HospitalInspections.org

Based on observation, interview and document review, it was determined that the facility failed to ensure Patient safety by not physically monitoring three (3) of three (3) Patients (Patient # 1, # 2 and # 3) and physically assessing one (1) of three (Patient # 2).

The findings include:

On December 1, 2021 between 11:00 a.m. and 1:00 p.m., Clinical Record reviews were conducted and the following was observed from video monitoring of Patients with Staff Members # 4 assisting and Staff Member # 1 present.

Patient # 1-
Patient # 1 arrived at the facility on November 10, 2021 at 7:08 p.m. and discharged at 10:01 p.m. Patient # 1 was low risk on the CTRS (Crisis Triage Rating Scale). There was no Staff Member physically monitoring Patient # 1 between 8:00 p.m. and 10:00 p.m. Documentation on November 10, 2021 reads in part "1:1 observation by: ED Tech".

Patient # 2-
Patient # 2 arrived at the facility on November 11, 2021 at 1:25 p.m. and was admitted to the facility on November 12, 2021 at 12:37 a.m. Patient # 2 was moderate risk (11) on CTRS scale.
There was no Staff Member physically monitoring Patient # 2 between 2:30 p.m. and 5:00 p.m. Patient # 2 had no hands on physical assessment by a Physician. There was a documented History and Physical around the time a person enter the room of Patient # 2. There was no observation of the person ever touching or assessing Patient # 2.

Patient # 3-
Patient # 3 went to a medical bed. There was no CTRS information.
There was no Staff Member physically monitoring Patient # 3 between 2:30 p.m. and 5:45 p.m. Documentation on November 10, 2021 reads in part "1:1 observation by: ED Tech".

On December 1, 2021 at 1:46 p.m., an interview with Staff Member # 4 revealed "There is one (1) person assigned to watch the monitors for Rooms 28 through 31 (1:4), when there is a high to moderate risk Patient. If there is low risk Patients only, no one is assigned to watch the video monitors. The person watching the monitors is trained in Handle with Care (HWC - training provide on how to manage behaviorally challenged patients). Staff have no routine to check on Patients, they basically monitor the Patients from the monitor."

According to the American Psychological Association (APA), 1:1 is one staff assigned to monitor one patient.

According to the American Nurses Association (ANA), Nursing scope and standard of practice is for Patient physical monitoring and reassessment no less frequently than every two (2) hours until clinically stable.

According to the American Journal of Medicine (AJM) the components of a physical exam include: Inspection (look), Palpation (touch), Percussion (tap) and Auscultation (listen).


The facility failed to treat Patients with dignity and respect by leaving Patients alone in a cold room without a blanket and no physical assessment or physical monitoring.

Based on observation, interview and document review, it was determined that the facility failed to ensure Psychosocial factors and reassessment of the patient's nursing care needs were met for three (3) of three (3) Patients (Patient # 1, # 2 and # 3).

The findings include:

On December 1, 2021 between 11:00 a.m. and 1:00 p.m. the following was observed from video monitoring of Patients with Staff Members # 4 assisting and Staff Member # 1 present.

Patient # 1-
Patient # 1 arrived at the facility on November 10, 2021 at 7:08 p.m. and discharged at 10:01 p.m. Patient # 1 was low risk on the CTRS (Crisis Triage Rating Scale).
Patient # 1 was in the room alone. No Staff Member entered the room to monitor or reassess Patient # 1 between 8:00 p.m. and 10:00 p.m.
An ED (Emergency Department) note at 8:15 p.m. reads in part "Visual checks every hour. 1:1 observation by ED Tech".

Patient # 2-
Patient # 2 arrived at the facility on November 11, 2021 at 1:25 p.m. and was admitted to the facility on November 12, 2021 at 12:37 a.m. Patient # 2 was moderate risk (11) on CTRS scale.
Patient # 2 was in the room with a visitor only.
No Staff Member entered the room to monitor or reassess Patient # 2 between 2:30 p.m. and 5:00 p.m.
Vital Signs were documented on November 11, 2021 at 1:27 p.m. and 11:26 p.m. (more than 8 hours).

Patient # 3-
No Staff Member entered the room to monitor or reassess Patient # 3 between 2:30 p.m. and 5:45 p.m. An ED note on November 11, 2021 at 8:37 a.m. reads in part "1:1 observation by ED Tech".

On December 1, 2021 at 1:46 p.m., an interview with Staff Member # 4 revealed "There is one (1) person assigned to watch the monitors for Rooms 28 through 31 (1:4), when there is a high to moderate risk Patient. If there is low risk Patients only, no one is assigned to watch the video monitors. The person watching the monitors is trained in Handle with Care (HWC - training provide on how to manage behaviorally challenged patients). Staff have no routine to check on Patients, they basically monitor the Patients from the monitor."

The facility policy provided by Staff Member # 2 on November 30, 2021 at 1:07 p.m. titled "Violence/Suicide Risk Assessment and Management" reads in part "The assessment scores determines the Patient's risk level: High Risk - 3 - 8, Medium Risk - 9 - 12 and Low Risk 12 - 15.
The Patient shall be re-assessed by an RN (Registered Nurse) using the appropriate tool based on location, every four (4) hours for High Risk Patients and every eight (8) hours for Moderate and Low Risk Patients."

According to the American Psychological Association (APA), 1:1 is one staff assigned to monitor one patient.

According to the American Nurses Association (ANA) Nursing scope and standard of practice is for Patient physical monitoring and reassessment no less frequently than every two (2) hours until clinically stable.


In conclusion, the facility failed to assess the Patient's nursing care needs (food, drink, toileting, warmth) as well Psychosocial factors.

Based on interview and document review, it was determined that the facility staff failed to ensure information in the clinical record was accurate for three (3) of five (5) Patients (Patient # 1, # 2 and # 3).

The findings include:

On December 1, 2021 between 9:00 a.m. and 11:00 a.m., Clinical Record reviews revealed the following inaccuracies:

Patient # 1-
There was no Staff Member physically monitoring Patient # 1 between 8:00 p.m. and 10:00 p.m. Documentation on November 10, 2021 reads in part "1:1 observation by: ED Tech".

Patient # 2-
The History and Physical (H & P) signed by Staff Member # 7 dated November 11, 2021 at 1:58 p.m. reads in part "[Patient # 2] uses tobacco, alcohol and marijuana occasionally.
Social History:
Smoking status: Not on file
Alcohol use: Not on file
Drug Use: Not on file
If the social history sections read "Not on file" or are left blank it reflects that the histories were verbally investigated but the Patient denies tobacco, alcohol or recreation drug use."

Interview with Staff Member # 4 interview at 10:00 a.m. revealed "Yes, that is a discrepancy."

Patient # 3-
There was no Staff Member physically monitoring Patient # 3 between 2:30 p.m. and 5:45 p.m. Documentation on November 10, 2021 reads in part "1:1 observation by: ED Tech".

On December 1, 2021 at 1:46 p.m., an interview with Staff Member # 4 revealed "There is one (1) person assigned to watch the monitors for Rooms 28 through 31 (1:4), when there is a high to moderate risk Patient. If there is low risk Patients only, no one is assigned to watch the video monitors. The person watching the monitors is trained in Handle with Care (HWC - training provide on how to manage behaviorally challenged patients). Staff have no routine to check on Patients, they basically monitor the Patients from the monitor. There is no set order for the medical screening and the psychiatric evaluation. They can be done in any order based on the Patient needs."

According to the American Psychological Association (APA), 1:1 is one staff assigned to monitor one patient.

The inaccurate record findings were discussed with Staff Members # 1, # 2, # 3, # 4, and # 6 during the exit interview.