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Based on observations, record review and staff interviews, it has been determined that the facility failed to Meet the Condition of Participation of Patient Rights for Patient ID #s 7, 8, 9 and 12 who were in the Low Stimuli Unit (LSU) of the Emergency Department (A 0144).

Findings are as follows:

1. The facility failed to provide care in a safe setting related to line of sight observation. The facility failed to follow hospital policy for patients ID #'S 7, 8, 9 and 12 (refer to A 144).

2. The facility failed to keep Patient ID# 7 free from abuse while he/she had an active order for line of sight observation (refer to A 145).

Based on surveyor observation, record review and staff interviews, it has been determined that the facility failed to provide care in a safe setting, relative to levels of observation in the Low Stimuli Unit (LSU) for 4 of 5 patients reviewed (Patient IDs # 7, 8, 9 and 12).

Findings are as follows:

The Hospital's policy for Levels of Observation, last revised on 1/3/2017 states in part;

"I. Purpose and Background:
To define and assign a level of observation (as defined in Section IV) to a patient so an employee can assist in maintaining a safe environment and/or protecting the patient from injury or harm to self or others...

Section IV: Level of Observation:
...Level 3-Line of Sight- Observation of one (1) to four (4) patients. Assigned staff is physically located such that one can scan and observe up to 4 patients in a general area...

V. Procedure...
2. Evaluation of Patients in the LSU: A physician, ED Clinician or primary nurse will assess a patient to determine if a patient needs to be placed under Level 1 or Level 2 Constant Observation in order to maintain safety for self or others. For patients presenting in the ED with psychiatric symptoms, detox requests, substance abuse, suicidal, homicidal or patients who have overdosed, an ED Physician or ED Clinician must complete a Risk Assessment as well as disrobement, medication, restraints, etc. to ensure patient and staff safety and document same in the Meditech Risk Assessment ...

Areas of Concern:
a) Toileting, showering and dressing: Patients with Level 1, Level 2 and Line of Sight, must have the door ajar so that an unobstructed view of the patient can be maintained. Auditory contact also is to be maintained so the assigned staff person can continuously maintain verbal contact with the patient...
c) Staffing Guideline: Staff is to be assigned to an observation level for a maximum of 2 consecutive hours. Staff will switch off with another staff person after the completion of 2 consecutive hours ..."

1. Record review revealed Patient ID #7 presented to the Hospital Emergency Department (ED) on 7/7/2019 reporting "increased depression and suicidal ideation" with a plan to jump in front of a car/bus.

Review of the Progress Note dated 7/7/2019 indicates the patient was identified as moderate risk, as he/she exhibited suicidal ideation and a plan. Patient ID #7 had an order dated 7/7/2019 at 2:16 PM for line of sight observation and was placed in the LSU.

Review of the ED Visit Note dated 7/8/2019 at 10:20 PM revealed Patient ID #7 was sleeping in a recliner in the LSU and awoke yelling at another patient (Patient ID #8) to stop touching him/her. The note indicates the security footage was reviewed and it was noted that Patient ID # 7 was touched in his/her genital area as well as other areas by Patient ID #8 while he/she was sleeping.

Surveyors review of the security tape with the System Director of Risk Management on 7/12/2019 at 8:22 AM, revealed Patient ID#8 touching Patient ID # 7 on different parts of his/her body including thigh, chest, groin and genital area over the course of approximately 17 minutes.

Record review of "Patient Observations" revealed Patient ID #7 was documented as "off watch" by a security officer (Staff A) on 7/8/2019 at 6:30 PM. There is no further patient observation documentation recorded until 7/9/2019 at 7:00 AM. There lacked evidence that the order for line of sight observation was discontinued by a provider.

During an interview on 7/12/2019 at 11:25 AM with the security officer (Staff A), who was on duty during the incident, he revealed that at approximately 6:45 PM on 7/8/2019, he was instructed by a unit nurse (Staff B) to remove Patient ID #7 from line of sight observation.

During an interview on 7/12/2019 at 12:00 PM with the nurse (Staff B), she acknowledged that on 7/8/2019 she instructed Staff A to remove Patient ID #7 from line of sight observation. Staff B further revealed she did not obtain an order from a provider to discontinue the line of sight observation.

The facility failure resulted in serious psychosocial harm to Patient ID #7 as evidenced by a record review which revealed Patient ID #7 was evaluated by psychiatry after the above incident. The psychiatry note indicates the patient had been "... re-experiencing where certain sounds individual remind (her/him) of past trauma to include trauma when (he/she) was 9 years old being molested, in addition to trauma (he/she) experienced while in the LSU ..." This note further revealed the patient's symptoms included "depressed mood, poor sleep, poor appetite, poor interest, guilt, increased anxiety, irritability, distractibility, poor concentration, poor energy, significant body tension." The note also indicated Patient ID #7 stated he/she was experiencing disturbing dreams and recollections of past trauma as well as feeling "hopeless, helpless and worthless."

2. Record review for Patient ID #8 revealed he/she presented to the ED on 7/8/2019 at 8:51 PM for evaluation of alcohol intoxication and was admitted to the LSU. An ED visit note dated 7/8/2019 revealed he/she presented as intoxicated with some difficulties with his/her gait and slurred speech.

Record review of Patient ID #8 revealed there was no Risk Assessment to determine the need for observation, per policy, upon admission to the LSU.

During an interview the System Director of Risk Management on 7/12/2019 at approximately 2:30 PM, she acknowledged that assessment of ID# 8's observation needs was not documented in the clinical record.

3. Record review for Patient ID #9 revealed he/she presented to the ED on 7/10/2019 for reporting hearing voices to kill himself/herself. Patient ID #9 had an order dated 7/10/2019 for line of sight observation.

Surveyor observation on 7/11/2019 at approximately 12:45 PM revealed Patient ID #9 was under line of sight observation by a security officer (Staff C). Patient ID #9 was observed walking to the telephone area and out into the secured hallway which was out of line of sight observation of Staff D (approximately 15 feet away from where he was standing).

During an interview immediately after the observation, Staff C acknowledged that Patient ID #9 was not in his line of sight as ordered, when he/she was near the telephone or when he/she went to the secured hallway.

Additionally, review of the "Patient Observations" documentation revealed the patient was monitored by the same security officer on 7/10/2019 to 7/11/2019 from 10:59 PM-3:00 AM (2 hours longer than policy states) and from 3:00 AM-6:45 AM (1 hour and 45 minutes longer than policy states). The record lacked evidence that staff switched off with another staff person after the completion of 2 consecutive hours per the facility's policy.

4. Record review for Patient ID #12 revealed he/she presented to the ED on 7/8/2019 at 10:23 PM for evaluation of suicidal ideation. On 7/9/2019 at 12:44 AM an order was placed for line of sight observation.

Record review of the Patient Observations documentation revealed the patient was on line of sight observation by the same security officer on 7/9/2019 from 11:23 PM-3:00 AM (1.5 hours longer than policy states), from 3:00 AM-9:00 AM (4 hours longer than policy states), and 7/10/2019 from 11:00 PM- 3:00 AM (2 hours longer than policy states).

There lacked evidence that staff switched off with another staff person after the completion of 2 consecutive hours per the facility's policy.

During an interview with the System Director of Risk Management on 7/12/2019 at approximately 2:30 PM, she was unable to provide evidence that the facility's policies were followed relative to line of sight observation.

Based on observation, record review and staff interview, it has been determined that the hospital failed to keep all patients free from abuse for 1 of 5 patients reviewed (Patient ID #7).

Findings are as follows:

Record review revealed Patient ID #7 presented to the Hospital ED on 7/7/2019 reporting increased depression and suicidal ideation. Patient ID # 7 had a physician's order dated 7/7/2019 at 2:16 PM for line of sight observation and he/she was placed in the LSU.

Review of the ED Visit Note dated 7/9/2019 documented at 10:20 PM revealed Patient ID #7 was sleeping in a recliner in the LSU and awoke yelling at another patient (Patient ID #8) to stop touching him/her. The note indicates the security footage was reviewed and it was noted that Patient ID # 7 was touched in his/her genital area as well as other areas by Patient ID #8 while he/she was sleeping.

Surveyors review of the security tape with the System Director of Risk Management on 7/12/2019 at 8:22 AM, revealed Patient ID#8 touching Patient ID # 7 on different parts of his/her body including thigh, chest, groin and genital area over the course of approximately 17 minutes. An Interview during this time, with the System Director of Risk Management revealed that according to another security footage, at least one staff was observed using a cell phone while the incident was occurring. She further stated the copy machine in the nursing station blocked the view of the lounge area where patient ID #7 was assaulted by Patient ID #8 and that all staff were notified that only one staff member can be in the nursing station, other staff members must be out in the unit to monitor patients.

During an interview on 7/12/2019 at 11:25 AM with the security officer (Staff A), who was on duty during the incident, he revealed that at approximately 6:45 PM on 7/8/2019, he had a total of 4 patients who needed line of sight observation in the LSU. When another patient who needed line of sight observation came in to the LSU, he told a unit nurse (Staff B) that he could only watch 4 patients and that 1 of those patients had to be watched by a nursing assistant. Staff A revealed that subsequently, he was instructed by Staff B to remove Patient ID #7 and another patient from line of sight observation. He further revealed he did not witness the incident because Patient ID #7 was removed from line of sight observation.

During an interview on 7/12/2019 at 12:00 PM with a unit nurse (Staff B) she revealed that on 7/8/2019 she instructed a security officer (Staff A) to remove Patient ID #7 from line of sight observation. Staff B revealed she did not obtain an order to discontinue line of sight observation and stated her practice was to take a patient off line of sight observation without obtaining an order. Staff B further revealed a clinician/social worker (Staff D) and a physician (Staff E) "said" if there is no concern they (nurses) can take patients off from line of sight observation. Additionally, Staff B revealed that she took Patient ID #7 of from line of sight observation because the patient had been in the LSU and had not mentioned that he/she wanted to kill himself/herself. Staff B stated "(He/she) was right there in front of us".

During an interview with the clinician/social worker (Staff D) on 7/12/2019 at 1:20 PM, she revealed in general she is the one that "takes" patients off line of sight observation. She revealed she saw the patient on 7/8/2009 but did not perform any assessment or discuss with other staff taking Patient ID #7 off line of sight observation. She was not on the unit at the time of the incident.

During an interview with the System Director of Risk Management on 7/12/2019 at approximately 2:30 PM, she was unable to provide evidence that the line of sight observation was maintained during the incident or that there was an order to discontinue.

The failure to provide line of sight observation, as ordered, resulted in serious psychosocial harm to Patient ID #7 as evidenced by a record review which revealed Patient ID #7 was evaluated by psychiatry after the above incident. The psychiatry note indicates the patient had been "... re-experiencing where certain sounds individual remind (her/him) of past trauma to include trauma when (he/she) was 9 years old being molested, in addition to trauma (he/she) experienced while in the LSU... and this triggered significant anxiety and agitation." This note further revealed the patient's symptoms included "depressed mood, poor sleep, poor appetite, poor interest, guilt, increased anxiety, irritability, distractibility, poor concentration, poor energy, significant body tension." The note also indicated Patient ID #7 stated he/she was experiencing disturbing dreams and recollections of past trauma as well as feeling "hopeless, helpless and worthless."

Additionally, review of a nurse's progress note dated 7/10/2019 documented at 8:26 PM revealed Patient ID #7 verbalized his/her frustration after the incident in the LSU. Patient ID #7 stated "I never thought it would happen again now... voiced that many patients on the unit are talking about it, and that is what is bothering her the most."