HospitalInspections.org

Based on review of medical records, policies and procedures, educational curriculum, nursing assignment sheets, camera surveillance, tour, and staff interviews, it was determined that Nursing Leadership failed to supervise patient care in a manner to ensure for the safety of patients (refer to A 395) and failed to assign nursing care in accordance with the patient's needs (refer to A 397) for 5 of 6 adult psychiatric units (Adult Mental Health Units- Pods A, B, and C, and General Mental Health Units-A and B).

Based on the review of medical records, facility policies and procedures, educational curriculum, nursing assignment sheets, camera surveillance, tour, and staff interviews, it was determined that Nursing Leadership failed to follow policy and appropriately supervise the care of patients for 5 of 6 adult psychiatric units (Adult Mental Health Units- Pods A, B, and C, and General Mental Health Units-A and B).


Findings were:

A review of facility policy # 03-501, entitled "Observation of Individuals to Ensure Safety" last reviewed September 2011, revealed that the facility utilizes three (3) levels of observation in order to ensure safety in the least restrictive manner that is commensurate with the clinical needs of the individuals being served. The three (3) levels of observation include: Routine, Line-of -Sight, and One-to-One. Routine observation involves maintaining a general awareness of the individual's whereabouts and status by visually observing the individual at least every thirty (30) minutes. Line-of sight observation involves maintaining visual observation of no more than three (3) individuals at a time. During this assignment the staff member is not responsible for individuals on routine observation. One-to-one observation involves maintaining an arm's length of the individual and continuous visual observation of no more than one (1) individual at a time. A physician or advanced practice nurse orders the level of observation that is needed for each individual based on their specific and immediate need. Documentation of routine observation is recorded every thirty (30) minutes on a 24 Hour Observation Sheet. Documentation of line-of-sight and one-to-one observation is recorded every fifteen (15) minutes on the Line-of-Sight & One-to-One Observation Flow Sheet. The nurse in charge or the shift supervisor on duty are responsible to ensure that the level of observation is appropriately maintained at all times. The nurse in charge or the shift supervisor identifies the staff member (s) assigned to care for each individual according to his or her required level of observation. The assignment is written and posted to identify staff responsibilities for each individual.

A review of nursing policy entitled, "Assignment/Delegation of Nursing Care", last reviewed August 2011, revealed that Registered Nurses and Licensed Practical Nurses provide direct care and delegate the performance to certain nursing care procedures or activities to other direct care personnel. Delegation and assignment must be in compliance with nursing and administrative policies. The nurse who delegates procedures to other personnel is responsible for supervision and evaluation of those personnel while performing delegated duties.

A review of the educational curriculum provided to staff in regard to observing individuals to ensure safety indicated that when individuals were sleeping, the staff member monitoring must see the person breathing before entering and initialing the code "sleeping" on the observation form.

A review of job responsibilities for the Health Specialized Technicians (Hosts) and Specialized Care Workers (SCW) revealed evidence of responsibility for observing and maintaining an awareness of individual's behavior and physical whereabouts to ensure for safety. Responsibilities also included completing the required documentation.

A review of the medical record for patient #1 revealed the patient, a 51 years old, was admitted to the Adult Mental Health Unit-Pod A on 05/01/12 as an involuntary admission. The patient was found walking on the railroad tracks and exhibiting behavior that indicated he/she was not able to care for self. The patient had a long history of psychiatric admissions. The medical history revealed that the patient had a history of injury to the left eye with diminished vision and gastroesophageal reflux disorder (GERDS-a chronic condition in which the lower esophageal sphincter allows gastric acids to reflux into the esophagus, causing heartburn and acid indigestion). The patient complained of symptoms from GERDS and was prescribed medication and received partial relief. No other significant medical problems were noted. At the time of admission, the patient was confused, angry, and paranoid (suspicious) and had not been compliant with medication. The patient was placed on line-of-sight observation via physician order. Two (2) days later, the patient was moved to routine supervision and remained on this level of supervision for the remainder of time.

Further review of the record revealed that on 05/14/12 at 6:30 a.m. an HST (employee #1) came to the Nurse Manager's office and reported that he/she did not think that patient #1 was breathing. They went to the patient's bedside (room 108-1) and found the patient unresponsive and with no pulse or respirations noted. Cardiopulmonary Resuscitation (CPR) was initiated at 6:35 a.m. by the Nurse manager and another nurse. A Code Blue (medical emergency) was called and Emergency Medical Services (EMS) was notified. No pulse or respirations were noted. The patient's skin color was noted as bluish and the patient's axillary temperature was 93.7. EMS arrived at 6:48 a.m. and the care was transferred to them and the patient was immediately transferred to a local acute care hospital. A progress note, written by the physician who responded to the code, indicated that the patient was found unresponsive, CPR started, EMS called, AED (defibrillator) applied but no shock advised x 3. The note also indicated that the patient was on routine observation, was last noted to be up to bathroom at 3:00 a.m., had two (2) stools, but no vomiting. The 24 Hour Observation Sheet revealed that employee #1 had documented 30 minute observation from 12:00 a.m. through 4:30 a.m. and from 5:30 a.m. through 6:30 a.m. and that employee #2 documented from 4:30 a.m. through 5:30 a.m. The observations indicated that the patient was in his/her bedroom throughout the night with a bathroom trip at 2:30 a.m. and again at 3:30 a.m. There was no documentation or indication that breathing was monitored during the night.

The death summary from the local acute care hospital indicated the patient was brought to the Emergency Department. The patient was pulseless; CPR was in progress. The patient continued with no pulse and the time of death was noted to be at 7:23 a.m. The death certificate for the patient revealed that the patient's cause of death was respiratory depression, subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover the brain) due to or as a consequence of ruptured berry aneurysm (a bulge in the artery, appearing like a berry, that classically occurs at the point at which a cerebral artery departs from the circular artery at the base of the brain, frequently rupturing or bleeding).

A review of the assignment sheet revealed that employee #1 was assigned to two (2) patients (#2 and 3) who were on line-of-sight observation. Employee #2 was assigned to routine observations for four (4) of the patients, including patient #1. Employee #3 was assigned to a patient who was on one-to-one observation. Employee #4 was assigned to the remaining five (5) patients on routine observation. The census was 12.

During the review of the assignment sheet, the Chief Nursing Officer and Risk Manager revealed that the assignment sheet was not followed and that the staff had made changes that were not reflected on the assignment sheet.

A review of the medical record for patient #2 and patient #3, patients on the Adult Mental health Unit-Pod A, revealed that both had physician orders for line-of-sight observation. Patient #2 was exhibiting psychotic behavior and had been on one-to-one observation and was moved to line-of-sight observation on 05/13/12. Patient #3 was exhibiting aggressive behavior and had an order on 05/13/12 to continue line-of-sight observation. The Line-of-Sight & One-to-One Observation Flow Sheets for both patients revealed that employee #2 documented 15 minute observations from 12:00 a.m. through 3:45 a.m. and employee #4 documented from 3:45 a.m. through 6:00 a.m. The observations from 12:00 a.m. on 05/14/12 through 6:00 a.m. indicated that patient #2 (in room 99) was sleeping in room or resting in room with one trip to the bathroom during that time. The observations from 12:00 a.m. on 05/14/12 through 6:00 a.m. indicated that patient #3 (in room 111) was sleeping in room. There was no documentation or indication that breathing was monitored during the time the patients were sleeping.

A review of camera surveillance for the hours of 12:08 a.m. through 6:53 a.m. on 5/14/12 of the Adult Mental Health Unit where patients #1, #2, and #3 resided revealed that at 12:08 a.m. employee #1 and #2 were on the unit at a desk area. Employee #1 was behind the desk and employee #2 was sitting in a chair by the side of the desk. Employee #3 was seen at the doorway of a patient's room. No observation rounds to patient rooms were noted between 12:08 a.m. and 1:08 a.m. At 1:08 a.m. patient #1 was seen out of room and going to the bathroom and then returned to bedroom shortly after. The patient's gait appeared steady. There was no obvious signs of discomfort/distress. No observation rounds to patient rooms were noted between 1:08 a.m. and 2:00 a.m. At 2:20 a.m. employee #1 and #2 got up from their area. Employee #1 went to the linen closet and employee #2 exited the unit toward the nurse's station and then returned within a few minutes. Both employees resumed their positions at the desk area. At 2:30 a.m. patient #1 was seen going to the bathroom and returned to room at 2:43 a.m. It appeared that patient #1 had a brief conversation with staff on his/her way back to room. No observation rounds to patient rooms were noted between 2:00 a.m. and 3:30 a.m. Employee #4 was noted to be on the unit periodically between 12:00 a.m. and 3:30 a.m.. and sat on the couch in the dayroom when present on unit. At 3:35 a.m. patient #1 was seen going to the bathroom again and returned to room. The patient appeared to be in no discomfort/distress. No observation rounds to patient rounds were noted between 3:30 a.m. and 6:00 a.m. Employee changes were noted. Employee #4 took over for employee #2 and sat in the chair. When employee #2 returned to the unit, he/she took over for employee #1 and was behind the desk. Most of the shift employee #1 and #2 were present. Employee #2, when sitting in the chair, made occasional observations to the right and straight across the day room toward patient rooms. Throughout the shift, employee #3 was noted to be at the bedside of the patient assigned or accompanying the same patient when out of his/her room. Employee #4 was on and off the unit. The nurse, employee #5, was noted to have been on the unit at intervals and walking around the day room in front of patient room. The camera review did not allow view of what the nurse was actually doing, but it appeared that after a walk through, the nurse exits the unit. Occasionally, the nurse was seen in conversation with the other employees before exiting the unit. At 6:10 a.m. patients and employees #1, #2, and #3 were seen moving about in the day room. Patient #1 was not present. At 6:30 a.m. employee #1 entered the room of patient #1 and then left the room and shut the door behind him. At 6:32 a.m. employee #2 entered the room of patient #1 and employee #1 was outside of the room. At 6:33 a.m. employee #1 and #2 were seen entering the room. At 6:34 a.m. both employee #1 and #2 walked out of patient #1's room and headed toward the day room. Employee #2 became involved in the activity in the day room. At 6:34:07 employee #1 exited the unit toward the nurse's station. However, camera review revealed that employee #1 walked past the nurse's station and down the hall to the nurse manager's office. Employee #1 was seen going in the office and closing the door. At 6:34:49 the nurse manager called a code and was at the bedside of patient #1 at 6:35 a.m. At 6:36 a.m. the crash cart (cart used for medical emergencies) was taken to the patient's room. At 6:37 a.m. CPR was initiated, seven (7) minutes after patient #1 was found unresponsive by employee #1. Other staff members were seen going into the patient's room. As the door was opened, staff could be seen doing compressions. At 6:39 a.m. the AED was taken to the room. At 6:40 a.m. the on-call physician entered the patient's room. At 6:46 a.m. EMS was present and took over the care. At 6:53 a.m. patient #1 was seen being transported via stretcher off the unit.

Present during the camera surveillance review (2:00 p.m. through 3:55 p.m. on 5/31/12) was the Chief Nursing Office (CNO). The CNO reported having done previous review of the incident. He/she confirmed that patients were not being monitored by the employees as per facility policy. The CNO also confirmed that the delayed response of the employees, after finding patient #1 unresponsive, was not acceptable.

A tour of the Adult Mental Health Unit was conducted at 12:50 p.m. on 06/01/2. The unit revealed nine (9) patient rooms with the day room in the center. A table (desk) was at one end of the dayroom. Room 99, where patient #2 was on 05/14/12, was to the right of the the desk and easily visible. Room 111, where patient #3 was on 05/14/12, was directly across the room from the desk, but on the other side of the dayroom. It was obvious that there was a bed was in that room and visible, but difficult to see closely into the room. The nurse's station was connected to the unit, but not visible from the unit. Unit staff members were required to exit a door to obtain a nurse. Likewise, the nurses was required to enter a door to the unit to observe the patient rooms, dayroom area, or employees.

An interview was conducted at 10:15 a.m. on 06/01/12 in the Nursing Administration area with the Nurse Manager for Adult Mental Health. The interviewee reported that he/she had arrived at the facility early on the morning of 05/14/12. The manager was in his/her office when employee #1 came in, closed the door, asked about his/her well being, then proceeded to sit. After several minutes, the employee stated that he/she needed to report to the manager that he/she believed that one of the patients (patient #1) on the unit was not alive. According to the manager, they went to the bedside of patient #1 and found the patient to be unresponsive. The manager initiated CPR, had a code blue called and EMS notified. The interviewee reported that it was not clear when the patient had last been seen. He/she reported that the patient was bluish in color and cold to the touch. The manager related that staff were trained in making observations and were educated regarding the need to watch for respirations when doing observation rounds. He/she also related that staff participate in mock codes, including code blue. The manager verbalized that facility staff seemed to not being watching the patients closely at night. Employee #1 (a SCW) had admitted to not doing 30 minute routine observation. The interviewee related that nurses were required to do hourly rounds.

A confirmation Interview with employee #1 was not feasible as the employee was no longer employed at the facility. The Hospital Administrator confirmed that employee #1 had admitted to not doing routine observations according to facility policy.

A telephone interview was conducted at 3:45 p.m. on 06/04/12 with the charge nurse (employee #5) who was assigned to Adult Mental Health on 05/14/12. The interviewee stated that he/she usually made rounds on the unit approximately every hour. The rounds included observing to see if HSTs or SCWs were making rounds and following assignments. According to the nurse, the rounds by the nurse did not include going into every patient room or seeing every patient. The nurse stated that the doors to the rooms of patients on routine observation were generally closed. The nurse only observed patients who were on line-of-sight or one-to-one observation because their doors were open. According to the nurse, changes in patient assignments were to be approved by the nurse. This interviewee was unaware that staff had made changes to the assignments. The nurse observed staff on the unit and observation logs being completed but did not remember seeing them make the observations. The nurse also reported that he/she had not seen patient #1 throughout the night. He/she was not notified in the a.m. when the patient was found unresponsive by the HST. The HST reported the information to the nurse manager even though the interviewee was in the nursing office on the unit.

A telephone interview was conducted at 11:55 a.m. on 06/01/12 with employee #4. The interviewee confirmed that he/she was a lead HST and was on duty on 05/14/12. He/she arrived about 11:30 p.m. on 05/13/12 and was on duty until the morning of 5/14/12. The HST received report and carried out some responsibilities before coming back to the unit at approximately 12:00 a.m. When the interviewee returned to the unit, the nurse (employee #5) had brought the assignment sheet. He/she spoke to employee #1 who indicated that employee #2 would be monitoring the two (2) line-of-sight patients (#2 and 3) and that employee #1 would be doing the routine observations. Employee #3 was assigned the patient who was on one-to-one observation. The interviewee stated he/she was not assigned to observations, but was assigned to make notes in the unit log book. The interviewee could not recall having seen the other staff making observation rounds. When questioned about the assignment sheet made out by the nurse, the interviewee stated that he/she had not looked at the assignments and, in fact, had not seen the assignment sheet until in the morning. He/she believed that employee #1 had discussed the changes with the nurse. The HST stated that he/she had seen patient #1 up to the bathroom at approximately 2:40 a.m. and that the patient appeared to be in no distress. He/she had not seen patient #1 after that and was in the chart room when he/she heard the code blue called.

A telephone interview was conducted at 12:30 p.m. on 06/01/12 with employee #2. The interviewee confirmed that he/she was one of the HSTs on duty on 05/14/12. The HST stated the assignment sheet was brought to the unit, but that he/she did not look at it and continued to be responsible for the line-of-sight patients (#2 and 3) and that employee #1 was responsible for the routine observations. He/she reported that employee #4 was not conducting rounds and thought that employee #4 was aware that changes in the assignment sheet had occurred. The interviewee stated that routine observations were to be made every 30 minutes but he/she was unsure as to how often employee #1 had conducted the observation rounds. The interviewee was also aware that patients were to be checked for breathing. The HST explained that he/she was able to see the patients on line-of-sight. One of the patients (#2) was in the room to the right side of where he/she was sitting and the other patient (#3) was straight across the day room and in sight. The HST reported that he/she checked on them in their rooms at times, but reiterated that the patients were in line-of-sight from the chair where he/she was sitting. The interviewee had seen patient #1 up to the bathroom at 2:40 a.m. The patient returned to his/her room and was making jokes and laughing with the staff. The HST did not see patient #1 again until morning. At approximately 6:30 a.m. employee #1 asked him/her to go into patient #1's room. He/she found the patient unresponsive and told employee #1 to report it to the nurse. The interviewee stated he/she did not want to yell out because other patients were up and in the day room. When questioned about the need to start CPR, the interviewee stated this was his/her first time to encounter a situation like this and was not sure what to do.

A review of camera surveillance was conducted from 12:45 p.m. through 3:30 P.M. on 06/19/12 for the hours of 12:30 a.m. through 4:45 a.m. on 06/19/12. On the General Mental Health Unit, during the observed hours of 1:00 a.m. through 4:00 a.m., the staff members were noted to be in the dayroom or at the table in the hallway. There appeared to be no evidence of 30 minute routine observation rounds being completed by staff. The Adult Mental Health Unit-Pod A revealed evidence of activity between staff and patients but, between the observed hours of 12:30 a.m. through 2:40 a.m., there was no evidence of 30 minute routine observation rounds being completed by staff. On Adult Mental Health Unit-Pod B, staff was observed making rounds at 1:23 a.m. A nurse was observed making rounds at 2:22 a.m. and 4:27 a.m. between the observed hours of 12:29 a.m. through 4:27 a.m. There was no evidence of staff making rounds between the nurse's rounds and no evidence of 30 minute routine observation rounds being completed by staff. The Adult Mental Health Unit-Pod C revealed staff making rounds at 12:32 a.m., 2:22 a.m., and 4:45 a.m. between the observed hours of 12:32 through 4:45 a.m. A nurse made rounds at 2:10 a.m. There was no evidence of 30 minute routine observation rounds being completed by staff. On all of the units observed, there appeared to be evidence of line-of-sight patients. Staff members were noted to be at the doorway or in fairly close proximity. However, it was not apparent that staff members were making consistent 15 minute observations or entering the patient rooms. It was also observed that staff members who were assigned to line-of-sight patients left their area for brief periods of time, leaving the patient out of line-of-sight.

Present during the camera surveillance (12:45 p.m. through 3:30 p.m. on 6/19/12) was the CNO. The CNO confirmed that patients were not being monitored by the employees as per facility policy on the Adult Mental Health Units-Pod A, B, and C and on the General Mental Health Units-A and B. Additionally, the CNO confirmed that the nurses were not adequately supervising the direct care staff and ensuring for patient safety. The CNO related that there was not a Nursing Supervisor for the facility at night. The charge nurses and staff nurses were responsible for making the assignments and supervising the staff. If the nurses needed back up or encountered a problem, they were to contact the Nurse Managers for their particular units.

Interviews were conducted on 06/18/12 with the Nurse Manager for Adult Mental Health Unit (#1) and with the Charge Nurses for the General Mental Health Unit (#2) and Educational Unit (#3) at 2:25 p.m., 1:30 p.m., and 3:15 p.m. respectively, in the nursing administration conference room. The interviewees all related that the nurses were to make rounds on the unit every hour and see the patients face to face. During sleeping hours, this included assessing the patient and noting respirations. According to the interviewees, the hourly rounds by nurses were not documented on the record, and in fact not documented at all on the General Mental Health Unit and the Educational Unit. On the Adult Mental Health Unit, the nurses were to complete a form entitled "Nurses Hourly Rounds". The form was not a part of the patient's medical record. A review of the form during the interview revealed that the information on the form lacked any evidence of what was actually done by the nurse when making rounds. All of the interviewees stated that the nurses making the assignments were responsible for monitoring to ensure that patient assignments were being followed and that patients were being monitored appropriately. The two (2) charge nurses indicated that nurses were to document each shift on each patient. The Nurse manager indicated that the nurses were to chart as necessary, not necessarily every shift. None of the interviewees were clear about the policy for documentation requirements and none were sure if there was a policy regarding hourly rounds. The expectations were from their own experience or what they believed to be required.

A review of facility policy entitled "Nursing Assessments: MH", last revised November 2008, indicated that nurses were to reassess the patient's response to treatment and current functioning every shift for 72 hours and document in the progress notes. The Registered Nurse was then to document summation notes weekly for two (2) months and monthly thereafter. Reassessment was also to be done if there was a significant change in condition or diagnosis. According to the facility, this was the only policy available regarding nursing documentation.

The CNO confirmed, after the interviews, that there was confusion about the requirements for hourly rounds and nursing documentation. He/she agreed that there was not a policy in place that clearly identified the nursing requirements.


06/19/12
Corrective Action taken by the facility in order to assure for safety of individuals through compliance with observation policy:

a. Facility Training Department will immediately (June 19,2012 at 10 p.m, 11p.m., and June 20, 2012 at 7a.m.) begin retraining staff to emphasize the importance of the observation policy, and detail responsibilities related to performance, including observance of respirations, and specific responsibilities related to all levels of observation (routine, line-of-sight, and one-to-one). Nursing Leadership will be present for training and to emphasize seriousness.

b. Staff will be informed that performance issues and non-compliance with policy will be dealt with by disciplinary action up to and including termination. Accountability will extend from HSTs to those in supervisory role on that shift, including Lead HSTs and Charge Nurses.

c. Currently, evening shift supervisory (House Supervisor) positions exist, but the night shift House Supervisor position is vacant. This is the shift that appears most problematic and vulnerable. Unit Nurse Managers will immediately (June 19, 2012) start an acting night shift supervisory rotation which will provide senior nursing supervision and oversight on this shift. This will remain in place until a permanent hire is made.

d. The duties of the Evening and Night Shift House Supervisors will include regular and spot check rounds on all units. They will perform real time education with staff on performance of observation duties and monitor shift assignments to assure compliance with policy. Observation sheets will be monitored as well as actual performance of HSTs.

e. Evening and Night shift Supervisors must submit daily round sheets and report of findings which will be reviewed in the daily AM morning report.

f. Video spot checks will be conducted on all units to monitor policy compliance via staff performance. Checks will also be made on Evening and Night Supervisors to ensure that they have made rounds on the units by observing video and correlating with their report sheet. This will be done by Hospital Leadership, including but not limited to Nurse Executive, Regional Hospital Administrator, and Risk Manager.

g. Staff observed in video in violation of policy on June 18, 2012 (for the night shift of June 19, 2012) will receive disciplinary action on June 20, 2012, demonstrating administration's response to non-compliance. Disciplinary action may include termination, but no less than written reprimand/final warning.


A review on 06/20/12 of the training that was done on 06/19/12 and 06/20/12 by the Training Department revealed that staff had received retraining as per the corrective action. Training included education about the observation policy, including staff responsibilities. The training also revealed evidence of education on the necessity of checking respirations of patients when they were sleeping.

A review of camera surveillance was conducted from 10:15 a.m. through 1:15 p.m. on 06/20/12 of all six (6) units (Adult Mental Health-Pod A, B, and C, General Mental Health Unit-A and B, and also the Educational Unit). The review included observation rounds at various times throughout the night of 06/20/12 from 11:30 p.m. - 5:00 a.m. Each unit was observed for three (3) consecutive 30 minute routine observations and each unit was found to be in compliance. There was also evidence of 15 minute observation rounds on line-of- sight patients. Staff members were at the door or in close proximity of patients who required line-of-sight or one-to-one observation. The Nurse Manager who was the acting Night Shift Supervisor was seen at various times on the camera surveillance. There was also some evidence of unit nurses making rounds and interacting with the other staff.

Based on review of medical records, policies and procedures, educational curriculum, assignments, camera surveillance, tour, and staff interviews, it was determined that Nursing Leadership failed to assign the nursing care in accordance with the patient's needs for 3 of 6 adult psychiatric units (Adult Mental Health Units- Pods A, B, and C).


Findings were:

A review of facility policy # 03-501, entitled "Observation of Individuals to Ensure Safety" last reviewed September 2011, revealed that the facility utilizes three (3) levels of observation in order to ensure safety in the least restrictive manner that is commensurate with the clinical needs of the individuals being served. The three (3) levels of observation include: Routine, Line-of -Sight, and One-to-One. Routine observation involves maintaining a general awareness of the individual's whereabouts and status by visually observing the individual at least every thirty (30) minutes. Line-of sight observation involves maintaining visual observation of no more than three (3) individuals at a time. During this assignment the staff member is not responsible for individuals on routine observation. One-to-one observation involves maintaining an arm's length of the individual and continuous visual observation of no more than one (1) individual at a time. A physician or advanced practice nurse orders the level of observation that is needed for each individual based on their specific and immediate need. Documentation of routine observation is recorded every thirty (30) minutes on a 24 Hour Observation Sheet. Documentation of line-of-sight and one-to-one observation is recorded every fifteen (15) minutes on the Line-of-Sight & One-to-One Observation Flow Sheet. The nurse in charge or the shift supervisor on duty are responsible to ensure that the level of observation is appropriately maintained at all times. The nurse in charge or the shift supervisor identifies the staff member (s) assigned to care for each individual according to his or her required level of observation. The assignment is written and posted to identify staff responsibilities for each individual.

A review of nursing policy entitled, "Assignment/Delegation of Nursing Care", last reviewed August 2011, revealed that Registered Nurses and Licensed Practical Nurses provide direct care and delegate the performance to certain nursing care procedures or activities to other direct care personnel. Delegation and assignment must be in compliance with nursing and administrative policies. The nurse who delegates procedures to other personnel is responsible for supervision and evaluation of those personnel while performing delegated duties.

A review of the educational curriculum provided to staff in regard to observing individuals to ensure safety indicated that when individuals were sleeping, the staff member monitoring must see the person breathing before entering and initialing the code "sleeping" on the observation form.

A review of job responsibilities for the Health Specialized Technicians (HSTs) and Specialized Care Workers (SCWs) revealed evidence of responsibility for observing and maintaining an awareness of individual's behavior and physical whereabouts to ensure for safety. Responsibilities also included completing the required documentation.

A review of the medical record for patient #1 revealed the patient, a 51 years old, was admitted to the Adult Mental Health Unit-Pod A on 05/01/12 as an involuntary admission. The patient was found walking on the railroad tracks and exhibiting behavior that indicated he/she was not able to care for self. The patient had a long history of psychiatric admissions. The medical history revealed that the patient had a history of injury to the left eye with diminished vision and gastroesophageal reflux disorder (GERDS-a chronic condition in which the lower esophageal sphincter allows gastric acids to reflux into the esophagus, causing heartburn and acid indigestion). The patient complained of symptoms from GERDS and was prescribed medication and received partial relief. No other significant medical problems were noted. At the time of admission, the patient was confused, angry, and paranoid (suspicious) and had not been compliant with medication. The patient was placed on line-of-sight observation via physician order. Two (2) days later, the patient was moved to routine supervision and remained on this level of supervision for the remainder of time.

Further review of the record revealed that on 05/14/12 at 6:30 a.m. an HST (employee #1) came to the Nurse Manager's office and reported that he/she did not think that patient #1 was breathing. They went to the patient's bedside (room 108-1) and found the patient unresponsive and with no pulse or respirations noted. Cardiopulmonary Resuscitation (CPR) was initiated at 6:35 a.m. by the Nurse manager and another nurse. A Code Blue (medical emergency) was called and Emergency Medical Services (EMS) was notified. No pulse or respirations were noted. The patient's skin color was noted as bluish and the patient's axillary temperature was 93.7. EMS arrived at 6:48 a.m. and the care was transferred to them and the patient was immediately transferred to a local acute care hospital. A progress note, written by the physician who responded to the code, indicated that the patient was found unresponsive, CPR started, EMS called, AED (defibrillator) applied but no shock advised x 3. The note also indicated that the patient was on routine observation, was last noted to be up to bathroom at 3:00 a.m., had two (2) stools, but no vomiting. The 24 Hour Observation Sheet revealed that employee #1 had documented 30 minute observation from 12:00 a.m. through 4:30 a.m. and from 5:30 a.m. through 6:30 a.m. and that employee #2 documented from 4:30 a.m. through 5:30 a.m. The observations indicated that the patient was in his/her bedroom throughout the night with a bathroom trip at 2:30 a.m. and again at 3:30 a.m. There was no documentation or indication that breathing was monitored during the night.

The death summary from the local acute care hospital indicated the patient was brought to the Emergency Department. The patient was pulseless; CPR was in progress. The patient continued with no pulse and the time of death was noted to be at 7:23 a.m. The death certificate for the patient revealed that the patient's cause of death was respiratory depression, subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover the brain) due to or as a consequence of ruptured berry aneurysm (a bulge in the artery, appearing like a berry, that classically occurs at the point at which a cerebral artery departs from the circular artery at the base of the brain, frequently rupturing or bleeding).

A review of the assignment sheet revealed that employee #1 was assigned to two (2) patients (#2 and 3) who were on line-of-sight observation. Employee #2 was assigned to routine observations for four (4) of the patients, including patient #1. Employee #3 was assigned to a patient who was on one-to-one observation. Employee #4 was assigned to the remaining five (5) patients on routine observation. The census was 12.

During the review of the assignment sheet, the Chief Nursing Officer and Risk Manager revealed that the assignment sheet was not followed and that the staff had made changes that were not reflected on the assignment sheet.

A review of the medical record for patient #2 and patient #3, patients on the Adult Mental Health Unit-Pod A, revealed that both had physician orders for line-of-sight observation. Patient #2 was exhibiting psychotic behavior and had been on one-to-one observation and was moved to line-of-sight observation on 05/13/12. Patient #3 was exhibiting aggressive behavior and had an order on 05/13/12 to continue line-of-sight observation. The Line-of-Sight & One-to-One Observation Flow Sheets for both patients revealed that employee #2 documented 15 minute observations from 12:00 a.m. through 3:45 a.m. and employee #4 documented from 3:45 a.m. through 6:00 a.m. The observations from 12:00 a.m. on 05/14/12 through 6:00 a.m. indicated that patient #2 (in room 99) was sleeping in room or resting in room with one trip to the bathroom during that time. The observations from 12:00 a.m. on 05/14/12 through 6:00 a.m. indicated that patient #3 (in room 111) was sleeping in room. There was no documentation or indication that breathing was monitored during the time the patients were sleeping.

A review of camera surveillance for the hours of 12:08 a.m. through 6:53 a.m. on 5/14/12 of the Adult Mental Health Unit where patients #1, #2, and #3 resided revealed that at 12:08 a.m. employee #1 and #2 were on the unit at a desk area. Employee #1 was behind the desk and employee #2 was sitting in a chair by the side of the desk. Employee #3 was seen at the doorway of a patient's room. No observation rounds to patient rooms were noted between 12:08 a.m. and 1:08 a.m. At 1:08 a.m. patient #1 was seen out of room and going to the bathroom and then returned to bedroom shortly after. The patient's gait appeared steady. There was no obvious signs of discomfort/distress. No observation rounds to patient rooms were noted between 1:08 a.m. and 2:00 a.m. At 2:20 a.m. employee #1 and #2 got up from their area. Employee #1 went to the linen closet and employee #2 exited the unit toward the nurse's station and then returned within a few minutes. Both employees resumed their positions at the desk area. At 2:30 a.m. patient #1 was seen going to the bathroom and returned to room at 2:43 a.m. It appeared that patient #1 had a brief conversation with staff on his/her way back to room. No observation rounds to patient rooms were noted between 2:00 a.m. and 3:30 a.m. Employee #4 was noted to be on the unit periodically between 12:00 a.m. and 3:30 a.m.. and sat on the couch in the dayroom when present on unit. At 3:35 a.m. patient #1 was seen going to the bathroom again and returned to room. The patient appeared to be in no discomfort/distress. No observation rounds to patient rounds were noted between 3:30 a.m. and 6:00 a.m. Employee changes were noted. Employee #4 took over for employee #2 and sat in the chair. When employee #2 returned to the unit, he/she took over for employee #1 and was behind the desk. Most of the shift employee #1 and #2 were present. Employee #2, when sitting in the chair, made occasional observations to the right and straight across the day room toward patient rooms. Throughout the shift, employee #3 was noted to be at the bedside of the patient assigned or accompanying the same patient when out of his/her room. Employee #4 was on and off the unit. The nurse, employee #5, was noted to have been on the unit at intervals and walking around the day room in front of patient room. The camera review did not allow view of what the nurse was actually doing, but it appeared that after a walk through, the nurse exits the unit. Occasionally, the nurse was seen in conversation with the other employees before exiting the unit. At 6:10 a.m. patients and employees #1, #2, and #3 were seen moving about in the day room. Patient #1 was not present. At 6:30 a.m. employee #1 entered the room of patient #1 and then left the room and shut the door behind him. At 6:32 a.m. employee #2 entered the room of patient #1 and employee #1 was outside of the room. At 6:33 a.m. employee #1 and #2 were seen entering the room. At 6:34 a.m. both employee #1 and #2 walked out of patient #1's room and headed toward the day room. Employee #2 became involved in the activity in the day room. At 6:34:07 employee #1 exited the unit toward the nurse's station. However, camera review revealed that employee #1 walked past the nurse's station and down the hall to the nurse manager's office. Employee #1 was seen going in the office and closing the door. At 6:34:49 the nurse manager called a code and was at the bedside of patient #1 at 6:35 a.m. At 6:36 a.m. the crash cart (cart used for medical emergencies) was taken to the patient's room. At 6:37 a.m. CPR was initiated, seven (7) minutes after patient #1 was found unresponsive by employee #1. Other staff members were seen going into the patient's room. As the door was opened, staff could be seen doing compressions. At 6:39 a.m. the AED was taken to the room. At 6:40 a.m. the on-call physician entered the patient's room. At 6:46 a.m. EMS was present and took over the care. At 6:53 a.m. patient #1 was seen being transported via stretcher off the unit.

Present during the camera surveillance review (2:00 p.m. through 3:55 p.m. on 5/31/12) was the Chief Nursing Office (CNO). The CNO reported having done previous review of the incident. He/she confirmed that patients were not being monitored by the employees as per facility policy. The CNO also confirmed that the delayed response of the employees, after finding patient #1 unresponsive, was not acceptable.

A tour of the Adult Mental Health Unit was conducted at 12:50 p.m. on 06/01/2. The unit revealed nine (9) patient rooms with the day room in the center. A table (desk) was at one end of the dayroom. Room 99, where patient #2 was on 05/14/12, was to the right of the the desk and easily visible. Room 111, where patient #3 was on 05/14/12, was directly across the room from the desk, but on the other side of the dayroom. It was obvious that there was a bed was in that room and visible, but difficult to see closely into the room. The nurse's station was connected to the unit, but not visible from the unit. Unit staff members were required to exit a door to obtain a nurse. Likewise, the nurses was required to enter a door to the unit to observe the patient rooms, dayroom area, or employees.

An interview was conducted at 10:15 a.m. on 06/01/12 in the Nursing Administration area with the Nurse Manager for Adult Mental Health. The interviewee reported that he/she had arrived at the facility early on the morning of 05/14/12. The manager was in his/her office when employee #1 came in, closed the door, asked about his/her well being, then proceeded to sit. After several minutes, the employee stated that he/she needed to report to the manager that he/she believed that one of the patients (patient #1) on the unit was not alive. According to the manager, they went to the bedside of patient #1 and found the patient to be unresponsive. The manager initiated CPR, had a code blue called and EMS notified. The interviewee reported that it was not clear when the patient had last been seen. He/she reported that the patient was bluish in color and cold to the touch. The manager related that staff were trained in making observations and were educated regarding the need to watch for respirations when doing observation rounds. He/she also related that staff participate in mock codes, including code blue. The manager verbalized that facility staff seemed to not being watching the patients closely at night. Employee #1 (a SCW) had admitted to not doing 30 minute routine observation. The interviewee related that nurses were required to do hourly rounds.

A confirmation Interview with employee #1 was not feasible as the employee was no longer employed at the facility. The Hospital Administrator confirmed that employee #1 had admitted to not doing routine observations according to facility policy.

A telephone interview was conducted at 3:45 p.m. on 06/04/12 with the charge nurse (employee #5) who was assigned to Adult Mental Health on 05/14/12. The interviewee stated that he/she usually made rounds on the unit approximately every hour. The rounds included observing to see if HSTs or SCWs were making rounds and following assignments. According to the nurse, the rounds by the nurse did not include going into every patient room or seeing every patient. The nurse stated that the doors to the rooms of patients on routine observation were generally closed. The nurse only observed patients who were on line-of-sight or one-to-one observation because their doors were open. According to the nurse, changes in patient assignments were to be approved by the nurse. This interviewee was unaware that staff had made changes to the assignments. The nurse observed staff on the unit and observation logs being completed but did not remember seeing them make the observations. The nurse also reported that he/she had not seen patient #1 throughout the night. He/she was not notified in the a.m. when the patient was found unresponsive by the HST. The HST reported the information to the nurse manager even though the interviewee was in the nursing office on the unit.

A telephone interview was conducted at 11:55 a.m. on 06/01/12 with employee #4. The interviewee confirmed that he/she was a lead HST and was on duty on 05/14/12. He/she arrived about 11:30 p.m. on 05/13/12 and was on duty until the morning of 5/14/12. The HST received report and carried out some responsibilities before coming back to the unit at approximately 12:00 a.m. When the interviewee returned to the unit, the nurse (employee #5) had brought the assignment sheet. He/she spoke to employee #1 who indicated that employee #2 would be monitoring the two (2) line-of-sight patients (#2 and 3) and that employee #1 would be doing the routine observations. Employee #3 was assigned the patient who was on one-to-one observation. The interviewee stated he/she was not assigned to observations, but was assigned to make notes in the unit log book. The interviewee could not recall having seen the other staff making observation rounds. When questioned about the assignment sheet made out by the nurse, the interviewee stated that he/she had not looked at the assignments and, in fact, had not seen the assignment sheet until in the morning. He/she believed that employee #1 had discussed the changes with the nurse. The HST stated that he/she had seen patient #1 up to the bathroom at approximately 2:40 a.m. and that the patient appeared to be in no distress. He/she had not seen patient #1 after that and was in the chart room when he/she heard the code blue called.

A telephone interview was conducted at 12:30 p.m. on 06/01/12 with employee #2. The interviewee confirmed that he/she was one of the HSTs on duty on 05/14/12. The HST stated the assignment sheet was brought to the unit, but that he/she did not look at it and continued to be responsible for the line-of-sight patients (#2 and 3) and that employee #1 was responsible for the routine observations. He/she reported that employee #4 was not conducting rounds and thought that employee #4 was aware that changes in the assignment sheet had occurred. The interviewee stated that routine observations were to be made every 30 minutes but he/she was unsure as to how often employee #1 had conducted the observation rounds. The interviewee was also aware that patients were to be checked for breathing. The HST explained that he/she was able to see the patients on line-of-sight. One of the patients (#2) was in the room to the right side of where he/she was sitting and the other patient (#3) was straight across the day room and in sight. The HST reported that he/she checked on them in their rooms at times, but reiterated that the patients were in line-of-sight from the chair where he/she was sitting. The interviewee had seen patient #1 up to the bathroom at 2:40 a.m. The patient returned to his/her room and was making jokes and laughing with the staff. The HST did not see patient #1 again until morning. At approximately 6:30 a.m. employee #1 asked him/her to go into patient #1's room. He/she found the patient unresponsive and told employee #1 to report it to the nurse. The interviewee stated he/she did not want to yell out because other patients were up and in the day room. When questioned about the need to start CPR, the interviewee stated this was his/her first time to encounter a situation like this and was not sure what to do.

Interviews were conducted on 06/18/12 with the Nurse Manager for Adult Mental Health Unit (#1) and with the Charge Nurses for the General Mental Health Unit (#2) and Educational Unit (#3) at 2:25 p.m., 1:30 p.m., and 3:15 p.m. respectively, in the nursing administration conference room. All were in agreement that unit nurses were responsible for making patient assignments for the other direct care staff (HSTs and SCWs) and assigning staff to patients with routine, line-of-sight and one-to-one observations. The two (2) Charge Nurses stated that a staff member who was assigned line-of-sight observations was not to be assigned patients on routine observation. The Nurse Manager for the Adult Mental Health Unit indicated that if a staff member was assigned only one (1) line-of-sight observation, the staff member could also be assigned up to three (3) patients on routine observation.

A review of nursing assignment sheets for all three (3) shifts (days, evenings, and nights) for random days (including week days and week ends) in May and June was conducted. The review of assignment sheets revealed that the Adult Mental Health Unit (AMH) had assignments that indicated patients were not being assigned according to policy. On the night shift of 05/13/12, AMH-Pod C revealed evidence of an HST assigned to a line-of sight observation and three (3) additional patients on routine observation. On the day shift of 05/14/12, AMH-Pod A revealed evidence of two (2) HSTs assigned to a line-of-sight observation and two (2) additional patients on routine observation. On the night shift of 05/14/12, AMH-Pod B revealed evidence of an HST assigned to a line-of-sight and an additional patient on routine observation. On the day shift of 05/18/12, both AMH-Pod A and B revealed evidence of HSTs assigned line-of-sights and one with three (3) additional patients on routine observation and the other HST assigned two (2) line-of-sights and an additional patient on routine observation. On the evening shift of 05/18/12, AMH-Pod B and C revealed evidence of three (3) HSTs assigned line-of-sights and up to three (3) additional patients on routine observation. On the night shift of 05/18/12, AMH-Pod B revealed evidence of all three HSTs working assigned to a line-of-sight and additional patients on routine observation and Pod C revealed evidence of an HST assigned to two (2) line-of-sights and two (2) additional patients on routine observation. On the day and evening shift of 05/28/12, AMH-Pod A and B revealed evidence on both units, both shifts, of four (4) HSTs assigned line-of-sights and up to three (3) additional patients on routine observation. On the night shift of 05/28/12, AMH- Pod A revealed evidence of an HST assigned to a line-of-sight and three (3) additional patients on routine observation. On the day shift of 06/02/12, AMH-Pod A and B revealed evidence of HSTs assigned line-of-sights and up to three (3) additional patients on routine observation. On the evening shift of 06/02/12, AMH-Pod A, B, and C all revealed evidence of HSTs assigned line-of-sights and up to three (3) additional patients on routine observation. On the night shift of 06/02/12, AMH-Pod C revealed evidence of an HST assigned to a line-of-sight and an additional patient on routine observation. On the day shift of 06/10/12, AMH-Pod A and B revealed evidence of HSTs assigned to line-of sights and an additional patient on routine observation.

The CNO confirmed that the above assignment sheets revealed evidence of nurses having assigned staff members both line-of-sight observations and routine observations which was out of compliance with the observation policy.


06/19/12
Corrective Action taken by the facility in order to assure for safety of individuals through compliance with observation policy:

a. Facility Training Department will immediately (June 19,2012 at 10 p.m., 11p.m., and June 20, 2012 at 7a.m.) begin retraining staff to emphasize the importance of the observation policy, and detail responsibilities related to performance, including observance of respirations, and specific responsibilities related to all levels of observation (routine, line-of-sight, and one-to-one). Nursing Leadership will be present for training and to emphasize seriousness.

b. Staff will be informed that performance issues and non-compliance with policy will be dealt with by disciplinary action up to and including termination. Accountability will extend from HSTs to those in supervisory role on that shift, including Lead HSTs and Charge Nurses.

c. Currently, evening shift supervisory (House Supervisor) positions exist, but the night shift House Supervisor position is vacant. This is the shift that appears most problematic and vulnerable. Unit Nurse Managers will immediately (June 19, 2012) start an acting night shift supervisory rotation which will provide senior nursing supervision and oversight on this shift. This will remain in place until a permanent hire is made.

d. The duties of the Evening and Night Shift House Supervisors will include regular and spot check rounds on all units. They will perform real time education with staff on performance of observation duties and monitor shift assignments to assure compliance with policy. Observation sheets will be monitored as well as actual performance of HSTs.

e. Evening and Night shift Supervisors must submit daily round sheets and report of findings which will be reviewed in the daily AM morning report.

f. Video spot checks will be conducted on all units to monitor policy compliance via staff performance. Checks will also be made on Evening and Night Supervisors to ensure that they have made rounds on the units by observing video and correlating with their report sheet. This will be done by Hospital Leadership, including but not limited to Nurse Executive, Regional Hospital Administrator, and Risk Manager.

g. Staff observed in video in violation of policy on June 18, 2012 (for the night shift of June 19, 2012) will receive disciplinary action on June 20, 2012, demonstrating administration's response to non-compliance. Disciplinary action may include termination, but no less than written reprimand/final warning.


A review on 06/20/12 of the training that was done on 06/19/12 and 06/20/12 by the Training Department revealed that staff had received retraining as per the corrective action. Training included education about the observation policy, including staff responsibilities. The training also revealed evidence of education on the necessity of checking respirations of patients when they were sleeping.

A review of camera surveillance was conducted from 10:15 a.m. through 1:15 p.m. on 06/20/12 of all six (6) units (Adult Mental Health-Pod A, B, and C, General Mental Health Unit-A and B, and also the Educational Unit). The review included observation rounds at various times throughout the night of 06/20/12 from 11:30 p.m. - 5:00 a.m. Each unit was observed for three (3) consecutive 30 minute routine observations and each unit was found to be in compliance. There was also evidence of 15 minute observation rounds on line-of- sight patients. Staff members were at the door or in close proximity of patients who required line-of-sight or one-to-one observation. The Nurse Manager who was the acting Night Shift Supervisor was seen at various times on the camera surveillance. There was also some evidence of unit nurses making rounds and interacting with the other staff.