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Based on review of facility policies, review of medical records, video surveillance, and staff interviews it was determined that the facility failed to protect and promote each patient's rights as evidenced by failure to prevent unauthorized access to a medication room, and failure to record patients' locations during routine observations accurately (A-0144).

On November 8, 2024 at 1:10 PM, as a result of this failure, Immediate Jeopardy (IJ) was identified. The immediate interventions implemented by the facility included staff re-education, implementation of scheduled environmental checks, and leadership auditing. These interventions were implemented and verified by the State Agency, and the IJ was removed on November 12, 2024 at 9:40 AM.

Cross Reference:
482.13(c)(2) Patient Rights: The patient has the right to receive care in a safe setting.

Based on review of hospital policies, review of hospital documents, review of medical records (MR), observations, and interviews with staff (EMP), it was determined that the agency failed to ensure a safe environment by leaving a medication room unlocked, and by failing to properly observe patients on the 2 West Unit. This deficient practice resulted in the hospital's inability to protect patient rights and provide services in a safe setting. This deficiency had the potential to impact all 24 patients receiving inpatient care on the 2 West Unit. Findings include:

Review of facility policy "Patient Rights", effective October 2024, last revised July 2018, stated, " ...Each patient shall receive care and treatment suited to the patient's needs ...Each patient shall have the right to be free from ...neglect ..."

Review of hospital admission packet provided to patients on admission included document titled "Patient and Family Information and Guidelines", no date, which stated, " ...Safety ...Safety Philosophy: The safety of all patients is the foremost staff concern and is the responsibility of everyone. All patients have the right to treatment in an environment that is safe and comfortable ..."

Review of hospital policy "Levels of Observation and Precaution Levels", Effective and Last reviewed May 2024, stated, " ...All patients will be routinely observed in compliance with physician orders and prescribed protocols ...Q [every] 15 Minute Observations ...minimum level of observation for all patients ...Assigned staff will make direct visual contact with patients and confirm they are in no danger or distress ..."

I. Unlocked medication room.

Review of MR1 "General Note", dated October 29, 2024 and signed by EMP13 (registered nurse), revealed, " ...Approximately 3:54 PM, this writer notified a blanket disappearing out of the rear medication room door. This writer looked out into hallway to see, what later was determined to be, the patient at the end of the hallway behind the 2-West RN station. This writer asked the [Patient] if [he/she] had been in the medication room, because the door was having problems latching. The [patient] replied, "No" ...The writer closed the door and proceeded with medication pass. In the meantime, [EMP15] from maintenance examined the door latch, and discovered the latch plate was stuffed with a soft, white material, and covered with tape which was removed, and the door latch worked ..."

Review of facility provided document "Investigation Summary", revealed that an incident occurred on October 29, 2024, in which Patient #1 was able to gain access to the 2 West medication room. At 3:32 PM, EMP10 (nurse manager), notified EMP11 (supervisor), that the lock on the medication room on 2 West was not locking. At 3:41 PM, EMP10 (nurse manager) and EMP13 (medication nurse) both leave the unit.
Patient #1 walked into the medication room at 3:48 PM and remained inside until 3:52 PM, attempting to break open a sharps container. Patient #1 exited through a rear door in the medication room and accessed a rear empty hallway, where he/she remained for a total of 47 minutes (3:52 PM until 4:35 PM). At 4:16 PM, tape and other materials were removed from the door lock plate. At 5:07 PM, additional items are removed from the door lock plate.

Review of video surveillance from October 29, 2024, from 1:10 PM to 3:40 PM revealed the following timeline of events:

1:10 PM- Patient #1 sits in a chair close to the medication window and appears to be watching staff at the nursing station.

1:12 PM to 1:13 PM- Patient #1 drops to the ground and crawls on the floor towards the medication room, pausing briefly behind a pillar before reaching the medication room. Patient #1 then appears to examine the closed medication door.

1:42 PM - Patient #1 obtains tape from the nursing staff at the nursing station and goes to sit in a chair next to the medication room.

1:43 PM to 2:55 PM- Patient #1 can be seen frequently standing at the medication room door. View of the lock not visible as Patient #1 was standing directly in front of the locking side of the door, wearing a blanket.

3:05 PM- Patient #1 can be seen squatting next to the door, looking at the lock.

3:10 PM- Patient #1 walks back to the nursing station, receives 3 pieces of tape from nursing staff, and walks back to the medication room door where she remains for 5 additional minutes.

3:16 PM- Patient #1 pushes on the medication room door and walks away.

3:40 PM- EMP13 (medication nurse) leaves the medication room, and pulls the door closed. The door does not close properly, and EMP13 can be seen attempting to pull the door closed a few more times before walking away.

3:48 PM- Patient #1 enters the medication room and closes the door. Patient #1 makes multiple unsuccessful attempts to gain access to the locked sharps container that is secured to the wall.

3:51 PM- EMP13 enters the medication room and Patient #1 enters the back hallway through the rear medication room door. EMP13 enters the rear hallway and looks around.

3:52 PM- EMP13 re-enters the medication room, goes out to the main unit and then returns to the medication room with EMP6 (registered nurse), and they look at door. EMP13 then begins medication administration at 3:53 PM.

4:35 PM- Patient #1 is seen looking out the window of the door to the back hallway, and at that time, EMP12, EMP13, and EMP14 see Patient #1 and open the door to let her back onto the 2 West Unit.

During an interview on November 8, 2024, between 11:20 AM and 11:30 AM, with EMP1, it was confirmed that multiple layers of leadership were aware that the door was not locking properly, however, no staff member was assigned to monitor the door until the issue was fixed. Staff knowingly left the medication door unlocked and unmonitored from 3:40 PM until 3:52 PM, in which time a patient was able to gain access. There was no staff within the line of sight of the medication room during the time the patient gained access.

During an observation of 2 West on 11/7/2024 between 9:40 AM and 10:15 AM, it was observed, and witnessed by EMP2, that the lock plate for the medication room door had a visible sugar substitute packet shoved into the opening.

During an interview on November 8, 2024, between 12:00 PM and 12:15 PM with EMP1, it was stated that the actions taken in response to the incident on October 29, 2024, included staff disciplinary action for appropriate staff members, as well as looking into alternate door options that would better a safer option for the unit.


II. Patient observations

Review of MR1 "Psychiatric Evaluation", dated October 29, 2024, revealed that Patient #1 was ordered routine Q15 minute checks.

Review of MR1 "Accountability Flow Sheet" for October 29, 2024, revealed that the observations indicated that Patient #1 was in the dayroom at 3:45PM, was outside at 4:00 PM, and was back in the dayroom for the 4:15 PM and 4:30 PM checks.

Review of video footage indicated that from 3:48 PM until 3:52 PM, Patient #1 was in the medication room and from 3:52 PM until 4:35 PM, Patient #1 was in the back hallway alone and out of view of staff.

The observations documented did not accurately reflect the location or status of the patient.

Review of MR2 "Accountability Flow Sheet" for October 29, 2024, revealed that the observations indicated that Patient #2 was in the dayroom from 3:45 PM to 4:30 PM.

Review of video footage indicated that on October 29, 2024, from 4:03 PM until 4:18 PM, Patient #2 was outside for a smoke break, accompanied by EMP12.

The observations documented did not accurately reflect the location or status of the patient.

Review of "Investigation Summary" for incident occurring October 29, 2024, revealed that another patient, Patient #2, was presenting herself as Patient #1 while Patient #1 was in the medication room and back hallway. The investigation summary confirmed that multiple Q15 minute observations were falsified for both Patient #1 and Patient #2. It was indicated that EMP12 did not confirm the identity of Patient #2 before going outside for a smoke break.

During an interview on November 7, 2024, between 2:11 PM and 2:24 PM, with EMP1, it was confirmed that there was a failure to properly identify patients and a failure to document accurate patient observations. It was also confirmed that when documenting for each patient, the patient's picture is shown on the tablet screen where documentation takes place.