HospitalInspections.org

The hospital must ensure that the exercise of patients' rights
requirements are met.

Based on observation and record review and interview the facility failed to ensure that the exercise of patients' rights requirements are met by allowing an inpatient with a reasonable opportunity to get food for 15 hours one of one patient (#F) on a 1:1 observation.

During a tour of the facility on 8/27/24 at 10:30 am patient #F was observed sitting in a unit day room watching television with a Mental Health Technician (MHT) #20 standing next to her as a 1:1 monitor. Patient #F requested this surveyor speak to her.

During an interview on 8/27/24 at 10:35. The patient reported to this surveyor that she was on 1:1 observation because she feels suicidal with plans to either be discharged and overdose or to "cheek" (not swallow and save for later) her pills and overdose in the facility. Patient #F stated the prior day, 8/26/24 she was hungry and had not eaten from after lunch at 11:30 on 8/25/25 until approximately 11:00 am on 8/26/24. She stated she sleeps a lot due to her depression thus missing meals.

On 8/25/24 she stated she took a nap after lunch and asked MHT #20 to awaken her for dinner. She stated she was not awakened for the evening meal and did not independently awaken until about 9:00 am the next morning, 8/26/25.
She explained she was very hungry when she awoke and wanted "real food" not snacks of chips.

She stated she was told by MHT #20 she would have to wait until snack time at approximately 10:00 to eat a snack and that lunch was at 11:00. She reported that MHT # 20 refused to give her any food until snack time and stated "It's not my problem you sleep. If you got up, you could eat."

Patient #F stated she became angry and acted out resulting in her receiving emergency meds and time in seclusion. She stated she was given food to eat when lunch was served at about 11:00 am on 8/26/24 approximately 23.5 hours later.

Patient #F's record contained a seclusion/ restraint form dated 8/26/24 indicating the patient was in seclusion from 09:55 am to 10:03 and had received Zyprexa 10 mg and Benadryl 50 mg IM as emergency medication for behaviors od agitation, kicking and swinging at staff.

When interviewed, 8/27/24 at 10:45 MHT #20 stated she was the staff assigned as the 1:1 for patient #C on 8/26/and 8/27/24. When asked if the patient had asked her to awaken her for dinner on 8/26/24 she said "Yes." When asked if she had awakened the patient, she said she hadn't, that that was not her job. She stated the patient sleeps a lot and she just lets her. MHT #20 was asked if there was a reason why she did not give the patient any food when she requested it, knowing the patient had not had dinner or breakfast as she had been wit the patient during those times. She adamantly responded "We can't give just anybody a snack when they want it. If we did that everybody would want a snack."

Review of MHT #F's personnel information revealed she was assigned to 1:1 patient #C alone on 8/26/27 and 8/27/24 while still in training as a new hire. She had with previous MHT experience at a prior employer.