HospitalInspections.org

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 PATIENT RIGHTS was out of compliance.

A-0144 The patient has the right to receive care in a safe setting. Based on interviews and document review, the facility failed to ensure a safe environment of care for patients. Specifically, the facility failed to ensure all Direct Patient Observers (DPOs) were educated and trained to monitor and supervise at-risk patients.

Based on interviews and document review, the facility failed to ensure a safe environment of care for patients. Specifically, the facility failed to ensure all Direct Patient Observers (DPOs) were educated and trained to monitor and supervise at-risk patients.

Findings include:

References:

The Direct Patient Observer Guide read, patients who have been identified to be at risk: suicide risk, confusion, delirium, harm to self or others, elopement risk, may be assigned a DPO. The purpose of the DPO is to provide continuous observation of at risk patients. Any staff member can serve as the DPO after completing education. Clinical staff documents in the electronic health record (EHR) and utilize the interventions tab under flowsheet to document under Precautions. Precautions are either Elopement Precautions, At Risk Precautions, or both. In the Vital Flowsheet, document under by 'Yes' to 'Continuous Observation at Bedside'. If staff member is clinical, performs care within their scope of practice. If staff member is not clinical, maintain safe environment and observation of patient. Guidelines for staff assigned as a DPO: Implement At Risk Precautions. Do not leave the patient room. At Risk Precautions are: Observation of the patient, bathroom safety, create a safe environment. To create a safe environment, evaluate the patient's immediate safety needs. Perform a facility-approved environmental risk assessment and remove sharp objects. Remove all items that can be used for self-harm. Remove all potentially hazardous chemicals and medications.

The Direct Patient Observer Labor Pool Training read, DPOs document patient behaviors and alert staff when patients have a medical or behavioral need. Inpatient Direct Patient Observer: Patients who have been identified to be at risk: suicide risk, confusion, delirium, harm to self or others, elopement risk, may be assigned a Direct Patient Observer (DPO). The purpose of the DPO is to provide continuous observation of at risk patients. At risk patients are at risk for harm to themselves or others and must be under constant observation. Remain within arm's reach of the patient. Maintain a secure environment. Remain within arm's reach of the patient inside the restroom, safety before modesty. Documentation Guidelines: All patients with At Risk Precautions orders are documented every shift.

1. The facility failed to ensure DPOs were trained and able to monitor and supervise patients at risk for self-harm.

a. Medical record review on 8/3/22 at 9:09 p.m., Patient #3 presented to the Emergency Department (ED) after she ingested a metal nail. According to the ED Provider Notes entered on 8/4/2022 at 12:38 a.m., Patient #3 ingested and inserted foreign objects and a DPO was assigned to continuously monitor Patient #3. Furthermore, "At Risk Precautions" were implemented for Patient #3 and all unnecessary objects, cords, tubing, cables, medical equipment and objects which could be used to self-harm were removed from Patient #3's room.

Further medical record review revealed from 8/4/22 through 8/15/22, Patient #3 self-harmed while being continuously monitored and observed by DPOs. Examples included:

i. According to the Hospitalist Progress Note entered at 9:56 a.m. on 8/7/2022, Patient #3 inserted a toilet paper holder and a drinking straw into her vagina when she was allowed to be unsupervised in the restroom 8/6/22.

ii. A Significant Event Note entered by Registered Nurse (RN) #6 on 8/8/22 at 7:35 p.m. read, Patient #3 intentionally swallowed a bottle cap while supervised by a DPO. According to the Significant Event Note, at 5:42 p.m., the DPO assigned to Patient #3 alerted RN #6 Patient #3 had self-harmed. The Significant Event Note further stated RN #6 assessed Patient #3 after she swallowed the bottle cap and the patient had developed a stridor (an abnormal high-pitched wheezing sound caused by an obstructed airway) and pain.

iii. According to a Nursing Note entered on 8/9/2022 at 9:21 p.m., Patient #3 swallowed two EKG pads (stickers placed on the chest which hold monitor leads that allow for heart monitoring) while a DPO was assigned to observe the patient.

iv. The Nursing Note documented on 8/10/2022 at 6:24 p.m. read, Patient #3 removed batteries from the telemetry box (a portable medical device used to monitor and collect information about the rhythm of the heart) worn by Patient #3 and inserted the batteries into her vagina.

v. According to the Nursing Note entered on 8/11/2022 at 6:57 p.m., a DPO was assigned to Patient #3 and was present in Patient #3's room with the patient. With the DPO in the room, Patient #3 swallowed two cleaning wipes.

vi. Clinical Notes entered on 8/14/2022 at 3:47 a.m. read, Patient #3 was given a can of soda and was able to separate the pull tab (a built-in device located on the top of a soda can used to open the soda) off of the soda can and swallowed the pull tab.

These examples were in contrast to the Direct Patient Observer Labor Pool Training which read, patients who were known to be a risk to themselves were required to have continual observation and monitoring by a DPO. The DPO must remain within reach of the patient and maintain a secure and safe patient environment. The DPO must remain within arm's reach of the patient at all times including when the patient uses the restroom.

c. On 8/17/22 at 9:13 a.m., an interview was conducted with Patient Care Assistant (PCA) #1, who provided care as a DPO for Patient #3. PCA #1 stated patients were assigned a DPO to ensure the safety of the patient. PCA #1 stated patients who were impulsive, suicidal, attempted self-harm or harm towards others would have a DPO assigned to them. PCA #1 stated DPOs were required to directly visualize and monitor the patient to ensure the patient remained safe and did not engage in harmful activities. However, PCA #1 stated he did not know what at-risk precautions consisted of and was unable to verbalize what needed to be monitored and observed when a patient was placed on at-risk precautions. In addition, PCA #1 was unable to advise what was expected to be observed and monitored when assigned the role of a DPO.

PCA #1 stated he did not recall completing any DPO training or education. PCA #1 stated DPOs used "common sense" to ensure the patients assigned a DPO remained safe. However, a review of PCA #1's personnel file and training revealed on 2/23/22 PCA #1 had received DPO training and education.

d. On 8/17/22 at 12:59 p.m., an interview was conducted with Clinical Educator (Educator) #5. Educator #5 stated training and education were provided for inpatient clinical staff assigned as DPOs for at-risk patients at the facility. Educator #5 stated non-clinical staff were also assigned to be a DPO for patients who were considered at-risk. However, Educator #5 stated non-clinical staff who were assigned as a DPO were not trained or educated by a clinical educator before the staff member was assigned to be a DPO.

e. On 08/18/22 at 8:42 a.m., an interview was conducted with Medical Assistant (MA) #4. MA #4 stated she was trained on how to perform Certified Nursing Assistant (CNA) and PCA roles, functions and responsibilities. MA #4 stated she had not had DPO training or education. MA #4 was unable to state what safety interventions were implemented when a patient was placed on at-risk precautions. MA #4 then stated she had worked as a DPO for Patient #3.

f. On 8/15/22 at 11:49 a.m., an interview was conducted with Registered Nurse (RN) #3 RN #3 stated at risk patients were patients who had medical safety concerns such as ingestion of foreign objects. RN #3 stated Patient #3 was considered an at risk patient and required a DPO at all times. RN #3 stated for a patient at risk for self-harm behavior, it was expected to remove items from the room that may have been used as a choking device and other objects such as the tray table and other bedside items that could be used to engage in self-harm behavior.

RN #3 stated non-clinical staff including outpatient staff had been assigned as a DPO for Patient #3. RN #3 stated non-clinical staff assigned to the DPO role were not oriented or trained on how to work as a DPO. RN #3 stated inpatient nurses did not instruct DPOs on what to watch for while performing the job. RN #3 stated patient activities and behaviors were not documented by DPOs in the electronic medical record. Furthermore, RN #3 stated nursing staff were unable to review or verify what was monitored and observed by the DPO. RN #3 stated Non-clinical DPOs did not touch or assist the patients they were assigned to and patient safety was at risk. RN #3 stated patients who were assigned a non-clinical DPO and attempted self-harm were at risk of physical injuries, disfigurement and even death.

e. On 8/17/22 at 1:42 p.m., an interview was conducted with Director #7. Director #7 stated non-clinical staff were utilized to meet the staffing needs of inpatient units. Director #7 stated outpatient MAs were assigned inpatient CNA roles and responsibilities. Director #7 stated MAs were non-clinical staff and were provided CNA skills training and education. Director #7 stated non-clinical staff were expected to be assigned direct patient observations for patients who were not placed on at-risk precautions. Director #7 stated patients who engaged in self harm were at-risk patients. Director #7 stated the RN documented all clinical observations performed by non-clinical DPOs in the patient medical record.