HospitalInspections.org

Based on record review, observation, and interview, the hospital failed to meet the requirements of the Condition of Participation for Patient Rights as evidenced by:

The hospital failed to ensure patients received care in a safe setting as evidenced by failure of the hospital to ensure a patient admitted with thoughts of self-harm, on suicide precautions, placed in a room with ligature risks (a metal framed " medical" bed with multiple ligature points) was placed on 1:1 observation as set forth in the hospital's risk mitigation plan for 1(#1) of 1 total patients on suicide precautions and failure to ensure MHTs observed patients every 15 minutes as ordered for 1 (#1) of 1 total inpatients on suicide precautions observed on a hospital-provided video. The video reviewed on 1/26/18 from 1:00 a.m. through 5:21 a.m. (a total of 4 hours and 19 minutes) provided a camera view of the longer of 2 halls with a direct view of Patient #1's room. The video revealed Patient #1 had not been observed for the following time frames: 1:02 a.m. - 1:49 a.m. (47 minutes with no observation); 1:49 a.m. - 2:23 a.m. (34 minutes without observation); 2:23 a.m. - 5:21 a.m. (2 hours and 58 minutes with no observations). (See findings under tag A-0144).

An Immediate Jeopardy situation was identified on 1/26/18 at 2:21 p.m. and reported to S1Adm, S3Quality, and S4CorpCompliance. The Immediate Jeopardy situation was a result of the hospital failing to ensure all patients were monitored as ordered by physician's order, including a patient admitted with thoughts of self-harm, on suicide precautions, who was placed in a room with ligature risks (a metal framed "medical" bed with multiple ligature points). The patient was not placed on 1:1 observation as set forth in the hospital's risk mitigation plan due to being on suicide precautions and being placed in a room with ligature risks. In addition, the failure to monitor patients as ordered every 15 minutes and to provide a safe environment placed patients at risk for harm to self and others. The provider had also been previously made aware of the lack of patient supervision/monitoring on 12/13/17 when a Condition level deficiency in Nursing Services was written due to lack of patient supervision/monitoring by the hospital staff in an environment with identified ligature risks (metal framed "medical" patient beds with multiple ligature anchor points).

Review of the hospital's Ligature Assessment/Risk Mitigation Plan, presented as current by S3Quality, revealed the following, in part: Rooms with medical beds (301- 2 beds, 302- 2 beds , 303- 2 beds, and 304-2 beds ) will not have patients with suicidal precautions or thoughts of suicide or self- harm assigned to these rooms with medical beds. If a patient with Suicidal or Self-harm thoughts is assigned to a room with a medical bed, the patient will be placed on 1:1 (Observation level) while assigned to a room with a medical bed.

Review of Patient #1's medical record revealed an admission date of 1/24/18 with an admission diagnosis of Major Depressive Disorder with Suicidal Ideations. Further review revealed the patient's legal status was PEC on 1/24/18 at 10:13 a.m. with a mental condition of confusion, disorganized thinking, and delusions. Additional review revealed Patient #1 was suicidal, homicidal, dangerous to self and others, gravely disabled, and unable to seek voluntary admission at the time of her PEC.

Review of Patient #1's admission physician's orders, dated 1/24/18 at 2:45 p.m., revealed an order for Suicide Precautions and Close observation with every 15 minute checks. Further review revealed no documented evidence that the patient had ever been placed on 1:1 Observation level.

Review of Patient #1's Initial Treatment Plan indicated the patient's primary problem was Risk for Self- harm.

Review of Patient #1's History and Physical, dated 1/24/18 at 3:30 p.m., revealed the chief complaint was documented as, "I've had some thoughts about doing some things to myself." Further review revealed the details of present illness were documented as: Patient with increased depression, with passive Suicidal Ideations and positive for delusions.

Review of Patient #1's Close Observation Check Sheets for 1/24/18 -1/26/18 revealed the patient was on Suicide Precautions with observation checks documented every 15 minutes. Further review revealed no documented evidence that the patient had ever been placed on 1:1 Observation level.

On 1/26/18 at 10:20 a.m., Patient #1 was observed seated at a table with two other patients. Patient #1 was wearing a cloth hospital gown that was tied with strings. Patient #1 also had a blanket, knotted in a cape-like fashion, around her shoulders. Patient #1 was not observed to be on 1:1 Observation.

On 1/26/18 at 10:35 a.m. Patient #1, who was on Suicide Precautions, was observed going to her room, alone and unattended by staff.

On 1/26/18 at 10:40 a.m., upon entry into the patient's room, with S2DON, the patient was observed to be seated on the bed, alone. The patient's room had 2 metal framed "medical" beds (multiple ligature anchor points). The 2 beds were each dressed with a full set of linens (2 sheets and 1 blanket per bed).

In an interview on 1/26/18 at 10:30 a.m. with S2DON, she indicated she would have to verify whether Patient #1 was currently on Suicide Precautions. S2DON confirmed Patient #1 was not on 1:1 Observation. S2DON also confirmed Patient #1 should have been placed on 1:1 Observation level if she was on Suicide Precautions due to being placed in a room with ligature risks (a metal framed "medical" bed with multiple anchor points in a room with sheets and blankets) per the hospital's risk mitigation plan.

On 1/26/18 at 11:30 a.m. an observation was made of a hospital provided video to review staff supervision of Patient #1 who was on Suicide Precautions with orders for every 15 minute observations. The patient was admitted to a room with ligature risks (a metal framed "medical" bed with sheets and blankets). The video reviewed was from 1:00 a.m. through 5:21 a.m. (a total of 4 hours and 19 minutes) on 1/26/18. The video provided a camera view of the longer of the hospital's 2 halls with a direct view of Patient #1's room. The video revealed Patient #1 had not been observed for the following time frames: 1:02 a.m. -1:49 a.m. (47 minutes with no observation); 1:49 a.m. -2:23 a.m. (34 minutes with no observation); 2:23 a.m. -5:21 a.m. (2 hours and 58 minutes with no observations).
The observations made during review of the above referenced video were verified with S3Quality (who assisted the surveyor in viewing the video). She confirmed the patient observation records had been documented to indicate the observations had been completed in q 15 minute intervals and acknowledged that documentation was not reflective of what had been observed on the video recording. S3Quality indicated the MHT staff had probably been rounding on the other hall at the time of the observations. S3Quality also indicated the nursing staff had not entered Patient #1's room because she had probably not had any medications due during the time interval observed.

In an interview on 1/26/18 at 11:55 a.m. with S1Adm, who was present when the video was reviewed, she verified Patient #1 had not been observed every 15 minutes as ordered. S1Adm also acknowledged that the patient not being observed by staff for hours at a time was not acceptable.

In an interview on 1/26/18 at 1:13 p.m.with S8LPN, she reported she had worked the day before (1/25/18). S8LPN stated there was one LPN and one RN on duty caring for all of the patients. S8LPN was asked what interventions were implemented when a patient was placed on suicidal precautions. S8LPN explained the patient(s) would be placed on 1:1 supervision, within arm's length at all times, including going to the bathroom and when the patient was asleep. She went on to explain that patients on suicidal precautions should have worn paper gowns and were not allowed to wear gowns with strings. When asked if there were any current patients on suicide precautions, S8LPN stated to her knowledge there were not any patients currently on suicidal precautions. S8LPN stated if there was a patient on suicide precautions, she would have received that information during shift change report.

In an interview on 1/26/18 at 2:50 p.m., S2DON acknowledged S8LPN had worked on 1/25/18. S2DON verified S8LPN should have known Patient #1 was placed on suicide precautions.

A request for interview of S5RN (RN charge nurse on 1/26/18 during the time interval reviewed) was made of S2DON. S2DON indicated S5RN had resigned and had declined an interview with the surveyor.

In an interview on 1/29/18 at 8:51 a.m. with S6MHT, she confirmed Patient #1 had been on suicide precautions with every 15 minute checks. S6MHT also confirmed Patient #1 had not been placed on 1:1 Observation. S6MHT reported she had normally done patient q (every) 15 minute checks on time, but she was sometimes late if she had been "stuck in a room with another patient." S6MHT said "a lot of times the MHT's caught up work that had been left when they got to work." S6MHT reported if they had gotten late night admits the patient q 15 minute checks would have sometimes "gotten behind." S6MHT reported at some point she was probably trying to stay awake between 1:00 a.m. and 5:21 a.m. because it had been a rough 2 nights. S6MHT said she hated that they "dropped the ball and missed patient q 15 minute checks". S6MHT acknowledged she had not performed her patient checks as ordered.

In an interview on 1/29/18 at 9:09 a.m. with S7MHT, she indicated each shift was usually staffed with 3 MHTs, a RN, and a LPN. S7MHT reported the patients were split as evenly as possible amongst the MHTs. S7MHT reported all of the patients on 1/26/18 (1:00 a.m. -5:21 a.m.) were on every 15 minute observation checks. S7MHT reported it was the MHTs assigned to the floor who were responsible for doing patient rounds. S7MHT indicated it was the Charge RN's responsibility to monitor the MHTs to ensure they were making rounds and to check off on their observation records every 2 hours when the charge nurse rounded. S7MHT verified patients, like Patient #1, who were on suicide precautions should have been monitored as ordered every 15 minutes. S7MHT reported she had never been told anything about patients being placed on 1:1 Observation if they were on suicide precautions and had been admitted in the rooms with the metal framed "medical" beds. S7MHT reported one MHT usually rounded on all of the patients and that MHT reported to the patient's assigned tech who then charted that observation on their assigned patient's observation records. S7MHT reported the MHTs were told to use a penlight to check on patients at night and to lay eyes on them to make sure they were breathing when they were sleeping. S7MHT agreed it was important to do every 15 minute patient observation checks as ordered.

On 1/26/18 at 3:15 p.m. S1Adm and S4CorpCompliance presented the 1st plan for lifting the immediacy of the IJ situation and the plan included the following:
a. Placing Patient #1 on 1:1 supervision immediately pending reassessment of the patient's current suicide risk by the attending Psychiatrist on 1/26/18. The patient was reassessed, identified as a low risk for suicide and the attending physician gave the order to discontinue the suicide precautions. Patient was immediately relocated to a ligature resistant room to be maintained under q 15 minute observations unless ordered by the attending psychiatrist.

b. The plan also included, effective immediately, that any patient assessed as high risk for suicide would be prioritized to ligature resistant rooms unless otherwise ordered by a physician. Physician orders for 1:1 Observation would be obtained for any patient assessed as high risk for suicide requiring placement in a non- ligature resistant room. Education would be provided by the DON to all nursing staff beginning on 1/26/18 and completed prior to nursing staff member working a shift on including, but not limited to appropriate assessment and documentation of patient suicide risks as well as the above noted room prioritization process to increase staff awareness and ensure ongoing compliance.

c. Additionally, the plan included a requirement that the DON or RN House Supervisor would maintain 24/7 onsite coverage in the geriatric inpatient hospital until all education was completed and until successfully achieving 100% for all every 15 minute observations for 72 consecutive hours to ensure ongoing compliance.

On 1/26/18 at 3:20 p.m. S1Adm and S4CorpCompliance were informed the 1st plan for lifting needed more detail regarding how the hospital was going to evaluate/measure compliance such as video review and/or direct observation, and the time frames after the initial 72 hours to evaluate and maintain compliance.

On 1/26/18 at 3:40 p.m. the 2nd revised plan for lifting was presented by S1Adm and S4CorpCompliance and was revised as follows: The DON or RN House Supervisor will maintain 24/7 onsite coverage in the Geriatric Hospital until all education is completed and to maintain physical observation of all every 15 minute observations until successfully achieving 100% compliance for 72 consecutive hours. The DON or designee will review at least 1 hour of video surveillance per shift/per day for every 15 minute observations.

Review of Patient #1's medical record revealed a Physician's Order for 1:1 Observation. Further review revealed the patient had been reassessed by the treating Psychiatrist as low risk and orders to discontinue Suicide Precautions and 1:1 Observation were noted.

An observation was made of Patient #1 on 1/26/18 at 2:45 p.m. She had been placed on 1:1 Observation and the assigned MHT had the patient in her line of sight and within her arm's reach.

Staff education (all staff including MHTs, RN, LPN, and Ward clerk) was immediately begun on 1/26/18 after declaration of the IJ situation. The staff education focused on patient supervision. The staff education sign in sheets were reviewed and all staff present had been in-serviced prior to survey team exit.

The Immediacy was lifted on 1/26/18 at 4:25 p.m. at survey team exit. However, there was not enough evidence to determine sustainability of Compliance for the Condition of Patient Rights to be cleared. Noncompliance remains at the Condition Level.