HospitalInspections.org

Based on surveyor observations, record review and confirmed in interview, the facility failed to implement their policies and procedures that promoted care in a safe setting. The facility failed to ensure staff observed patients per doctor's orders as line of sight (LOS) for two of ten patients reviewed (Patient # 3 and 4).

The findings include:

In review of facility policy Levels of Observation and Precautions (Policy Stat ID 14807112, effective 03/2024), it stated "To ensure there is clear differentiation between patients' needs when different levels of risk are present. The levels of observation and precautions are identified based on the risk assessment as well as by patient behavior. The nursing staff and medical providers will assess patients for risk level and make level of observation and precaution recommendations based on the risk level assessment findings and patient behavior. It is critical that patient observation level and precautions are documented on the Close Observation Sheet and communicated to team members...

2. Line of sight observation:

This level of observation is very restrictive and involves continuous visual monitoring at all times.

Documentation should reflect the need for continued line of sight or improvement in behaviors.

Staff must be within visual contact of the patient at all times.

A staff member may observe more than one patient on line of sight observation only while those patients remain in an area for scheduled activity (i.e. group therapy, dining, outside break or activity).

If a staff member is observing more than one patient and one or more of the patients go to separate areas, the staff must transfer responsibility for line of sight to other staff members) so that there is continuous observation of all patients on line of sight precautions.

Staff shall maintain a continuous log which indicates the patient's location and behavior every 15 minutes and document throughout each shift."

Review of Patient #3's chart revealed he was admitted on 06/19/2024 for Major Depressive Disorder for mood stabilization and safety monitoring with a level of observation ordered as a line of sight at admission.

Review of patient #4's chart revealed she was admitted on 06/19/2024 for Major Depressive Disorder for mood stabilization and safety monitoring with a level of observation ordered as a line of sight after her history and physical assessment.

Surveyor review of video recording in the Willows unit on 08/27/24 revealed Patients #3 and 4 in the hallway of their unit down the hall from the nursing station on 07/09/2024 at approximately 5:33 PM. For two minutes, Patient #3 and #4 had privacy to engage in inappropriate touching. Video review showed a tech entering the unit onto the hallway at 5:35 PM who subsequently separated the two patients.

No staff had line of sight visualization for either Patient #3 and Patient #4 for two minutes on 07/09/2024.

An interview with Staff # 1 on 08/27/2024 at 2:20 PM in the conference room confirmed the above findings.