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Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights as evidenced by:

1) Failing to ensure patients received care in a safe setting as evidenced by failure to ensure patients were monitored as ordered by the physician which placed patients at risk for harm to self and others. This was evidenced by failure of staff to monitor psychiatric patients admitted to the BHU every 15 minutes as ordered by the psychiatrist for 8 patients (#2, #3, #4, R1, R2, R3, R4, R5) observed on a hospital-provided video recording (see findings in tag A0144).

2) Failing to ensure the psychiatric unit was free from ligature and suffocation risks as evidenced by having the sink faucets in each patient's bathroom (entered from within the patient's room with a door that can be closed) extending approximately 5 to 6 inches from the point of installation that presented a ligature risk and having pillows covered with a thin plastic that was easily torn apart that presented a risk for suffocation and the opportunity for hiding contraband (see findings in tag A0144).


An Immediate Jeopardy situation was identified on 09/13/17 at 3:30 p.m. and reported to S2CNO. The Immediate Jeopardy situation was a result of the hospital failing to ensure that all patients were monitored as ordered by the physician. In addition, the hospital failed to ensure the environment was free from ligature and suffocation risks on the BHU. The failure to monitor patients as ordered and to provide a safe environment placed patients at risk for harm to self and others.


Observation on the BHU 09/14/17 at 10:40 a.m. revealed S25LPN was sitting 1:1 with patient R6 who had physician orders to be observed 1:1 while awake and/or having suicidal threats. During the observation S25LPN indicated that she left for a break from 9:30 a.m. to 9:45 p.m. while Patient R6 was asleep. She further indicated she notified the charge nurse that Patient R6 asleep and she was leaving on break. She further indicated if Patient R6 had been awake, she would have arranged for a staff member to replace her at his bedside. She confirmed that S26LPN wasn't present in Patient R6's room when she left on break. When asked how she knew when Patient R6 was asleep, she indicated if she speaks to him and he doesn't answer, she knows he's asleep.

Observation on 09/14/17 at 10:55 a.m. of a hospital-provided video recording with S23FMD, present during the entire time the video was viewed by the surveyor, for the time period on 09/14/17 from 2:30 a.m. through 3:52 a.m. revealed the following:

Rooms "f", "g", and "h" were observed.

Patient R3 was in Room "f", had a diagnosis of Schizoaffective Disorder, bipolar type, and had physician orders for suicide precautions and modified visual contact (observations to be done every 15 minutes).

Patient R4 was in Room "g", had a diagnosis of Bipolar Disorder, most recent episode manic, and had physician orders for suicide precautions and modified visual contact (observations to be done every 15 minutes).

Patient R5 was in Room "h", had a diagnosis of Psychosis, unspecified, and had physician orders for suicide precautions and modified visual contact (observations to be done every 15 minutes).

Observation revealed a staff member looked in Rooms "f", "g", and "h" at 2:47 a.m. and at 2:56 a.m.

A staff member looked in Room "f" only at 3:05 a.m.

A staff member looked in Rooms "f", "g", and "h" at 3:52 a.m.

There was no observation of Patient R3 every 15 minutes for 47 minutes from 3:05 a.m. to 3:52 a.m.

There was no observation of Patients R4 and R5 every 15 minutes for 56 minutes from 2:56 a.m. to 3:52 a.m.

All above observations were confirmed by S23FMD during the observation of each hospital-provided video recording.


In an interview on 09/14/17 at 10:45 a.m., S26LPN confirmed she did not sit with Patient R6 while S25LPN was on break, but she did wake him to assess him at 9:45 a.m.

In an interview on 09/14/17 at 12:00 p.m. with S1CNO, S18PID, S19ADM, and S20MD, the surveyor informed the attendees of the observations made on the BHU and by the hospital-provided video recording. S1CNO indicated that S23FMD had informed him of the results of the observations seen on video.

In an interview on 09/14/17 at 1:52 p.m. with S1CNO, S18PID, S24UM, S19ADM, and S20MD prior to the exit conference, all were informed that based on the above observations, the plan for lifting the Immediate Jeopardy was not accepted due to continuation of the identified issues that led to the Immediate Jeopardy being called. The Immediate Jeopardy situation remained in place at the time of the survey exit on 09/14/17 at 1:55 p.m.

Based on observation, record review, and interview, the hospital failed to establish a process to inform each patient and/or patient representative of the hospital's internal Grievance Process, including whom to contact to file a grievance, and failed to provide the patient and/or patient's representative with a phone number and address for lodging a grievance with the State Agency, LDH, that has licensure responsibility for the hospital. This failed practice was evident by no documentation of the above information in the Patient Rights Handbook provided to each patient and/or patient's representative upon admit.

Findings:

Observation on 09/12/17 at 1:45 p.m. revealed no observation of the hospital's grievance process posted on the BHU that included whom to contact to file a grievance and the phone number and address for lodging a grievance with the LDH.

A review of the Patient Rights Handbook, as provided by S17Comp, revealed no information related to the hospital's Grievance Process, no documented evidence of whom to contact to file a grievance, or the LDH's address or phone number in the Patient Rights Handbook.

In interview on 09/12/17 at 1:00 p.m. with S17Comp, she reviewed the Patient Rights Handbook. She indicated that the Patient Rights Handbook was provided to each patient and/or patient's representative upon admit, and she indicated that it did not contain information on the hospital's Grievance Process or whom to contact to file a grievance. She further indicated the handbook did not provide the patient and/or patient's representative with a phone number and address for lodging a grievance with the LDH. She further indicated that the Patient Rights Handbook was the only written patient's rights information provided to the patient and/or patient's representative upon admit. S17Comp indicated the grievance process and related contact information was not posted on the BHU.

Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by:

1) Failing to ensure patients were monitored as ordered by the physician which placed patients at risk for harm to self and others. This was evidenced by failure of staff to monitor psychiatric patients admitted to the BHU every 15 minutes as ordered by the psychiatrist for 9 patients (#2, #3, #4, R1, R2, R3, R4, R5, R6) observed on a hospital-provided video recording from a sample of 5 patients and 6 random patients.

2) Failing to ensure the psychiatric unit was free from ligature risks, suffocation risks, and an opportunity to hide contraband as evidenced by having the sink faucets in each patient's bathroom (entered from within the patient's room with a door that can be closed) extend approximately 5 to 6 inches from the point of installation that presented a ligature risk and having pillows covered with a thin plastic that was easily torn apart that presented a risk for suffocation and an opportunity for hiding contraband.

Findings:

1) Failing to ensure patients were monitored as ordered by the physician which placed patients at risk for harm to self and others:
Observation on 09/12/17 at 11:24 a.m. of a hospital-provided video recording with S23FMD, present during the entire time the video was viewed by the surveyor, for the time period on 09/11/17 from 8:05 p.m. through 10:48 p.m. revealed the following:

Patient #2

Patient #2 entered her room (Room "c") at 8:58 p.m., closed the door, and left the door with a small crack in the door. Staff looked into her room at 9:38 p.m. and at 10:48 p.m. There was no observation of staff monitoring Patient #2 every 15 minutes as ordered by the psychiatrist for 40 minutes from 8:58 p.m. to 9:38 p.m., and for 1 hour and 10 minutes from 9:38 p.m. to 10:48 p.m. Patient #2 was admitted with a diagnosis of Bipolar Disorder and had physician orders for modified visual contact (defined by staff as every 15 minutes) and suicide precautions.


Patient #4

Patient #4 entered her room (Room "b") at 8:05 p.m. Staff went into Room "b" at 8:49 p.m. and looked into Room "b" at 9:38 p.m. and 10:47 p.m. There was no observation of staff monitoring Patient #4 every 15 minutes as ordered by the psychiatrist for 42 minutes from 8:05 p.m. to 8:47 p.m., for 49 minutes from 8:49 p.m. to 9:38 p.m., and for 1 hour and 9 minutes from 9:38 p.m. to 10:47 p.m. Patient #4 was admitted with a diagnosis of Bipolar Disorder and had physician orders for modified visual contact and suicide precautions.


Patient R2

Patient R2 entered her room (Room "a") at 9:45 p.m. Staff looked into Room "a" at 10:47 p.m. There was no observation of staff monitoring Patient R2 every 15 minutes as ordered by the psychiatrist for 1 hour and 2 minutes from 9:45 p.m. to 10:47 p.m. Patient R2 was admitted with a diagnosis of Depression and had physician orders for modified visual contact and suicide precautions.


Observation on 09/12/17 at 9:25 a.m. of a hospital-provided video recording with S23FMD, present during the entire time the video was viewed by the surveyor, for the time period on 07/22/17 from 5:15 p.m. through 7:59 p.m. revealed the following:

Patient #3

Patient #3 was admitted with a diagnosis of Psychosis, unspecified type and had physician orders for modified visual contact and suicide precautions. Patient #3 was in his room (Room "e") with the door closed. Patient #3 exited his room, walked toward the nursing station, re-entered his room at 5:40 p.m., and closed the door. Patient #3 exited his room at 5:46 p.m., walked toward Room "j", stood by the patio door, re-entered his room at 5:48 p.m. and closed the door. He exited his room at 5:49 p.m. and was observed using the telephone. At 5:54:04 p.m. Patient #3 re-entered his room and closed the door. At 5:54:33 p.m. a staff member passed and was observed to touch the door handle of Room "e", did not open the door, and walked down the hall. At 7:16 p.m. a staff member was observed touching the door of Patient #3 but doesn't open the door. At 7:17 p.m. S11US knocks on Patient #3's door, touches the handle, and the door doesn't open. At 7:18:07 p.m. 2 staff members with S12Sec were observed at Patient #3's door. One staff member puts a key in the door, and another staff member waves her hand (appeared to be calling staff to come to room). S12Sec was observed at 7:18:25 p.m. pushing on the door with his shoulder while staff attempted to use the key again. At 1:18:35 p.m. S12Sec opens the door. A nurse enters the room at 7:19:01 p.m. and another nurse enters at 7:19:20 p.m. Another person was observed entering the room at 7:20:09 p.m. The emergency cart was observed to be brought into the room at 7:20:31 p.m. Observation of the video revealed Patient #3 was not observed every 15 minutes as ordered by the psychiatrist for 34 minutes from 5:15 p.m. to 5:49 p.m. and for 1 hour and 24 minutes from 5:54 p.m. to 7:18 p.m.

In an interview on 09/13/17 at 9:27 a.m., S11US indicated when she went to Patient #3's room to get him to meet with the coroner who was on the unit to evaluate patients for a coroner's emergency certificate, she turned the door handle, but it wouldn't open. She further indicated she told S10MHT that she needed to get in the room, because she (S11US) didn't have the door room key with her. S11US indicated S10MHT tried to open the door, but it wouldn't open. She indicated S12Sec was on the unit, and she told him that she needed to get the door open. She further indicated S12Sec and S10MHT got the door open which had a chair pushed against the door. When she entered the room, S11US indicated Patient #3 had paper scrubs on the door handle of the bathroom door that was tied around his neck, and he had hung himself. She further indicated Patient #3 was seated on the floor in front of the bathroom door in an upright position. S11US indicated the nurses who were in report was immediately called to the room, and someone called a Code Blue. She further indicated she didn't think Patient #3 was responsive when she entered the room, and his face had started changing color. S11US indicated S13MHT was assigned to observe Patient #3, but she had clocked out at the time of the event.

In an interview on 09/13/17 at 10:57 a.m., S8RN indicated she was assigned Patient #3's care on 07/22/17. She further indicated she wasn't aware the MHT wasn't observing him every 15 minutes as ordered. She indicated she rounded about every 2 to 3 hours. S8RN indicated when the nurses were called out from report and she arrived in Patient #3's room, Patient #3 sitting up in his room with something tied around his neck, another nurse took what was stuck in the door, and she (S8RN) helped to lay Patient #3 on the floor, and CPR was initiated. When asked what the RN's role was, S8RN indicated the RNs are responsible for patient care, administering medications, and assuring the well-being of the patient. S8RN indicated every person should be responsible for their job..."if it's your job duty, you should do your job duty." When asked if that includes ensuring the MHT makes observations as ordered, she indicated "it always falls back on the nurse." S8RN indicated there was no system in place for the RN to review the MHT's observation sheets to assure the the MHT knows the level of observation for each patient and special precautions that are ordered.

In an interview on 09/13/17 at 10:57 a.m., S8RN indicated she was assigned Patient #3's care on 07/22/17. She further indicated she wasn't aware the MHT wasn't observing him every 15 minutes as ordered. She indicated she rounded about every 2 to 3 hours. S8RN indicated when the nurses were called out from report and she arrived in Patient #3's room, Patient #3 sitting up in his room with something tied around his neck, another nurse took what was stuck in the door, and she (S8RN) helped to lay Patient #3 on the floor, and CPR was initiated. The patient expired. When asked what the RN's role was, S8RN indicated the RNs are responsible for patient care, administering medications, and assuring the well-being of the patient. S8RN indicated every person should be responsible for their job..."if it's your job duty, you should do your job duty." When asked if that includes ensuring the MHT makes observations as ordered, she indicated "it always falls back on the nurse." S8RN indicated there was no system in place for the RN to review the MHT's observation sheets to assure the the MHT knows the level of observation for each patient and special precautions that are ordered.


Patient R1

Patient R1 was admitted with a diagnosis of Schizophrenia and had physician orders for modified visual contact and suicide precautions. Patient R1 was in his room (Room "d") at 5:15 p.m. At 5:28 p.m. he was observed opening his door, looking down the hall, and closing the door at 5:29 p.m. At 5:34 p.m. he opens his door, looks out, and leaves the door with a slight crack in the door. At 5:37 p.m. a staff member was observed passing Room "d" and glancing back at the room. Patient R1 exits his room at 5:39 p.m. and was observed to enter his room at 5:54 p.m. and close the door. At 5:56 p.m. a staff member opened Patient R1's door, looked in the room, and left the door with a slight crack in the door. At 6:32 p.m. a staff member was observed walking from the nursing station and looking in Room "d" as she passed. Observation revealed Patient R1 was not observed every 15 minutes as ordered by the physician for 22 minutes from 5:15 p.m. to 5:37 p.m. while he was in his room and for 36 minutes from 5:56 p.m. to 6:32 p.m.

Observation on the BHU 09/14/17 at 10:40 a.m. revealed S25LPN was sitting 1:1 with patient R6 who had physician orders to be observed 1:1 while awake and/or having suicidal threats. During the observation S25LPN indicated that she left for a break from 9:30 a.m. to 9:45 p.m. while Patient R6 was asleep. She further indicated she notified the charge nurse that Patient R6 asleep and she was leaving on break. She further indicated if Patient R6 had been awake, she would have arranged for a staff member to replace her at his bedside. She confirmed that S26LPN wasn't present in Patient R6's room when she left on break. When asked how she knew when Patient R6 was asleep, she indicated if she speaks to him and he doesn't answer, she knows he's asleep.


Observation on 09/14/17 at 10:55 a.m. of a hospital-provided video recording with S23FMD, present during the entire time the video was viewed by the surveyor, for the time period on 09/14/17 from 2:30 a.m. through 3:52 a.m. revealed the following:

Rooms "f", "g", and "h" were observed.

Patient R3 was in Room "f", had a diagnosis of Schizoaffective Disorder, bipolar type, and had physician orders for suicide precautions and modified visual contact.

Patient R4 was in Room "g", had a diagnosis of Bipolar Disorder, most recent episode manic, and had physician orders for suicide precautions and modified visual contact.

Patient R5 was in Room "h", had a diagnosis of Psychosis, unspecified, and had physician orders for suicide precautions and modified visual contact.

Observation revealed a staff member looked in Rooms "f", "g", and "h" at 2:47 a.m. and at 2:56 a.m. A staff member looked in Room "f" only at 3:05 a.m. A staff member looked in Rooms "f", "g", and "h" at 3:52 a.m.
There was no observation of Patient R3 every 15 minutes for 47 minutes from 3:05 a.m. to 3:52 a.m. There was no observation of Patients R4 and R5 every 15 minutes for 56 minutes from 2:56 a.m. to 3:52 a.m.

All above observations were confirmed by S23FMD during the observation of each hospital-provided video recording.


Review of the policy titled "Precautionary Measures for Patients", presented as a current policy by S1CNO, revealed that the levels of observation included 1:1 Eye contact, Eye Contact, and Close Contact. 1:1 Eye Contact required the patient to be in eye view and not more than 5 feet away from the assigned staff member at all times, including groups, bathroom, and shower use. An eye contact form is completed every 15 minutes. Eye Contact required the patient to be restricted to the unit and restricted from using sharps while under eye contact. An eye contact form is completed every 15 minutes by an assigned staff member. Close Contact allowed patients to move freely throughout the unit, and staff must be aware of the patient's location at all times. Patients are monitored at a minimum of every 30 minutes. There was no documented evidence that the policy included the level of observation ordered by the physician of modified visual contact. Further review revealed suicide precaution included that no sharp item may be given by the staff to the patient, patients may not attend any recreation group where sharps are to be used in the activity. A patient on moderate risk suicide precaution will be placed on eye contact. A patient on high risk suicide prevention will be monitored on 1:1 Eye Contact and will be reassessed daily,and an environment assessment will be completed each shift. There was no documented evidence that nursing assessments included whether patients were placed on low, moderate, or high risk suicide precautions.


Review of the policy titled "Rounds: Observation and accountability", presented as a current policy by S1CNO, revealed that all patients are accounted for every 15 minutes by documenting their whereabouts and activity on the unit using the BHU Routine Rounds and EYE Contact Form.


Review of the policy titled "Suicide/Homicide Precautions", presented as a current policy by S1CNO, revealed the policy presented was a nursing policy related to the medical/surgical unit, emergency department, and intensive care unit. There was no documented evidence that the policy included the BHU.


Patient #2

Review of Patient #2's "Routine Rounds/Eye Contact Sheet" documented by S15MHT on 09/11/17 revealed no documented evidence of the observation level ordered and suicide precautions. Further observation revealed S15MHT documented that Patient #2 was calm in her bed at 9:15 p.m., 9:30 p.m., and 9:45 p.m. and sleeping/respirations observed at 10:00 p.m., 10:15 p.m., 10:30 p.m., and 10:45 p.m. when video review revealed there was no observation of staff monitoring Patient #2 every 15 minutes from 8:58 p.m. to 9:38 p.m. and from 9:38 p.m. to 10:48 p.m.


Patient #4

Review of Patient #4's "Routine Rounds/Eye Contact Sheet" documented by S15MHT on 09/11/17 revealed no documented evidence of the observation level ordered and suicide precautions. Further observation revealed S15MHT documented that Patient #4 was calm in her bed at 8:15 p.m. and 8:30 p.m., sleeping/respirations observed at 8:45 p.m., calm in her bed at 9:00 p.m., 9:15 p.m., 9:30 p.m., and 9:45 p.m., and sleeping/respirations observed at 10:00 p.m., 10:15 p.m., 10:30 p.m., and 10:45 p.m. when video review revealed staff was not observed monitoring Patient #4 from 8:05 p.m. to 8:47 p.m., from 8:49 p.m. to 9:38 p.m., and from 9:38 p.m. to 10:47 p.m.


Patient R2

Review of Patient R2's "Routine Rounds/Eye Contact Sheet" documented by S15MHT on 09/11/17 revealed no documented evidence of the observation level ordered and suicide precautions. Further observation revealed S15MHT documented that Patient R2 was in the dining area at 9:45 p.m., in her room awake at 9:00 p.m., calm in her room at 10:15 p.m. and 10:30 p.m., and sleeping/respirations observed at 10:45 p.m. when the video review revealed no staff observed Patient R2 from 9:45 p.m. to 10:47 p.m.


Patient #3

Review of Patient #3's "Routine Rounds/Eye Contact Sheet" documented by S13MHT on 07/22/17 revealed no documented evidence of the observation level ordered and suicide precautions. Further observation revealed S13MHT documented that Patient #3 was in his room asleep at 5:15 p.m., 5:30 p.m., and 5:45 p.m., on the phone at 6:00 p.m., and in his room awake at 6:15 p.m., 6:30 p.m., 6:45 p.m., 7:00 p.m., and 7:15 p.m. Further review revealed a hand-written note on the "Routine Rounds/Eye Contact Sheet" across the spaces from 7:30 p.m. to 9:00 p.m. of "patient was found coding in room." Video review revealed no observations of staff monitoring Patient #3 from 5:15 p.m. to 5:49 p.m. and from 5:54 p.m. to 7:18 p.m.


Patient R1

Review of Patient R1's "Routine Rounds/Eye Contact Sheet" documented by S13MHT on 07/22/17 revealed no documented evidence of the observation level ordered and suicide precautions. Further observation revealed S13MHT documented that Patient R1 was in the dining area eating at 5:15 p.m. and in his room awake at 5:30 p.m., 5:45 p.m., 6:00 p.m., and 6:30 p.m. when the video review revealed Patient R1 was in his room at 5:15 p.m. and no observations made by staff from 5:15 p.m. to 5:37 p.m. while he was in his room and from 5:56 p.m. to 6:32 p.m.


Patient R6

Review of Patient R6's medical record revealed he was admitted on 09/12/17 at 10:44 a.m. with a PEC in place due to being suicidal and a danger to self. Further review revealed documentation by S26LPN on 09/14/17 at 8:45 a.m. that patient R6 was lying in bed continuing to have suicidal thoughts. Further review revealed S26LPN documented "Pt. (patient) stated 'I still haven't figured it out yet" when asked about a plan."


In an interview on 09/13/17 at 2:40 p.m., S24UM confirmed the hospital did not have a system in place for the RN to review the documentation of MHTs to assure the the MHT knows the level of observation for each patient, the special precautions that are ordered, and are making observations as ordered. S24UM had no explanation to offer related to the above observations. S24UM confirmed the hospital had no RN assessment in place that determines the level of suicide risk as low, moderate, or high as stated in policy.

In an interview on 09/14/17 at 10:45 a.m., S26LPN confirmed she did not sit with Patient R6 while S25LPN was on break, but she did wake him to assess him at 9:45 a.m.

In an interview on 09/14/17 at 12:00 p.m. with S1CNO, S18PID, S19ADM, and S20MD, the surveyor informed the attendees of the observations made on the BHU and by the hospital-provided video recording. S1CNO indicated that S23FMD had informed him of the results of the observations seen on video. None of the administrative staff had comments related to the information provided by the surveyor.


2) Failing to ensure the psychiatric unit was free from ligature risks, suffocation risks, and an opportunity to hide contraband:

Observation on the BHU on 09/11/17 at 9:35 a.m. with S2RN present revealed the patient bathroom is accessed from inside the patient's room with a door that can be closed. Further observation revealed the latch had been removed that prevents the door from remaining shut if someone pushed or pulled against it. Further observation revealed all sink faucets in the patient bathrooms extended approximately 5 to 6 inches from the point of installation that presented a ligature risk. During the observation S2RN tied a sheet around the faucet, pulled downward toward the wall next to the sink, and the sheet did not release from the faucet. S2RN conformed at this time that the faucets in the patients' bathrooms were a ligature risk. Continued observation in Room "k" revealed a pillow on the bed had a thin plastic covering that was torn across one end that left the possibility of contraband being hidden between the covering and the pillow and an opportunity for suffocation from the plastic. During this observation S2RN confirmed the pillows present a risk for suffocation. He confirmed that all pillows on the BHU have the thin plastic covering that can be easily torn and used for hiding contraband or for suffocation.

Based on record review and interview, the hospital failed to ensure that a patient placed in restraints was seen face-to-face within one hour after initiation of the intervention by a physician, licensed independent practitioner, or a registered nurse or physician assistant for 1 (#1) of 1 current patient whose medical record was reviewed for use of restraints from a total of 5 sampled patients.

Findings:

A review of the hospital policy titled "Seclusion and Restraint", provided by administration as the most current, revealed in part: Contact the Emergency Department physician, psychiatrist, or a licensed independent practitioner designated by the attending physician to conduct the face-to-face evaluation within one hour of initiating restraint on a patient.


A review of Patient #1's medical record revealed she was a 38 year old female admitted to the Behavioral Health Unit on 08/21/17 with diagnoses of Schizo-affective Disorder, Bipolar Disorder, and Paranoia Delusions. A review of the medical record entry dated 08/30/17 at 9:45 a.m. revealed the patient was placed in restraints, as ordered by her psychiatrist, for a violent behavior episode. A further review revealed that the face-to-face evaluation was documented as being conducted on 08/30/17 at 12:31 p.m. by the psychiatrist, 2 hours and 46 minutes after initiation of the restraints.


In an interview on 09/12/17 at 12:45 p.m. with S8RN, charge nurse on the Behavioral Health Unit, she reviewed the patient's medical record and indicated that the face-to-face evaluation was not conducted within one hour, according to hospital policy, after initiating restraints. She further indicated that the only face-to-face evaluation documentation was on 08/30/17 at 12:31 p.m.

Based on observations, record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:

1) The RN failing to ensure the assigned MHT observed patients in accordance with physician orders. This deficient practice placed patients at risk for harm to self and others and was evidenced by failure of staff to monitor psychiatric patients admitted to the BHU every 15 minutes as ordered by the psychiatrist for 8 patients (#2, #3, #4, R1, R2, R3, R4, R5) observed on a hospital-provided video recording.

2) The RN failed to ensure the observation records were complete and included the patient's level of observation and special precautions for 7 (#1, #2, #3, #4, #5, R1, R2) of 7 patient observation sheets reviewed for completion from a sample of 5 patients (#1 - #5) and 6 random patients (R1, R2, R3, R4, R5, R6).

Findings:


30172

1) The RN failing to ensure the assigned MHT observed patients in accordance with physician orders:

Observation on 09/12/17 at 11:24 a.m. of a hospital-provided video recording with S23FMD, present during the entire time the video was viewed by the surveyor, for the time period on 09/11/17 from 8:05 p.m. through 10:48 p.m. revealed the following:

Patient #2

Patient #2 entered her room (Room "c") at 8:58 p.m., closed the door, and left the door with a small crack in the door. Staff looked into her room at 9:38 p.m. and at 10:48 p.m. There was no observation of staff monitoring Patient #2 every 15 minutes as ordered by the psychiatrist for 40 minutes from 8:58 p.m. to 9:38 p.m. and for 1 hour and 10 minutes from 9:38 p.m. to 10:48 p.m. Patient #2 was admitted with a diagnosis of Bipolar Disorder and had physician orders for modified visual contact (defined by staff as every 15 minutes) and suicide precautions.


Patient #4

Patient #4 entered her room (Room "b") at 8:05 p.m. Staff went into Room "b" at 8:49 p.m. and looked into Room "b" at 9:38 p.m. and 10:47 p.m. There was no observation of staff monitoring Patient #4 every 15 minutes as ordered by the psychiatrist for 42 minutes from 8:05 p.m. to 8:47 p.m., for 49 minutes from 8:49 p.m. to 9:38 p.m., and for 1 hour and 9 minutes from 9:38 p.m. to 10:47 p.m. Patient #4 was admitted with a diagnosis of Bipolar Disorder and had physician orders for modified visual contact and suicide precautions.


Patient R2

Patient R2 entered her room (Room "a") at 9:45 p.m. Staff looked into Room "a" at 10:47 p.m. There was no observation of staff monitoring Patient R2 every 15 minutes as ordered by the psychiatrist for 1 hour and 2 minutes from 9:45 p.m. to 10:47 p.m. Patient R2 was admitted with a diagnosis of Depression and had physician orders for modified visual contact and suicide precautions.


Observation on 09/12/17 at 9:25 a.m. of a hospital-provided video recording with S23FMD, present during the entire time the video was viewed by the surveyor, for the time period on 07/22/17 from 5:15 p.m. through 7:59 p.m. revealed the following:

Patient #3

Patient #3 was in his room with the door closed. Patient #3 exited his room (Room "e"), walked toward the nursing station, re-entered his room at 5:40 p.m., and closed the door. Patient #3 exited his room at 5:46 p.m., walked toward Room "j", stood by the patio door, re-entered his room at 5:48 p.m. and closed the door. He exited his room at 5:49 p.m. and was observed using the telephone. At 5:54:04 p.m. Patient #3 re-entered his room and closed the door. At 5:54:33 p.m. a staff member passed and was observed to touch the door handle of Room "e", did not open the door, and walked down the hall. At 7:16 p.m. a staff member was observed touching the door of Patient #3 but doesn't open the door. At 7:17 p.m. S11US knocks on Patient #3's door, touches the handle, and the door doesn't open. At 7:18:07 p.m. 2 staff members with S12Sec were observed at Patient #3's door. One staff member puts a key in the door, and another staff member waves her hand (appeared to be calling staff to come to room). S12Sec was observed at 7:18:25 p.m. pushing on the door with his shoulder while staff attempted to use the key again. At 1:18:35 p.m. S12Sec opens the door. A nurse enters the room at 7:19:01 p.m. and another nurse enters at 7:19:20 p.m. Another person was observed entering the room at 7:20:09 p.m. The code cart was observed to be brought into the room at 7:20:31 p.m. Observation of the video revealed Patient #3 was not observed every 15 minutes as ordered by the psychiatrist for 34 minutes from 5:15 p.m. to 5:49 p.m. and for 1 hour and 24 minutes from 5:54 p.m. to 7:18 p.m. Patient #3 was admitted with a diagnosis of Psychosis, unspecified type and had physician orders for modified visual contact and suicide precautions.


Patient R1

Patient R1 was in his room (Room "d") at 5:15 p.m. At 5:28 p.m. he was observed opening his door, looking down the hall, and closing the door at 5:29 p.m. At 5:34 p.m. he opens his door, looks out, and leaves the door with a slight crack in the door. At 5:37 p.m. a staff member was observed passing Room "d" and glancing back at the room. Patient R1 exits his room at 5:39 p.m. and was observed to enter his room at 5:54 p.m. and close the door. At 5:56 p.m. a staff member opened Patient R1's door, looked in the room, and left the door with a slight crack in the door. At 6:32 p.m. a staff member was observed walking from the nursing station and looking in Room "d" as she passed. Observation revealed Patient R1 was not observed every 15 minutes as ordered by the physician for 22 minutes from 5:15 p.m. to 5:37 p.m. while he was in his room and for 36 minutes from 5:56 p.m. to 6:32 p.m. Patient R1 was admitted with a diagnosis of Schizophrenia and had physician orders for modified visual contact and suicide precautions.

Observation on the BHU 09/14/17 at 10:40 a.m. revealed S25LPN was sitting 1:1 with patient R6 who had physician orders to be observed 1:1 while awake and/or having suicidal threats. During the observation S25LPN indicated that she left for a break from 9:30 a.m. to 9:45 p.m. while Patient R6 was asleep. She further indicated she notified the charge nurse that Patient R6 asleep and she was leaving on break. She further indicated if Patient R6 had been awake, she would have arranged for a staff member to replace her at his bedside. She confirmed that S26LPN wasn't present in Patient R6's room when she left on break. When asked how she knew when Patient R6 was asleep, she indicated if she speaks to him and he doesn't answer, she knows he's asleep.


Observation on 09/14/17 at 10:55 a.m. of a hospital-provided video recording with S23FMD, present during the entire time the video was viewed by the surveyor, for the time period on 09/14/17 from 2:30 a.m. through 3:52 a.m. revealed the following:

Rooms "f", "g", and "h" were observed.

Patient R3 was in Room "f", had a diagnosis of Schizoaffective Disorder, bipolar type, and had physician orders for suicide precautions and modified visual contact.

Patient R4 was in Room "g", had a diagnosis of Bipolar Disorder, most recent episode manic, and had physician orders for suicide precautions and modified visual contact.

Patient R5 was in Room "h", had a diagnosis of Psychosis, unspecified, and had physician orders for suicide precautions and modified visual contact.

Observation revealed a staff member looked in Rooms "f", "g", and "h" at 2:47 a.m. and at 2:56 a.m. A staff member looked in Room "f" only at 3:05 a.m. A staff member looked in Rooms "f", "g", and "h" at 3:52 a.m.
There was no observation of Patient R3 every 15 minutes for 47 minutes from 3:05 a.m. to 3:52 a.m. There was no observation of Patients R4 and R5 every 15 minutes for 56 minutes from 2:56 a.m. to 3:52 a.m.

All above observations were confirmed by S23FMD during the observation of each hospital-provided video recording.


Review of the policy titled "Precautionary Measures for Patients", presented as a current policy by S1CNO, revealed that the levels of observation included 1:1 Eye contact, Eye Contact, and Close Contact. 1:1 Eye Contact required the patient to be in eye view and not more than 5 feet away from the assigned staff member at all times, including groups, bathroom, and shower use. An eye contact form is completed every 15 minutes. Eye Contact required the patient to be restricted to the unit and restricted from using sharps while under eye contact. An eye contact form is completed every 15 minutes by an assigned staff member. Close Contact allowed patients to move freely throughout the unit, and staff must be aware of the patient's location at all times. Patients are monitored at a minimum of every 30 minutes. There was no documented evidence that the policy included the level of observation ordered by the physician of modified visual contact. Further review revealed suicide precaution included that no sharp item may be given by the staff to the patient, patients may not attend any recreation group where sharps are to be used in the activity. A patient on moderate risk suicide precaution will be placed on eye contact. A patient on high risk suicide prevention will be monitored on 1:1 Eye Contact and will be reassessed daily,and an environment assessment will be completed each shift. There was no documented evidence that nursing assessments included whether patients were placed on low, moderate, or high risk suicide precautions.


Review of the policy titled "Rounds: Observation and accountability", presented as a current policy by S1CNO, revealed that all patients are accounted for every 15 minutes by documenting their whereabouts and activity on the unit using the BHU Routine Rounds and EYE Contact Form.


Review of the policy titled "Suicide/Homicide Precautions", presented as a current policy by S1CNO, revealed the policy presented was a nursing policy related to the medical/surgical unit, emergency department, and intensive care unit. There was no documented evidence that the policy included the BHU.


Patient #2

Review of Patient #2's "Routine Rounds/Eye Contact Sheet" documented by S15MHT on 09/11/17 revealed no documented evidence of the observation level ordered and suicide precautions. Further observation revealed S15MHT documented that Patient #2 was calm in her bed at 9:15 p.m., 9:30 p.m., and 9:45 p.m. and sleeping/respirations observed at 10:00 p.m., 10:15 p.m., 10:30 p.m., and 10:45 p.m. when video review revealed there was no observation of staff monitoring Patient #2 every 15 minutes from 8:58 p.m. to 9:38 p.m. and from 9:38 p.m. to 10:48 p.m.


Patient #4

Review of Patient #4's "Routine Rounds/Eye Contact Sheet" documented by S15MHT on 09/11/17 revealed no documented evidence of the observation level ordered and suicide precautions. Further observation revealed S15MHT documented that Patient #4 was calm in her bed at 8:15 p.m. and 8:30 p.m., sleeping/respirations observed at 8:45 p.m., calm in her bed at 9:00 p.m., 9:15 p.m., 9:30 p.m., and 9:45 p.m., and sleeping/respirations observed at 10:00 p.m., 10:15 p.m., 10:30 p.m., and 10:45 p.m. when video review revealed staff was not observed monitoring Patient #4 from 8:05 p.m. to 8:47 p.m., from 8:49 p.m. to 9:38 p.m., and from 9:38 p.m. to 10:47 p.m.


Patient R2

Review of Patient R2's "Routine Rounds/Eye Contact Sheet" documented by S15MHT on 09/11/17 revealed no documented evidence of the observation level ordered and suicide precautions. Further observation revealed S15MHT documented that Patient R2 was in the dining area at 9:45 p.m., in her room awake at 9:00 p.m., calm in her room at 10:15 p.m. and 10:30 p.m., and sleeping/respirations observed at 10:45 p.m. when the video review revealed no staff observed Patient R2 from 9:45 p.m. to 10:47 p.m.


Patient #3

Review of Patient #3's "Routine Rounds/Eye Contact Sheet" documented by S13MHT on 07/22/17 revealed no documented evidence of the observation level ordered and suicide precautions. Further observation revealed S13MHT documented that Patient #3 was in his room asleep at 5:15 p.m., 5:30 p.m., and 5:45 p.m., on the phone at 6:00 p.m., and in his room awake at 6:15 p.m., 6:30 p.m., 6:45 p.m., 7:00 p.m., and 7:15 p.m. Further review revealed a hand-written note on the "Routine Rounds/Eye Contact Sheet" across the spaces from 7:30 p.m. to 9:00 p.m. of "patient was found coding in room." Video review revealed no observations of staff monitoring Patient #3 from 5:15 p.m. to 5:49 p.m. and from 5:54 p.m. to 7:18 p.m.

In an interview on 09/13/17 at 9:27 a.m., S11US indicated when she went to Patient #3's room to get him to meet with the coroner who was on the unit to evaluate patients for a coroner's emergency certificate, she turned the door handle, but it wouldn't open. She further indicated she told S10MHT that she needed to get in the room, because she (S11US) didn't have the door room key with her. S11US indicated S10MHT tried to open the door, but it wouldn't open. She indicated S12Sec was on the unit, and she told him that she needed to get the door open. She further indicated S12Sec and S10MHT got the door open which had a chair pushed against the door. When she entered the room, S11US indicated Patient #3 had paper scrubs on the door handle of the bathroom door that was tied around his neck, and he had hung himself. She further indicated Patient #3 was seated on the floor in front of the bathroom door in an upright position. S11US indicated the nurses who were in report was immediately called to the room, and someone called a Code Blue. She further indicated she didn't think Patient #3 was responsive when she entered the room, and his face had started changing color. S11US indicated S13MHT was assigned to observe Patient #3, but she had clocked out at the time of the event.

In an interview on 09/13/17 at 10:57 a.m., S8RN indicated she was assigned Patient #3's care on 07/22/17. She further indicated she wasn't aware the MHT wasn't observing him every 15 minutes as ordered. She indicated she rounded about every 2 to 3 hours. S8RN indicated when the nurses were called out from report and she arrived in Patient #3's room, Patient #3 sitting up in his room with something tied around his neck, another nurse took what was stuck in the door, and she (S8RN) helped to lay Patient #3 on the floor, and CPR was initiated. The patient expired. When asked what the RN's role was, S8RN indicated the RNs are responsible for patient care, administering medications, and assuring the well-being of the patient. S8RN indicated every person should be responsible for their job..."if it's your job duty, you should do your job duty." When asked if that includes ensuring the MHT makes observations as ordered, she indicated "it always falls back on the nurse." S8RN indicated there was no system in place for the RN to review the MHT's observation sheets to assure the the MHT knows the level of observation for each patient and special precautions that are ordered.


Patient R1

Review of Patient R1's "Routine Rounds/Eye Contact Sheet" documented by S13MHT on 07/22/17 revealed no documented evidence of the observation level ordered and suicide precautions. Further observation revealed S13MHT documented that Patient R1 was in the dining area eating at 5:15 p.m. and in his room awake at 5:30 p.m., 5:45 p.m., 6:00 p.m., and 6:30 p.m. when the video review revealed Patient R1 was in his room at 5:15 p.m. and no observations made by staff from 5:15 p.m. to 5:37 p.m. while he was in his room and from 5:56 p.m. to 6:32 p.m.


Patient R6

Review of Patient R6's medical record revealed he was admitted on 09/12/17 at 10:44 a.m. with a PEC in place due to being suicidal and a danger to self. Further review revealed documentation by S26LPN on 09/14/17 at 8:45 a.m. that patient R6 was lying in bed continuing to have suicidal thoughts. Further review revealed S26LPN documented "Pt. (patient) stated 'I still haven't figured it out yet" when asked about a plan."


In an interview on 09/13/17 at 2:40 p.m., S24UM confirmed the hospital did not have a system in place for the RN to review the documentation of MHTs to assure the the MHT knows the level of observation for each patient, the special precautions that are ordered, and are making observations as ordered. S24UM had no explanation to offer related to the above observations.

In an interview on 09/14/17 at 10:45 a.m., S26LPN confirmed she did not sit with Patient R6 while S25LPN was on break, but she did wake him to assess him at 9:45 a.m.

In an interview on 09/14/17 at 12:00 p.m. with S1CNO, S18PID, S19ADM, and S20MD, the surveyor informed the attendees of the observations made on the BHU and by the hospital-provided video recording. S1CNO indicated that S23FMD had informed him of the results of the observations seen on video. None of the administrative staff had comments related to the information provided by the surveyor.


2) The RN failed to ensure the observation records were complete and included the patient's level of observation and special precautions:

Patient #1

A review of Patient #1's medical record revealed she was a 38 year old female admitted to the Behavioral Health Unit on 08/21/17 with diagnoses of Schizo-affective Disorder, Bipolar Disorder, and Paranoia Delusions. The patient's medical record revealed in part: The observation sheets from 08/21/17 to 09/11/17 (22 observation sheets) revealed that 22 of 22 observation sheets failed to identify the patient's precautions on the observation sheets. A further review revealed that 10 of 22 observation sheets failed to have documented evidence of the patient's level of observation on the observation sheets.


Patient #2

Review of Patient #2's "Routine Rounds/Eye Contact Sheet" documented by MHTs on 09/11/17 revealed no documented evidence of the level of observation and special precautions ordered by the physician. Patient #2 was ordered to be on modified visual contact and suicide precautions.


Patient #3

Review of Patient #3's "Routine Rounds/Eye Contact Sheet" documented by MHTs on 07/22/17 revealed no documented evidence of the level of observation and special precautions ordered by the physician. Patient #3 was ordered to be on modified visual contact and suicide precautions.


Patient #4

Review of Patient #4's "Routine Rounds/Eye Contact Sheet" documented by MHTs on 09/11/17 revealed no documented evidence of the level of observation and special precautions ordered by the physician. Patient #4 was ordered to be on modified visual contact and suicide precautions.


Patient #5

Review of Patient #5's "Routine Rounds/Eye Contact Sheet" documented by MHTs on 09/07/17/17 daily through 09/12/17 revealed no documented evidence of the level of observation and special precautions ordered by the physician. Patient #5 was ordered to be on modified visual contact and suicide precautions.


Patient R1

Review of Patient R1's "Routine Rounds/Eye Contact Sheet" documented by MHTs on 07/22/17 revealed no documented evidence of the level of observation and special precautions ordered by the physician. Patient R1 was ordered to be on modified visual contact and suicide precautions.


Patient R2

Review of Patient R2's "Routine Rounds/Eye Contact Sheet" documented by MHTs on 09/11/17 revealed no documented evidence of the level of observation and special precautions ordered by the physician. Patient R2 was ordered to be on modified visual contact and suicide precautions.

In an interview on 09/12/17 at 11:40 a.m. with S8RN, she indicated that the RNs are not expected to review the observation sheets for completeness nor or the RNs required to sign the observation sheets.

In an interview on 09/13/17 at 2:40 p.m., S24UM confirmed the hospital did not have a system in place for the RN to review the documentation of MHTs to assure the the MHT knows the level of observation for each patient and the special precautions that are ordered.

Based on record reviews and interview, the hospital failed to ensure the RN assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the available nursing staff as evidenced by:

1) Failing to have documented evidence of assignments made on the night shift (6:45 p.m. to 7:15 a.m.) of 09/11/17.

2) Failing to have documented evidence of competency evaluations for 3 (S13MHT, S15MHT, SS22AC) of 5 (S8RN, S9RN, S13MHT, S15MHT, S22AC) employee personnel files reviewed for competency.

Findings:

1) Failing to have documented evidence of assignments made on the night shift (6:45 p.m. to 7:15 a.m.) of 09/11/17:

Review of the "Daily assignment" form for 09/11/17 revealed no documented evidence of which patients were assigned to which nurse and MHT.

In an interview on 09/13/17 at 10:57 a.m., S8RN indicated the charge nurse makes the assignments for each shift. She further indicated it should be documented on the staffing assignment sheet.


2) Failing to have documented evidence of competency evaluations:

Review of the personnel files of S13MHT, S15MHT, and S22AC revealed no documented evidence of a competency evaluation related to their job duties.


In an interview on 09/13/17 at 2:40 p.m., S24UM offered no explanation for the above-listed employees not having competency evaluations.

Based on record review and interviews, the hospital failed to ensure non-employee licensed nurses who are working in the hospital were provided adequate supervision and evaluation of their clinical activities by an appropriately qualified hospital-employed RN as evidenced by failure to have documented evidence of orientation and competency evaluation conducted by a hospital-employed RN for 1 (S14RN) of 1 agency-employed RN's personnel file reviewed for orientation and competency.

Findings:

Review of S14RN's personnel file revealed she was a RN provided by a contracted agency. Further review revealed no documented evidence that S14RN had received hospital orientation and been evaluated for competency of her clinical skills by a hospital-employed RN.

In a telephone interview on 09/13/17 at 10:20 a.m., S14RN indicated she went through hospital orientation, worked one shift on floor with a hospital-employed RN, and then worked on her own.

In an interview on 09/13/17 at 2:40 p.m., S24UM offered no explanation for not having evidence of orientation and a competency evaluation conducted by a hospital-employed RN for S14RN.