HospitalInspections.org

Based on document review and interview, it was determined for 1 of 10 (Pt. #1) records reviewed, the Hospital failed to ensure patients received care in a safe setting by conducting observations per policy. This potentially affects current and future patients admitted to the Hospital. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure observations were conducted per policy . See deficiency cited at A-144.

Based on document review, observation and interview, it was determined the Hospital failed to ensure observations were conducted per policy. This has the potential to affect all patients who receive care on the youth unit with an average daily census of 27 patients.

Findings include:

1. The policy titled "Patient Observation" (revised 12/22/20) was reviewed on 9/8/22. The policy noted "2. Nurse/Lead Mental Health Technician (MHT) c. Ensures the patient observations occur a minimum of every 15 minutes, 24 hours a day, seven days a week, for every patient and are documented concurrently on the observation Flow Record... d. While monitoring hallways and patient care area: ensures patients are not entering rooms not assigned to them... MHT (or any employee assigned to Observation) ... c. Observe each patient, a minimum of every 15 minutes... i. All patients are carefully monitored and assessed a minimum of every 15 minutes. Observe patients on bed rest or when sleeping by: i. Looking for the rise and fall of the chest, ii. Counting at least three respirations, and iii. Making sure that the patient has moved from his/her previous sleeping position ... o. Hand off from shift to shift: i. Off-going and oncoming staff will walk/monitor the unit jointly, correlating the patient location/behaviors with the Patient Observation Rounds form(s) to ensure continuity of care."

2. The video surveillance of 9/5/22 at approximately 8:30 PM to 11:45 PM of the East Hallway on the Youth Unit (room #216, 218, 220, 222, 224 and 226) was observed on 9/8/22 at approximately 2:40 PM with the Director of Performance Improvement and Risk Manager (E#1). Between approximately 8:30 PM and 11:45 PM the following were observed:
a) Pt #2 (admit: 9/2/22, Major Depressive Disorder, assigned to room #218) was observed to enter Pt #1's (admit 8/24/22, Major Dsyregulation Disorder, assigned to room #220) room at approximately 8:37 PM;
b)E#3 (Mental Health Technician) was observed not entering the patient's rooms (#216, #218,#220; rooms #222 and #226 was not visualized well) every 15 minutes, with a flash light and observe the chest rise and fall 3 times as per policy;
c) E#4 (Mental Health Technician) was observed to be at the end of the hallway braiding a residents hair;
d) E#5 (Registered Nurse) was observed to be talking on a personal cell phone;
e) E#5 and E#9 (Registered Nurse) were observed to enter room #218 at approximately 9:48 PM for 1 minute and 13 seconds;
f) E#6 (Mental Health Technician) and E#8 (Mental Health Technician) were observed completing shift rounds, however they did not enter patient rooms with a flash light to ensure rise and fall of chest 3 times per policy at approximately 11:17 PM;
g) E#7 (Registered Nurse) and E#6 were observed to enter and exit room #218 at approximately 11:36 PM;
h) E#10 (House Supervisor) was observed to enter room #220 and exit with Pt #2 at 11:41 PM.

3. During an interview on 9/8/22 at approximately 3:15 PM, E#1 verbally agreed staff were distracted, conducted inadequate rounds by not entering the Pt's rooms with a flashlight and watching the chest rise and fall 3 times every 15 minutes, nurses were not observed to have oversight of the Mental Health Technicians and the end of the shift hand-off was not correctly conducted per policy and should have been.