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Based on observations and interviews, the hospital failed to provide care in a safe setting for four patients (Patient #1, Patient #2, Patient #3, Patient #4) in the behavioral health section of the Emergency Department (ED).

See tag 0144.

Based on observations and interviews, the hospital failed to provide a patient's right to care in a safe setting, for four (Patient #1, Patient #2, Patient #3, Patient #4) of ten patients sampled, in the behavioral health section of the Emergency Department (ED).

Findings include:

The hospital report, dated 01/14/2022, indicated that on 01/09/2022, Patient #1 attempted to remove his eye while in a bathroom of the behavioral health section of the Emergency Department (ED). Patient #1 suffered from vitreous hemorrhage (bleeding into the fluid that fills the center of the eye), corneal abrasion (scratch at the front of the eye) and ecchymosis (a discoloration of the skin resulting from bleeding underneath). This self-harm event occurred despite Patient #1 having a physician order for constant observation.

The policy titled Constant Observer Assessment, Implementation, and Discontinuation for Patients under Harm Precautions, effective date 09/08/2020, defines Line of Sight observation as "Line of Sight observation means one competent constant observer (CCO) in direct line of sight with one or more patients."

The Constant Observer Flow Sheet Appendix C, last revised 03/18/2022, states (under the section "For the Behavioral Health Patient, the following will also apply") that "Assist nurse to inspect all items brought in by visitors, nurse will instruct you if assistance is needed."

Medical record review, conducted on 05/19/2022 at 1:20 P.M. confirmed that Patient #2, Patient #3 and Patient #4 had the following order under the orders section: "Section 12 - Line of Sight Observation."

The following observations were made by the surveyor during an ED tour of the hospital. The surveyor was accompanied by the Nursing Director of the ED and the Director of Quality and Patient Safety. The observations occurred on 05/18/2022 between approximately 4:00 P.M. and 4:30 P.M.:

1) CCO #1 was responsible for providing Line of Sight observation for three patients, Patient #2, Patient #3 and Patient #4.

2) The surveyor observed, on multiple occasions that CCO #1 was not maintaining Line of Sight with Patient #2. The CCO's sitter desk location does not provide optimal view of Patient #2 while Patient #2 is lying down in bed. Only part of Patient #2's room is visible from the CCO's desk location.

3) The surveyor observed that CCO #1 was continuously leaving the CCO's sitter desk to check in on Patient #2, entering into Patient #2's room multiple times, and as a result breaking Line of Sight observation with Patient #3 and Patient #4.

4) The surveyor observed that Patient #3 was requesting/attempting to utilize the restroom. Although CCO #1 followed Patient #3 to provide appropriate observation of Patient #3 during restroom use, the CCO #1 failed to request assistance from other staff to cover for CCO #1's other two patients, Patient #2 and Patient #4. As a result, Line of Sight observation was broken for Patient #2 and Patient #4.

5) The surveyor observed a visitor of Patient #4 walk past the surveyor and entered Patient #4's room. The visitor was in Patient #4's room for approximately one to two minutes prior to Nurse #1 completing a belongings check on the visitor's items.

The surveyor interviewed CCO #1 on 05/19/2022 at 3:15 P.M. CCO #1 acknowledged that from the CCO sitter desk location and where it is positioned in relation to Room 30, Hallway Bed 30 and Room 1, one cannot fully visualize a patient in Room 30.

The surveyor interviewed CCO #1 on 05/19/2022 at 3:15 P.M. CCO #1 acknowledged that a belongings check may not occur prior to a visitor entering a behavioral health patient's room. CCO #1 stated that at times a nurse may not be readily available to perform a belongings check (CCO #1 provided an example such as the nurse being in a medication room getting medications for a patient) and as a result, a visitor may enter a patient's room prior to the nurse getting back in time to intervene with the visitor to ensure any and all belongings have been inspected and deemed safe.

The surveyor interviewed Patient Care Associate (PCA) #1 on 05/20/2022 at 10:38 A.M. PCA #1 acknowledged that the current setup of the behavioral health section of the ED makes it impossible for a PCA/CCO to do the CCO role correctly in accordance with policy. PCA #1 indicated that when the behavioral health section of the ED is at high capacity, behavioral health patients span two hallways. PCA #1 stated that a PCA/CCO has to be continuously walking and patrolling the hallway(s) to check in on all the patients assigned to a given PCA/CCO. PCA #1 added that when a PCA/CCO goes on break there is typically no additional coverage provided. PCA #1 stated that the PCAs/CCOs have to cover each other's patients during the time a PCA/CCO may be on break.

The policy titled Constant Observer Assessment, Implementation, and Discontinuation for Patients under Harm Precautions, effective date 09/08/2020, states under Section 5, Part A1c: "Patients requiring 4 point non-violent restraints or 3-4 point violent restraints, will have a CCO implemented immediately."

The CCO FlowSheet for Patient #1, dated 01/09/2022, failed to have documentation that would indicate that a CCO was assigned to Patient #1 between the hours of 3:00 P.M. and 11:00 P.M. The CCO FlowSheet is filled out between 7:00 A.M. and 3:00 P.M. The CCO FlowSheet is blank from 3:00 P.M. to 11:00 P.M. The CCO FlowSheet resumes documentation at 11:00 P.M. The Violent Restraint FlowSheet indicated that Patient #1 was in 4-point restraints beginning 01/09/2022 at 12:55 P.M. and remained in place for the rest of 01/09/2022.

The surveyor interviewed the Nursing Director of the ED on 05/19/2022 at 1:20 P.M. The Nursing Director said that when 4 point restraints are implemented on a patient, the Violent Restraint FlowSheet can serve as a substitute for the CCO FlowSheet.

Based on observations and interviews, the hospital failed to maintain an effective, ongoing performance improvement program, for one (Patient #1) of ten patients sampled.

See tag 0283.

Based on observations and interviews, the hospital failed to maintain an effective, ongoing performance improvement program in response to Patient #1's self-harm event that occurred on 01/09/2022.

Findings include:

The hospital report, dated 01/14/2022, indicated that on 01/09/2022, Patient #1 attempted to remove his eye while in a bathroom of the behavioral health section of the Emergency Department (ED). Patient #1 suffered from vitreous hemorrhage (bleeding into the fluid that fills the center of the eye), corneal abrasion (scratch at the front of the eye) and ecchymosis (a discoloration of the skin resulting from bleeding underneath). This self-harm event occurred despite Patient #1 having a physician order for constant observation.

Document review, conducted by the surveyor on 05/18/2022, indicated that a Root Cause Analysis (RCA, an analysis of the hospital's investigation to identify the root causes and contributing factors that may have led to a particular event) of Patient #1's self-harm event was completed by 01/21/2022. As a result of the RCA, the hospital implemented a Corrective Action Plan (CAP), which included re-education of security staff and constant observer staff (staff who are responsible for performing constant observation on patients, i.e. CCOs and PCAs) as well as a plan for continued audits by nursing administration daily, to ensure that constant observer staff are performing their tasks in accordance with hospital policies and procedures. The responsible parties for this CAP were one of the Nursing Directors and the Security Manager.

The surveyor interviewed the Nursing Director of Float Pool on 05/18/2022 at 2:15 P.M. The Nursing Director stated that the constant observer re-education and staff attestations (staff signing that they are aware of the hospital's policy/procedures regarding constant observation) were completed by the end of March 2022. The Nursing Director stated that active staff attestations were at 100%, (meaning that all pertinent constant observer staff had been re-educated in accordance to the CAP).

Despite an implemented CAP, the CAP failed to be effective nor was it ongoing. This was indicated by the following observations made by the surveyor during the ED tour of the behavioral health section of the ED on 05/18/2022 between 4:00 P.M. and 4:30 P.M.

1) CCO #1 was responsible for providing Line of Sight observation for three patients, Patient #2, Patient #3 and Patient #4.

2) The surveyor observed, on multiple occasions that CCO #1 was not maintaining Line of Sight with Patient #2. The CCO's sitter desk location does not provide optimal view of Patient #2 while Patient #2 is lying down in bed. Only part of Patient #2's room is visible from the CCO's sitter desk location.

3) The surveyor observed that CCO #1 was continuously leaving the CCO's sitter desk to check in on Patient #2, entering into Patient #2's room multiple times, and as a result breaking Line of Sight observation with Patient #3 and Patient #4.

4) The surveyor observed that Patient #3 was requesting/attempting to utilize the restroom. Although CCO #1 followed Patient #3 to provide appropriate observation of Patient #3 during restroom use, CCO #1 failed to request assistance from other staff to cover for CCO #1's other two patients, Patient #2 and Patient #4. As a result, Line of Sight observation was broken for Patient #2 and Patient #4.