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Based on record review and , the psychiatric hospital failed to provide care in a safe setting. The deficient practice is evidenced by failure to observe the patient per physicians orders in 2 (#2, #5) of 5 reviewed medical records.

Findings:

Review of Policy CS-23, Level of Observation, revised 03/01/2023, revealed in part, " Purpose: To provide staff with a framework for monitoring patients to ensure safety. Observation should be both safe and therapeutic. Respect should be shown for the patient's need for autonomy while ensuring safety. . . . Staff members utilize the close observation checklist form (Q15 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 dialing living). The observing staff initials the 15 minute increments on the form to indicate the patient was observed. This form or vital sign form will also be utilized for 1: 1 monitoring when a stricter level of monitoring is ordered and will notated as such on top of the form. The staff member signs the signature line at the bottom of the form to validate their initials and credentials. The Registered Nurse (RN) will conduct routine rounds to visually observe each patient for safety at least every 2 hours (unless more often is warranted) and will validate rounds by initialing in the appropriate section of the form."

Patient #2
Review of the medical record for Patient #2 revealed admission on 08/05/2023 for major depression and neurocognitive disorder. The admission orders indicate the patient was on Q 15 minute observation.

Review of the Observation Check/ Graphic Flowsheet for 08/08/ 2023 revealed the patient was not appropriately observed every 15 minutes between 2:00 p.m. and 4:00 p.m. by the Mental Health Tech (MHT). The Registered Nurse (RN) on duty did sign the observation for 3:00 p.m.

Review of the Observation Check/ Graphic Flowsheet for 08/16/ 2023 revealed the patient was not appropriately observed every 15 minutes between 7:00 p.m. and 7:00 a.m. The patient's location and behavior was not documented all night but the form was signed by the MHT and the RN in all the required locations.

In interview on 09/12/2023 at 10:50 a.m., S1DON verified the MHT did not properly monitor Patient #2 on 08/08/2023 and 08/16/2023.

Patient #5
Review of the medical record for Patient #5 revealed admission on 08/11/2023 for bipolar depression with suicidal ideation. The admission orders indicate the patient was on Q 15 minute observation and was on suicide precautions.

Review of the Observation Check/ Graphic Flowsheet for 08/14/ 2023 revealed the patient was not appropriately observed every 15 minutes between 12:00 p.m. and 1:00 p.m. The patient's location and behavior were not documented but the Mental Health Tech (MHT) and the Registered Nurse (RN) signed in the appropriate locations.

In interview on 09/12/2023 at 9:10 a.m., S1DON verified the MHT did not properly monitor Patient #5 who was on suicide precautions.

Based on record review and interview, the psychiatric hospital failed to ensure a Registered Nurse (RN) monitored the care provided to each patient. The deficient practice is evidenced by failure to properly monitor Mental Health Tech (MHT) observation of patients in 2 (#2, #5) of 5 (#1-#5) reviewed medical records.

Findings:

Review of Policy CS-23, Level of Observation, revised 03/01/2023, revealed in part, " Purpose: To provide staff with a framework for monitoring patients to ensure safety. Observation should be both safe and therapeutic. Respect should be shown for the patient's need for autonomy while ensuring safety. . . . Staff members utilize the close observation checklist form (Q15 check sheet) to document the ongoing observation and location of the patient. . . . The observing staff initials the 15 minute increments on the form to indicate the patient was observed. . . . The Registered Nurse (RN) will conduct routine rounds to visually observe each patient for safety at least every 2 hours (unless more often is warranted) and will validate rounds by initialing in the appropriate section of the form."

Patient #2
Review of the medical record for Patient #2 revealed admission on 08/05/2023 for major depression and neurocognitive disorder. The admission orders indicate the patient was on Q 15 minute observation.
Review of the Observation Check/ Graphic Flowsheet for 08/08/ 2023 revealed the patient was not appropriately observed every 15 minutes between 2:00 p.m. and 4:00 p.m. by the MHT. The MHT did sign in the signature boxes between 2:00 p.m. and 4:00 p.m., but did not document the location and behavior of the patient. The RN on duty did sign the observation for 3:00 p.m. There is no evidence the RN corrected the actions of the MHT who did not resume documentation until 4:00 p.m.

Review of the Observation Check/ Graphic Flowsheet for 08/16/ 2023 revealed the patient was not appropriately observed every 15 minutes between 7:00 p.m. and 7:00 a.m. The form was signed by the MHT and the RN in all the signature boxes, but the patient's location and behavior was not documented all night.

In interview on 09/12/2023 at 10:50 a.m., S1DON verified the RN did not properly monitor the care provided by the MHT for Patient #2.

Patient #5
Review of the medical record for Patient #5 revealed admission on 08/11/2023 for bipolar depression with suicidal ideation. The admission orders indicate the patient was on Q 15 minute observation and was on suicide precautions.

Review of the Observation Check/ Graphic Flowsheet for 08/14/ 2023 revealed the patient was not appropriately observed every 15 minutes between 12:00p.m. and 1:00 p.m. The patient's location and behavior were not documented for 2 of the 15 minute checks, but the MHT signed in all the signature boxes. The RN signed the form at 11:00 a.m. and 1:00 p.m.

In interview on 09/12/2023 at 9:10 a.m., S1DON verified the RN did not properly monitor the care provided by the MHT for Patient #5.

Based on record review and interview, the psychiatric hospital failed to ensure the Infection Control Professional was qualified through education, training, experience, or certification in infection prevention and control. The deficient practice is evidenced by failure to document certification or formal training or education related to directing an infection control program in a hospital setting.

Findings:

Review of the provided documentation for S2IC revealed a date of hire of 01/10/2023. Review of the provided education revealed in addition to the standard hospital orientation provided for all employees, the Infection Control Officer had an additional 1 hour of training influenza management in special populations, 1 hour training in environmental cleaning, 1.2 hours of training in personal protective equipment, 2 hours training in Clostridium difficile infection. There was also a certificate for biohazard waste training which was a topic included in the routine orientation.

In interview on 09/12/2023 at 1:15 p.m., S1DON verified this was all the documentation she had related to training for the Infection Control Officer. S1DON verified she had no further information about S2IC's training and experience related to performing the duties of an infection control officer.