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Based on record review, policy review, observation and interview, it was determined the facility failed to appropriately monitor patients requiring focused supervision. See A-0144.

Based on observation, policy review, interview and record review, the facility failed to ensure that patients with physician's orders for 1:1 staffing received supervision as ordered during staff breaks in order to ensure a safe environment for 6 of 6 patients reviewed (#1, #2, #3, #4, #5, #7). The facility also failed to ensure that patients' treatment plans included 1:1 observation when ordered by a physician for patient safety. Findings include:

The facility policy titled, "Protocol for 1:1 Continuous Observation" states:
a) "The assigned staff is to be free of all responsibilities with the exception of the patient requiring 1:1 observation."
b) "Staff must be within arm's length distance, eyes on the patient at all times"
c) "Staff person present during toileting, bathing, sleeping etc."

The policy titled "Nursing Assignment Sheet:" states:
a) "The R.N. will document assignments on the Daily Assignment Sheet for each member of the patient care team."
b) "Delegation includes but is not limited to patient care assignments:...breaks/meals."

On 3/9/11 at approximately 1030, during a tour of the Child/Adolescent Unit, 4 North, Daily Assignment Sheets from March 3-8, 2011 were reviewed. 3 North lunch time assignments were not made from 3/1/11-3/3/11. Only one shift had designated lunch/break times on: 3/4/11
3/8/11. No assignments delegating patient care during breaks/meals were noted.

From 3/3/11-3/6/11, when there were 3 staff scheduled, and 2 staff were assigned patients on 1:1's, there was no documentation explaining how coverage was assigned during breaks/lunch. These findings were verified by the Director of Nursing (DON) on 3/9/11 at approximately 1400. The DON also verified that break/meal coverage assignments should be documented on the Daily Assignment Sheet.

Review of patient #1's clinical record revealed physician's orders for 1:1 monitoring written at 12 noon on 3/2/11. The 1:1 monitoring assignment was not added to the 0700-1530 Daily Assignment Sheet on 3/2/11. On 3/4/11, the "Night" assignment sheet notes that 2 residents have staff assigned to 1:1 coverage, but the sheet does not provide any identifying information of the resident assignments. On 3/8/11, nursing notes document that patient #1 was on 1:1 supervision during the day shift. However, the Daily Assignment Sheet for Day shift of 3/8/11 does not document a staff member assigned to 1:1 monitoring of patient #1. The above findings were verified by the Director of Nursing (DON) on 3/9/11 at approximately 1400.

A 3/3/11 Incident Report notes that at 1215 "patient attempted to hang self with socks while in bathroom." A teacher and MHA (Mental Health Assistant) #1 were listed as individuals in the area at the time of the incident. As noted above, the 3/3/11 Daily Assignment Sheet did not specify who would be responsible for 1:1 supervision during lunch. On 3/9/11 at approximately 1530, MHA #1 stated that she was the only MHA on the unit at the time of this incident. She stated that it was her understanding that she was responsible for supervising the boys elsewhere at the time of the incident.

On 3/9/11 at 1200 the Unit Teacher was asked whether she had been assigned any supervision duties at the time of the incident on 3/3/11. The Teacher stated that she did not have an assignment to supervise patients at that time, but was in a Day Room across from the bathroom where the incident occurred. On 3/9/11 at approximately 1430 the DON stated that the Unit Charge Nurse was responsible for ensuring that 1 staff member was assigned to monitor patient #1 at all times.



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Patients #1, # 2, #3, #4, #5 and #7 had physician orders for 1:1 supervision but their Master Treatment Plans entries did not include individualized interventions and objectives to ensure patient safety and remove the need for 1:1 supervision. These findings were verified with the DON on 3/09/11.