based on documentation review, clinical record reviews and interviews it was determined the Behavioral Health (BH) Unit Nurse Manager failed to monitor and ensure BH patient care assistants/BH nurse technicians complete patient safety checks every fifteen (15) minutes per hospital policy. (See Tag A 395). This failure has the potential to place all patients at risk for serious harm.

Based on document review, clinical record reviews and interviews it was revealed the Behavioral Health Unit Nurse Manager failed to ensure patient safety checks are completed every fifteen (15) minutes in accordance with hospital policy. This failure was identified in three (3) out of twelve (12) behavioral health patient records (patients #2, #3 and #8). This failure has the potential to place all patients at risk for harm.

Findings include:

1. A review of policy "Patient Checks and Suicide Precautions," revision date 09/18, states in part: "It is the responsibility of the Nurse Manager or RN staff, in the absence of the Nurse Manager, to assure that all patients are monitored as per unit policy or physician order. ... There will be a staff member dedicated exclusively to conducting fifteen (15) minute safety checks twenty-four (24) hours a day. ... These checks will include a review of patient rooms for elements of harm. It is the responsibility of the Nurse Manager to regularly review nursing documentation to assure that unit standards for patient checks and physician orders pertaining to suicide precautions are met at the one hundred (100) percent level."

2. A review of the facility job description for the Behavioral Health Nurse Manager states in part: "Plans, directs, supervises and monitors the activities of psychiatric nursing unit to achieve optimum patient care by meeting established goals and objectives. ... Accountable for the following activities of the nursing unit on a twenty-four (24) hour basis. ... Supervises the implementation of patient care. Evaluates the effectiveness of care delivered."

3. A review of the medical record for patient #2's clinical record of the "Behavioral Health (BH) Close Observations" fifteen (15) minute checks dated 11/14/19 revealed staff failed to record observing the patient between 9:45 a.m. and 10:00 a.m.

4. A review of the medical record for patient #3's clinical record of the "Behavioral Health (BH) Close Observations" fifteen (15) minute checks dated 11/15/19 revealed staff failed to record observing the patient between 10:30 a.m. and 10:45 a.m. and between 10:45 p.m. and 11:00 p.m.

5. A review of the medical record for patient #8's clinical record of the "Behavioral Health (BH) Close Observations" fifteen (15) minute checks dated 10/19/19 revealed staff failed to record observing the patient between 2:45 p.m. and 3:00 p.m.

6. An interview was conducted with the Regulatory and Patient Safety Manager on 11/21/19 at approximately 9:30 a.m. When asked if staff should complete all fifteen (15) minute patient safety checks on each patient as per the BH Close Observations on the unit, she concurred with the above findings.

Based on observation and the hospital's patient room ligature safety risk assessment the hospital failed to ensure sixteen (16) of sixteen (16) patient doors were free from ligatures. This failure has the potential for all patients admitted to the behavior health unit to be at risk for death.

1. Observation of the behavior health unit in the presence of supervisor #1 on 11/20/19 at 3:45 p.m. revealed all patient rooms have a hinge the length of the door inside the patient's room.

2. A review of the ligature patient room risk assessment completed by the hospital revealed no risk assessment of the hinges on the behavior health unit was completed.

3. An interview was conducted with supervisor #1 during the observation and she concurred the internal hinge poses a ligature which a patient could hang themselves from.

4. A joint interview was conducted on 11/21/19 at 7:25 a.m. with the Vice President of Support Services and the Facility Manager. When asked if they agreed the hinges on the doors were a ligature risk for patients to cause self-harm, they both stated, "Yes."