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Tag No.: A0115
Based on observations, record reviews and interviews, the facility failed to ensure patient rights were protected and promoted, and implement their written policy and procedures that protect and promote each patient's rights for 1 of 1 patient (Patient #1) reviewed.
Specifically, the facility failed to ensure Patient #1's rights to be free from neglect by failing to implement interventions to prevent and protect Patient #1 from self-harm when facility staff neglected the physician ordered patient supervision and the implementation of facility policies and procedures for Patient Observations every 15 minutes resulting in Patient #1 committing self-harm; resulting in death.
Refer to A 0145 for evidence of specific findings.
The cumulative effect of these deficient practices resulted in the facility's inability to meet the Condition of Participation for Patient Rights.
Tag No.: A0145
Based on observations, record reviews and interviews, the facility failed to ensure patient's rights to be free from all forms of abuse and neglect by failing to implement interventions to prevent and protect patients from self-harm when facility staff neglected the physician ordered patient supervision and the implementation of facility policies and procedures for Patient Observations every 15 minutes for 1 of 1 patient reviewed (Patient #1) that committed self-harm; resulting in death.
Specifically, on 5/13/22 facility staff failed to conduct Patient Observations every 15 minutes for Patient #1 who was in his bedroom continuously according to camera reviews from 6:37 PM to 7:08 PM (31 minutes) without any staff supervision during this time period for safety. Patient #1 was found in his bedroom non-responsive at 7:08 PM and pronounced deceased at 7:43 PM.
Findings included:
Review of the Facility's Psychiatric Hospital Incident Report (Form 6107) the facility Self-Reported to the state department on 5/16/22 documented the following:
Patient #1 was admitted to the facility on 5/13/22 for voluntary Inpatient Detox (voluntary veteran substance abuse program) and was admitted to Unit (1100) at 4:48 PM. Patient was on low-risk alert for suicided and self-injury based on Veterans Administration (VA) collateral and admission assessments. Patient #1 was found covered by his blanket and unresponsive in bed by Registered Nurse (RN) #1 at 7:08 PM [5/13/22] due to ingesting toilet paper and obstructing airway. A Code Blue was immediately called, as well as 911. Patient #1's time of death was called by Emergency Medical Services (EMS) at 7:43 PM.
Review of Patient #1's Admitting Doctor's Orders dated 5/13/22 at 3:21 PM signed by a physician revealed Patient #1 met the medical and psychiatric admission criteria for inpatient level of care. Patient #1 with a history of substance abuse, Post Traumatic Stress Disorder (PTSD), Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD). Patient #1's level of observation was checked for "Q [every]15 Minutes."
Review of the Urine Drug Screen dated 5/13/22 at 3:50 PM revealed Patient #1 positive for Cocaine and Marijuana.
Review of the Nursing Admission Assessment dated 5/13/22 at 4:48 PM completed by Registered Nurse (RN) #2 documented Patient #1's chief complaint as "having withdrawals." RN #2 further documented Patient #1 positive for Suicidal Ideation, "I want to hurt myself" and positive for Visual Hallucinations, "I think I'm starting to see things."
Review of the 4- Hour Request for Release-Discharge for Patient #1 revealed he signed this request for discharge on 5/13/22 at 18:38 (6:38 PM); which is less than 2 hours after being admitted to the unit.
Review of the Staff Assignment Sheet for Friday, May 13, 2022 revealed for 7:00 AM-7:00 PM, RN #1 was assigned to 1100 hall and Mental Health Tech (MHT) #1 was assigned to 1100 hall. From 7:00 PM -7:00 AM, RN #3 was assigned to 1100 hall and MHT #2 was assigned to 1100 hall.
Review of the census report for the 1100 hall (monarch unit) for 5/13/22 was 8 patients.
On 5/20/22 beginning at 11:15 AM, camera observations were conducted with the facility's Risk Manager and other facility administrative staff in the conference room for Camera "C57" for the 1100 Hallway where Patient #1 was admitted on 5/13/22. The following camera observations were conducted in collaboration of the documentation from Patient #1's record for the Q 15-minute check documentation for 5/13/22 to determine a timeline of events that occurred on 5/13/22 from 5:00 PM to 7:10 PM.
Note: The Patient Observation/MHT Notes Form is used for the Patient Observation checks every (Q) 15 minutes; also known as the Q-15's and/or Q's. The Patient observation form has autogenerated times documented for every 15 minutes per hour (i.e. 5:00, 5:15, 5:30, 5:45, 6:00 .....)
5/13/22:
5:00 PM- Patient Observation/MHT Notes documented by RN #2 indicated Patient #1 was with staff in the nurses station (conducting nursing admission assessment).
5:15 PM- Patient Observation/MHT Notes documented by an unknown staff according to interviews with initial "s" that Patient was 2. Asleep in A. Bedroom.
5:20 PM- Camera Observation revealed RN #1 walking with Patient #1 to his bedroom and then RN #1 returns down the hallway towards the nurses station and Patient #1 stays in his room (#1112).
5:27 PM- Camera Observation revealed MHT #1 is gathering other patients from the 1100 unit and leaves the unit (to the cafeteria according to MHT interview)
5:30 PM- Patient Observation/MHT Notes documented by an unknown staff according to interviews with initial "s" that Patient was 2. Asleep in A. Bedroom. Note: There were not any observations according to camera review that this check was completed while Patient #1 was in his room.
5:37 PM- Camera Observation revealed Patient #1 is seen leaving his bedroom and walking down the hallway.
Camera Observations for Patient #1 revealed he remained in his room from 5:20 PM until 5:37 PM (17 minutes) without staff conducting observation checks in his room during this time according to camera review.
5:42 PM- Camera Observation revealed Patient #1 is seen walking back to his bedroom and stays in his room.
5:45 PM- Patient Observation/MHT Notes documented by an unknown staff according to interviews with initial "s" that Patient was 2. Asleep in A. Bedroom. Note: There were not any observations according to camera review that this check was completed while Patient #1 was in his room.
6:00 PM- Patient Observation/MHT Notes documented by an unknown staff according to interviews with initial "s" that Patient was 2. Asleep in A. Bedroom. Note: There were not any observations according to camera review that this check was completed while Patient #1 was in his room.
6:03 PM - Camera Observation revealed MHT #1 is seen returning to the unit with other patients (from the cafeteria according to interview)
6:04 PM- Camera Observation revealed Patient #1 walked out of his room.
Camera Observations for Patient #1 revealed he remained in his room from 5:42 PM until 6:04 PM (22 minutes) without staff conducting observation checks in his room during this time according to camera review. The MHT #1 was not in the unit at this time and was in the cafeteria according to interview and camera reviews.
6:15 PM- Camera Observation revealed Patient #1 is on the Patio (smoking area).
6:15 PM- Patient Observation/MHT Notes documented by an unknown staff according to interviews with initial "s" that Patient was 2. Asleep in A. Bedroom. Note: This documentation does not correlate with the camera review that revealed Patient #1 was on the Patio at 6:15 PM.
6:19 PM- Camera Observation revealed Patient #1 was in the day room. Patient #1 is seen speaking to staff in the nurses station area.
Note: There is a half door that separates the nurses station to the day room of the unit.
6:29 PM- Camera Observation revealed Patient #1 walked down to his room and entered his room.
6:30 PM- Camera Observation revealed Patient #1 returned to the day room.
6:30 PM- Patient Observation/MHT Notes documented Patient was M. on the unit patio/smoke 24. Handwritten with "smoking." Staff initials including MHT #1 with handoff to MHT #2.
Note: This documentation does not correlate with the camera review that revealed Patient #1 was on the Patio at 6:15 PM and not
6:30 PM. Patient was seen on camera in the dayroom at 6:30 PM and his bedroom at 6:31 PM.
6:31 PM- Camera Observation revealed Patient #1 walked down the hallway and entered his room (#1112)
6:32 PM- Camera Observation revealed Patient #1 returned to the day room.
6:37 PM- Camera Observation revealed Patient #1 talking to RN #1 at the half door while RN#1 is in the nurses station. (Interviews and documentation correlate this time of when Patient #1 signed his 4 hour request for release-discharge from the facility).
6:37.27 (seconds) PM - Camera Observation revealed Patient #1 walking down the hall towards his room with a piece of paper in hand and enters his bedroom at 6:37.42 (seconds) PM.
This is the last observation of Patient #1 seen on camera (6:37.42 seconds PM) before Patient #1 is found unresponsive by RN #1 at 7:08 PM (31 minutes later).
6:38 PM- Review of the "4 Hour Request for Release-Discharge" is signed by Patient #1 with a date of 5/13/22 and time of "18:38."
Note: This time correlates within one minute of the Camera Review observation at 6:37/18:37 PM.
6:45 PM - Patient Observation/MHT Notes documented by MHT #2 that Patient #1 was in C. in the TV Room and 10. With staff.
Note: This documentation does not correlate with the camera review that revealed Patient #1 was seen going into his room at 6:37 PM and remained in his room.
7:00 PM- Patient Observation/MHT Notes revealed the area was blank without documentation of observation checks for Patient #1.
7:08.49 (seconds) PM- Camera Observation reveals RN #1 walking down the hallway and enters Patient #1's bedroom. Note: Interview with RN #1 revealed when he entered Patient #1's room at 7:08 PM, Patient #1 was found unresponsive/pulseless, and a Code Blue was yelled out from the room.
The last observation of Patient #1 on camera was 6:37 PM when walking to his bedroom. At 7:08 PM; 31 minutes later RN #1 walks down to Patient #1's bedroom and finds Patient #1 unresponsive. Camera Reviews revealed no staff were observed walking down the hallway to conduct observation checks on Patient #1 after 6:37 PM. There should have been two additional visual observation(s) conducted between 6:38-6:52 PM and 6:53-7:07 PM to ensure Patient #1 was visualized by observation every 15 minutes according to Physician Orders and facility policy.
7:09 PM- Camera Observation revealed MHT #2 was seen running down the hallway towards Patient #1's bedroom.
7:10 PM- Camera Observation revealed additional staff with the emergency cart were being taken to Patient #1's bedroom.
Further review of the Patient Observation/MHT Notes for Patient #1 for 5/13/22 revealed there was not an RN signature confirming the accuracy of the patient observation rounding in accordance with the facility's observation policy.
Review of the facility's Investigation with Camera Review of Event dated 5/13/22 by the facility's Risk Manager confirmed the findings that at 6:37 (40 seconds) Patient #1 re-enters his bedroom and this was the last time patient is seen on camera. At 7:08 PM (49 seconds) RN #1 enters Patient #1's bedroom. A staff is seen running down hallway at 7:09.18 seconds. Further documentation indicated; "Although Q15 documentation states they were conducted on schedule; camera footage does not show staff having eyes on patient from 18:37 (6:37 PM) to 1908 (7:08 PM).
Review of the facility's Inquiry Report and Findings Form dated 5/16/22 revealed Medical Examiners Cause of Death, intentional upper airway obstruction by foreign material.
Interview on 5/20/22 at 2:00 PM with RN #1 stated the following:
Patient 15-minute observation checks/rounds were the responsibility of the MHT and the nursing staff. Nursing will do the 15-minute rounding if the MHT's were not available, or off the unit. The Q-15-minute checks are to be done within the 15-minute time frames; by "laying eyes on everyone."
RN #1 stated that on Friday 5/13/22; "we were busy" and he worked "2 units that day; 1200 and 1100 hallways" due to other RN's calling in. He said that the house supervisor, RN #2 did the admission assessment for Patient #1.
RN #1 stated Patient #1 was on unit restriction (UR) until the psychiatrist could see him and evaluate him. RN #1 stated he was monitoring Patient #1 while the MHT was in the cafeteria with the other patients from the unit; and the MHT brought Patient #1 a food trey back. RN #1 said Patient #1 was upset and wanted to leave. RN #1 said he indicated to Patient #1 that the Doctor needed to see him; but had him sign a 4-hour letter since he was voluntarily admitted. RN #1 said Patient #1 signed the 4-hour letter at approximately 6:35-6:40. At this point, Patient #1 had only been seen by a "Telepsych" Physician in Admissions; but had not yet seen the unit Psychiatrist-A.
RN #1 said after Patient #1 signed the 4-hour letter; timed at 6:38 PM, he went and gave report to the oncoming unit RN #3 for the 7:00 PM shift. RN #1 stated that the Psychiatrist said to "hold" Patient #1 until the morning until she could evaluate him. RN #1 said he then went to go tell Patient #1 what the Psychiatrist/Doctor stated (hold until morning), and he went by MHT #2 who was working the 7PM-7AM shift and conducting vital signs; to ask her if she had done Patient #1's vital signs yet; which she reported she had not, and RN#1 warned MHT #2 to keep a close eye on Patient #1 because he was upset and "paranoid." RN #1 said he then went down the hallway to Patient #1's bedroom and opened the door that was ajar approximately 4 inches and called out his name; with no response. RN #1 then put his hand on Patient #1 to wake him and rolled him over with no response. RN #1 said he then yelled out of the room for "Code Blue" and saw a roll of toilet paper on Patient #1's bed and he had three fingers in his mouth. RN #1 removed his fingers and saw toilet paper stuffed into Patient #1's mouth and removed what he could to begin Cardiopulmonary Resuscitation (CPR) chest compressions. RN #1 said Patient #1 did not have a pulse, was not breathing and that he was never able to obtain a pulse.
Further interview on 6/3/22 at 12:45PM with RN #1 reviewed the Documentation for Patient #1's Observation/MHT Notes dated 5/13/22 that documented a staff with initial "s" for the Q-15 minute checks for 17:15, 17:30, 17:45 18:00 and 18:15. Documentation revealed Patient #1 in his bedroom (A) and asleep (2) for all five Q-15 minute checks (17:15, 17:30, 17:45 18:00 and 18:15) in which RN#1 stated that was not his documentation. RN#1 said the staff initials looked like his; but that he did not complete that documentation on Patient #1's Q-15 minute observations. RN#1 further stated that was not accurate documentation for the time periods 17:15, 17:30, 17:45 18:00 and 18:15; because Patient #1 was not in his room asleep during each of those time periods. RN#1 stated he was monitoring Patient #1 on 5/13/22 when the MHT #1 was off the unit in the cafeteria with other patients. RN #1 stated during the time that MHT #1 was in the cafeteria (from 5:27PM to 6:03PM according to camera reviews) he was monitoring Patient #1 who was coming and going from his room to the living area. RN #1 was asked during shift change if the staff conducted a 15-minute rounding together for hand off and he stated "they don't do that, but that's a good idea." RN #1 further confirmed that he did not sign Patient #1's 15 minute Observation form where it requires an RN signature twice per shift.
Interview with MHT #1 on 5/24/22 at 12:50 PM stated the following:
Friday 5/13/22; she was conducting the observation 15-minute checks for Patient #1 until between 6:30 to 6:45 PM. She said the MHT #2 for the PM shift usually comes in early and then they would conduct shift change. MHT #1 said they conduct their shift change in the "exam room" in the nurses station away from patient's on the unit because they are discussing confidential information about patient's. She said shift change is conducted at the same time for the MHT's and the nursing staff (RN/LVN, etc). MHT#1 said on 5/13/22 she asked to leave early; approximately 6:30-6:45. MHT#1 said Patient #1 told her he "wanted to leave." MHT#1 asked RN#1 if he wanted Patient #1 to complete a 4-hour letter. MHT#1 said RN#1 told her, "I'll talk to him; he hasn't' been assessed by the Dr."
MHT#1 said her "last round" for patient observations was at 18:30 (6:30PM) for Patient #1 when she documented "24" he was outside in the smoking area with another patient. MHT#1 said you can see the patients from the half door of the nurses unit; the doors are see through to the patio. MHT#1 said MHT #2 "took over at 18:30". MHT#1 said her staff initials consisted of a "line" and confirmed she did a line at 18:30 (6:30 PM) for the handoff to MHT#2 for Patient #1's Observation 15 minute checks.
MHT#1 was asked what she is supposed to do if she is not able to conduct the Q's and she said that she will give them to the nurse to do; or if she is off the unit, she will give them to the nurse to do.
MHT #1 said the last time she saw Patient #1 on 5/13/22 was when he asked for the 4-hour letter (6:38PM) and right before that he was outside in the smoking area.
This surveyor reviewed the Patient Observation Rounds, Policy # PC.3.02 with MHT #1 that indicated, "At the end of shift, the in-coming and the departing staff shall conduct a unit round together and confirm the location / status of patients and safety of unit, and sign-off on the same line on the Patient Observation sheet, confirming hand-off of unit and patients." MHT #1 responded by saying; "we try to; but others will sometimes say they don't have time."
MHT #1 said the "Q's" were required every 15 minutes or "as close as possible to every 15 minutes." She said that when Q's were done; it would go into the 15 minute block that was closest to that time; stating it may early or late in the specific 15 minute designated block.
MHT#1 said you have to get to the closest time of the block because there is not a "specific time" in the block because they already have times put in (every 15 minute increments). If you do a round at 6:18, there is no way to put 6:18. She said 6:18 could go into a 6:15 block or even a 6:20 block.
MHT#1 reported Patient #1's behavior as "bizarre." She felt he didn't belong in the 1100 unit, stating he was "not suited; paranoid and delusional." When asked for more specifics; MHT #1 said Patient #1 was seeing things, thinking people were out to get him.
Interview on 5/26/22 at 11:55 AM with MHT #2 stated the following:
On 5/13/22, she clocked in at 6:00 PM after being off for 2 weeks and then began to get report from MHT#1. MHT #2 said after she got report she began conducting vital signs for the patients in the unit. While she was conducting vital signs in the day room, RN #1 came and told her to keep a close eye on Patient #1; that he was "unstable and paranoid." MHT #2 said she responded, "if this is the case, then I may need help then." RN #1 said he was going to go check on him. MHT #2 said she then heard "Code Blue" and responded to Patient #1's room where RN #1 was taking out toilet tissue from Patient #1's mouth that he "apparently stuck in his mouth." MHT #2 said she assisted from there with the code and that Patient #1 was nonresponsive.
MHT#2 further stated that she had only seen Patient #1 briefly while she was getting shift change report from MHT #1 and when she saw Patient #1, he was speaking to RN #1. MHT #2 said she heard Patient #1 talking to RN #1 about leaving the facility. MHT #2 says that Q 15-minute checks are supposed to be conducted every 15 minutes by "having eyes on the patient."
MHT #2 was asked about Policy # PC.3.02, for Patient Observation Rounds that states; "At the end of shift, the in-coming and the departing staff shall conduct a unit round together and confirm the location / status of patients and safety of unit, and sign-off on the same line on the Patient Observation sheet, confirming hand-off of unit and patients." MHT #2 responded by saying that she has not ever done that.
MHT #2 was asked about Patient #1's Patient Observation/MHT Rounds that documented at 6:30 PM as taking handoff from MHT #1 with documentation of M. (on the unit patio/smoke) and 24. Handwritten with "smoking." Staff initials including MHT #1 with handoff to MHT #2. In addition, at 6:45 PM, MHT #2 documented that Patient #1 was in C. in the TV Room and 10. With staff.
MHT #2 responded by saying that initially on 5/13/22, the 6:30 PM (1830) and 6:45 PM (1845) time slots were blank for Patient #1 and that those time slots should have been done by MHT #1 before she left her shift. MHT #2 said she was approached by the Psychiatrist/Doctor on 5/13/22 prior to leaving her shift early at 9:30 PM; stating the Q 15-minute checks had not been completed for 6:30 and 6:45 PM and that she needed to fill it out by putting where the patient was at these times. MHT #2 said she did not remember specifically as she only remembered that Patient #1 was talking to RN #2 and that was what she documented.
Note: This documentation does not correlate with the camera review that revealed Patient #1 was seen smoking at 6:15 PM and then going into his room at 6:37 PM and remained in his room during the 6:45 PM time.
Review of the facility's policy titled Patient Observation Rounds, Policy # PC.3.02, last revised 06/2021 revealed the following procedure(s); in part:
Policy- The status and location of all patients shall be directly observed and assessed in compliance with provider orders and prescribed protocols, in order to ensure maximum safety. Zero tolerance will be enforced for failure to adhere to the guidelines provided herein.
A. Levels of Observation
1. 15-minute observation.
a) Minimum level of observation for all patients.
b) Staff will observe and document patient's location and behavior every 15 minutes.
B. Patient Rounds:
2. Conducting Rounds:
a) Patient observation rounding sheets shall be carried while conducting rounds and confirmation of observation shall be documented concurrently.
b) Order of rounding pattern and timing of rounds shall be staggered to reduce the opportunity for planed activity.
c) When checking on patients, the staff shall:
(1) Confirm Patient's identity
(2) Ensure respirations are normal
(3) Ensure patient is not in distress,
(a) If awake, engage patient verbally to determine well-being.
(b) If patient is asleep or resting:
(i) Approach patient quietly to arm's length proximity, (ii) Observe rise and fall of chest, (iii) Count at least three respirations, (iv) Note if patient has changed position.
3. Patient Observation form must be signed over to another staff member when leaving the unit (meals, breaks, etc.) and handing-off assigned patients.
4. At the end of shift, the in-coming and the departing staff shall conduct a unit round together and confirm the location / status of patients and safety of unit, and sign-off on the same line on the Patient Observation sheet, confirming hand-off of unit and patients.
6. RN shall confirm the safety of patients and the accuracy of the patient observation rounds by conducting a minimum of two rounds per shift. Documentation of the RN rounds shall be entered on the designated section of the Patient Observation from.
D. Registered Nurse
1. Review the Patient observation form twice per shift to ensure the safety of the patients and proper completion of documentation by the MHT.
2. Sign and time designated area to confirm review of rounds.
Review of the facility's Training for Patient observation Guidelines revealed when conducting observation rounds, in part:
Round at least every 15 minutes.
Stagger order/time of rounds.
Document every 15 minutes (not ahead of time or after time has passed)
Hand-off must be documented by 2 staff initial on same line in space providing (staff giving AND staff receiving care of patient/forms)
RN must round twice a shift and sign-off on RN section of Q15's
Neglect, for the purpose of this requirement, is considered a form of abuse and is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.
Tag No.: A0395
Based on observation, record review and interviews, the facility's nursing services failed to supervise and evaluate the nursing care for each patient in accordance with the patient's physician orders and the facility's policies for 4 of 4 patient's reviewed (Patient #1, Patient #2, Patient #3 and Patient #4). Specifically,
The facility Registered Nurse's (RN's) delegated the performance of the physician/provider ordered 15-minute observation safety checks of patients to the Mental Health Tech's (MHT's). As a result;
1.) The documented 15 minute observation checks for Patient #1 on 5/13/22 were not accurate in correlation with camera reviews when staff failed to conduct Patient Observations every 15 minutes for Patient #1 who was in his bedroom continuously according to camera reviews from 6:37 PM to 7:08 PM (31 minutes) without any supervision during this time period for safety. Patient #1 was found in his bedroom non-responsive at 7:08 PM and pronounced deceased at 7:43 PM and;
2.) On 5/13/22 the supervision and monitoring for Patient's #1, #2, #3, and #4 with ordered observations to be conducted every 15 minutes for patient safety; and in accordance with the facility policy, were not completed according to the physician and/or provider orders.
Findings included:
Review of the facility's policy titled Patient Observation Rounds, Policy # PC.3.02, last revised 06/2021 revealed the following procedure(s); in part:
Policy- The status and location of all patients shall be directly observed and assessed in compliance with provider orders and prescribed protocols, in order to ensure maximum safety. Zero tolerance will be enforced for failure to adhere to the guidelines provided herein.
A. Levels of Observation
1. 15-minute observation.
a) Minimum level of observation for all patients.
b) Staff will observe and document patient's location and behavior every 15 minutes.
B. Patient Rounds:
1.) Staff assignment:
a.) The unit RN will assign staff to perform observations rounds on a designated set of patients at the beginning of a shift.
2. Conducting Rounds:
a) Patient observation rounding sheets shall be carried while conducting rounds and confirmation of observation shall be documented concurrently.
b) Order of rounding pattern and timing of rounds shall be staggered to reduce the opportunity for planed activity.
3. Patient Observation form must be signed over to another staff member when leaving the unit (meals, breaks, etc.) and handing-off assigned patients.
4. At the end of shift, the in-coming and the departing staff shall conduct a unit round together and confirm the location / status of patients and safety of unit, and sign-off on the same line on the Patient Observation sheet, confirming hand-off of unit and patients.
6. RN shall confirm the safety of patients and the accuracy of the patient observation rounds by conducting a minimum of two rounds per shift. Documentation of the RN rounds shall be entered on the designated section of the Patient Observation from.
D. Registered Nurse
1. Review the Patient observation form twice per shift to ensure the safety of the patients and proper completion of documentation by the MHT.
2. Sign and time designated area to confirm review of rounds.
1.) Patient #1
Review of Patient #1's Admitting Doctor's Orders dated 5/13/22 at 3:21 PM signed by a physician revealed Patient #1 met the medical and psychiatric admission criteria for inpatient level of care. Patient #1 with a history of substance abuse, Post Traumatic Stress Disorder (PTSD), Major Depressive Disorder (MDD) and Generalized Anxiety Disorder (GAD). Patient #1's level of observation was checked for "Q [every]15 Minutes."
On 5/20/22 beginning at 11:15 AM, camera observations were conducted with the facility's Risk Manager and other facility administrative staff in the conference room for Camera "C57" for the 1100 Hallway where Patient #1 was admitted on 5/13/22. The following camera observations were conducted in collaboration of the documentation from Patient #1's record for the Q 15-minute check documentation for 5/13/22 to determine a timeline of events that occurred on 5/13/22 from 5:00 PM to 7:10 PM.
Note: The Patient Observation/MHT Notes Form is used for the Patient Observation checks every (Q) 15 minutes; also known as the Q-15's and/or Q's. The Patient observation form has autogenerated times documented for every 15 minutes per hour (i.e. 5:00, 5:15, 5:30, 5:45, 6:00 .....)
5/13/22:
5:00 PM- Patient Observation/MHT Notes documented by RN #2 indicated Patient #1 was with staff in the nurses station (conducting nursing admission assessment).
5:15 PM- Patient Observation/MHT Notes documented by an unknown staff according to interviews with initial "s" that Patient was 2. Asleep in A. Bedroom.
5:20 PM- Camera Observation revealed RN #1 walking with Patient #1 to his bedroom and then RN #1 returns down the hallway towards the nurses station and Patient #1 stays in his room (#1112).
5:27 PM- Camera Observation revealed MHT #1 is gathering other patients from the 1100 unit and leaves the unit (to the cafeteria according to MHT interview)
5:30 PM- Patient Observation/MHT Notes documented by an unknown staff according to interviews with initial "s" that Patient was 2. Asleep in A. Bedroom. Note: There were not any observations according to camera review that this check was completed while Patient #1 was in his room.
5:37 PM- Camera Observation revealed Patient #1 is seen leaving his bedroom and walking down the hallway.
Camera Observations for Patient #1 revealed he remained in his room from 5:20 PM until 5:37 PM (17 minutes) without staff conducting observation checks in his room during this time according to camera review.
5:42 PM- Camera Observation revealed Patient #1 is seen walking back to his bedroom and stays in his room.
5:45 PM- Patient Observation/MHT Notes documented by an unknown staff according to interviews with initial "s" that Patient was 2. Asleep in A. Bedroom. Note: There were not any observations according to camera review that this check was completed while Patient #1 was in his room.
6:00 PM- Patient Observation/MHT Notes documented by an unknown staff according to interviews with initial "s" that Patient was 2. Asleep in A. Bedroom. Note: There were not any observations according to camera review that this check was completed while Patient #1 was in his room.
6:03 PM - Camera Observation revealed MHT #1 is seen returning to the unit with other patients (from the cafeteria according to interview)
6:04 PM- Camera Observation revealed Patient #1 walked out of his room.
Camera Observations for Patient #1 revealed he remained in his room from 5:42 PM until 6:04 PM (22 minutes) without staff conducting observation checks in his room during this time according to camera review. The MHT #1 was not in the unit at this time and was in the cafeteria according to interview and camera reviews.
6:15 PM- Camera Observation revealed Patient #1 is on the Patio (smoking area).
6:15 PM- Patient Observation/MHT Notes documented by an unknown staff according to interviews with initial "s" that Patient was 2. Asleep in A. Bedroom. Note: This documentation does not correlate with the camera review that revealed Patient #1 was on the Patio at 6:15 PM.
6:19 PM- Camera Observation revealed Patient #1 was in the day room. Patient #1 is seen speaking to staff in the nurses station area.
Note: There is a half door that separates the nurses station to the day room of the unit.
6:29 PM- Camera Observation revealed Patient #1 walked down to his room and entered his room.
6:30 PM- Camera Observation revealed Patient #1 returned to the day room.
6:30 PM- Patient Observation/MHT Notes documented Patient was M. on the unit patio/smoke 24. Handwritten with "smoking." Staff initials including MHT #1 with handoff to MHT #2.
Note: This documentation does not correlate with the camera review that revealed Patient #1 was on the Patio at 6:15 PM and not
6:30 PM. Patient was seen on camera in the dayroom at 6:30 PM and his bedroom at 6:31 PM.
6:31 PM- Camera Observation revealed Patient #1 walked down the hallway and entered his room (#1112)
6:32 PM- Camera Observation revealed Patient #1 returned to the day room.
6:37 PM- Camera Observation revealed Patient #1 talking to RN #1 at the half door while RN#1 is in the nurses station. (Interviews and documentation correlate this time of when Patient #1 signed his 4 hour request for release-discharge from the facility).
6:37.27 (seconds) PM - Camera Observation revealed Patient #1 walking down the hall towards his room with a piece of paper in hand and enters his bedroom at 6:37.42 (seconds) PM.
This is the last observation of Patient #1 seen on camera before Patient #1 is found unresponsive by RN #1 at 7:08 PM.
6:38 PM- Review of the "4 Hour Request for Release-Discharge" is signed by Patient #1 with a date of 5/13/22 and time of "18:38."
Note: This time correlates within one minute of the Camera Review observation at 6:37/18:37 PM.
6:45 PM - Patient Observation/MHT Notes documented by MHT #2 that Patient #1 was in C. in the TV Room and 10. With staff.
Note: This documentation does not correlate with the camera review that revealed Patient #1 was seen going into his room at 6:37 PM and remained in his room.
7:00 PM- Patient Observation/MHT Notes revealed the area was blank without documentation of observation checks for Patient #1.
7:08.49 (seconds) PM- Camera Observation reveals RN #1 walking down the hallway and enters Patient #1's bedroom. Note: Interview with RN #1 revealed when he entered Patient #1's room at 7:08 PM, Patient #1 was found unresponsive/pulseless, and a Code Blue was yelled out from the room.
The last observation of Patient #1 on camera was 6:37 PM when walking to his bedroom. At 7:08 PM; 31 minutes later RN #1 walks down to Patient #1's bedroom and finds Patient #1 unresponsive. Camera Reviews revealed no staff were observed walking down the hallway to conduct observation checks on Patient #1 after 6:37 PM. There should have been two additional visual observation(s) conducted between 6:38-6:52 PM and 6:53-7:07 PM to ensure Patient #1 was visualized by observation every 15 minutes according to Physician Orders and facility policy.
7:09 PM- Camera Observation revealed MHT #2 was seen running down the hallway towards Patient #1's bedroom.
7:10 PM- Camera Observation revealed additional staff with the emergency cart were being taken to Patient #1's bedroom.
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Further review of the Patient Observation/MHT Notes dated 5/13/22 for Patient #1 revealed there was not an RN signature confirming the accuracy of the patient observation rounding in accordance with the facility's observation policy.
Review of the facility's Investigation with Camera Review of Event dated 5/13/22 by the facility's Risk Manager confirmed the findings that at 6:37 (40 seconds) Patient #1 re-enters his bedroom and this was the last time patient is seen on camera. At 7:08 PM (49 seconds) RN #1 enters Patient #1's bedroom. A staff is seen running down hallway at 7:09.18 seconds. Further documentation indicated; "Although Q15 documentation states they were conducted on schedule; camera footage does not show staff having eyes on patient from 18:37 (6:37 PM) to 1908 (7:08 PM).
2.) Patient #2
Review of the Patient Observation/MHT Notes dated 5/13/22 for Patient #2 revealed there was not an RN signature for the 7AM-7PM shift confirming the accuracy of the patient observation rounding in accordance with the facility's observation policy. The ordered observation level was Q-15 minute.
Further review of the Patient Observation Q-15 minute checks for 18:30 and 18:45 (6:30 PM and 6:45 PM) were blank without documentation.
The Q-15 minute checks for 1900, 1915, 1930, 1945, 2000, and 2015 (7:00 PM, 7:15 PM, 7:30 PM, 7:45 PM, 8:00 PM and 8:15 PM) were blank with the word "Incident" written across the form for these time periods.
3.) Patient #3
Review of the Patient Observation/MHT Notes dated 5/13/22 for Patient #3 revealed there was not an RN signature for the 7AM-7PM shift confirming the accuracy of the patient observation rounding in accordance with the facility's observation policy. The ordered observation level was Q-15 minute.
Further review of the Patient Observation Q-15 minute checks for 18:30 and 18:45 (6:30 PM and 6:45 PM) were blank without documentation.
The Q-15 minute checks for 1900, 1915, 1930, 1945, 2000, and 2015 (7:00 PM, 7:15 PM, 7:30 PM, 7:45 PM, 8:00 PM and 8:15 PM) were blank with the word "Incident" written across the form for these time periods.
4.) Patient #4
Review of the Patient Observation/MHT Notes dated 5/13/22 for Patient #4 revealed there was not an RN signature for the 7AM-7PM shift confirming the accuracy of the patient observation rounding in accordance with the facility's observation policy. The ordered observation level was Q-15 minute.
Further review of the Patient Observation Q-15 minute checks for 18:30 and 18:45 (6:30 PM and 6:45 PM) were blank without documentation.
The Q-15 minute checks for 1900, 1915, 1930, 1945, 2000, and 2015 (7:00 PM, 7:15 PM, 7:30 PM, 7:45 PM, 8:00 PM and 8:15 PM) were blank with the word "Incident" written across the form for these time periods.
Interview on 5/20/22 at 2:00 PM with RN #1 stated the following:
Patient 15-minute observation checks/rounds were the responsibility of the MHT and the Nursing staff. Nursing will do the 15-minute rounding if the MHT's were not available, or off the unit. The Q-15-minute checks are to be done within the 15-minute time frames; by "laying eyes on everyone."
Further interview on 6/3/22 at 12:45PM with RN #1 reviewed the Documentation for Patient #1's Observation/MHT Notes dated 5/13/22 that documented a staff with initial "s" for the Q-15 minute checks for 17:15, 17:30, 17:45 18:00 and 18:15. Documentation revealed Patient #1 in his bedroom (A) and asleep (2) for all five Q-15 minute checks (17:15, 17:30, 17:45 18:00 and 18:15) in which RN#1 stated that was not his documentation. RN#1 said the staff initials looked like his; but that he did not complete that documentation on Patient #1's Q-15 minute observations. RN#1 further stated that was not accurate documentation for the time periods 17:15, 17:30, 17:45 18:00 and 18:15; because Patient #1 was not in his room asleep during each of those time periods. RN#1 stated he was monitoring Patient #1 on 5/13/22 when the MHT #1 was off the unit in the cafeteria with other patients. RN #1 stated during the time that MHT #1 was in the cafeteria (from 5:27PM to 6:03PM according to camera reviews) he was monitoring Patient #1 who was coming and going from his room to the living area. RN #1 was asked during shift change if the staff conducted a 15-minute rounding together for hand off and he stated "they don't do that, but that's a good idea."
RN #1 further confirmed that he did not sign Patient #1, Patient #2, Patient #3 and Patient #4's 15 minute Patient Observation form on 5/13/22 where it requires an RN signature twice per shift to confirm the safety and accuracy in accordance with the facility's policy.
Interview with MHT #1 on 5/24/22 at 12:50 PM stated the following:
Friday 5/13/22; she was conducting the observation 15-minute checks for Patient #1 until between 6:30 to 6:45 PM. She said the MHT #2 for the PM shift usually comes in early and then they would conduct shift change. MHT #1 said they conduct their shift change in the "exam room" in the nurses station away from patient's on the unit because they are discussing confidential information about patient's. She said shift change is conducted at the same time for the MHT's and the nursing staff (RN/LVN, etc). MHT#1 said on 5/13/22 she asked to leave early; approximately 6:30-6:45. MHT#1 said Patient #1 told her he "wanted to leave." MHT#1 asked RN#1 if he wanted Patient #1 to complete a 4-hour letter. MHT#1 said RN#1 told her, "I'll talk to him; he hasn't' been assessed by the Dr."
MHT#1 said her "last round" for patient observations was at 18:30 (6:30PM) for Patient #1 when she documented "24" he was outside in the smoking area with another patient. MHT#1 said you can see the patients from the half door of the nurses unit; the doors are see through to the patio. MHT#1 said MHT #2 "took over at 18:30". MHT#1 said her staff initials consisted of a "line" and confirmed she did a line at 18:30 (6:30 PM) for the handoff to MHT#2 for Patient #1's Observation 15 minute checks.
MHT#1 was asked what she is supposed to do if she is not able to conduct the Q's and she said that she will give them to the nurse to do; or if she is off the unit, she will give them to the nurse to do.
MHT #1 said the last time she saw Patient #1 on 5/13/22 was when he asked for the 4-hour letter (6:38PM) and right before that he was outside in the smoking area.
This surveyor reviewed the Patient Observation Rounds, Policy # PC.3.02 with MHT #1 that indicated, "At the end of shift, the in-coming and the departing staff shall conduct a unit round together and confirm the location / status of patients and safety of unit, and sign-off on the same line on the Patient Observation sheet, confirming hand-off of unit and patients." MHT #1 responded by saying; "we try to; but others will sometimes say they don't have time."
MHT #1 said the "Q's" were required every 15 minutes or "as close as possible to every 15 minutes." She said that when Q's were done; it would go into the 15 minute block that was closest to that time; stating it may early or late in the specific 15 minute designated block.
MHT#1 said you have to get to the closest time of the block because there is not a "specific time" in the block because they already have times put in (every 15 minute increments). If you do a round at 6:18, there is no way to put 6:18. She said 6:18 could go into a 6:15 block or even a 6:20 block.
MHT #1 was asked about Patient #2, Patient #3, and Patient #4's Q-15 minute checks for 18:30 and 18:45 (6:30 PM and 6:45 PM) on 5/13/22 that were blank without documentation of Q-15 minute safety observation checks completed and she responded that she "came back from dinner and probably didn't do it; to be honest." MHT #1 said everyone was coming in and it was shift change and she began shift change with MHT #2 that was coming on and handed her the Q-15 minute checks "binder." MHT #1 further confirmed that she did not conduct a staff handoff with MHT #2 on the Q-15 minute checks for Patient #2, #2 and #4.
Interview on 5/26/22 at 11:55 AM with MHT #2 stated the following:
On 5/13/22, she clocked in at 6:00 PM after being off for 2 weeks and then began to get report from MHT#1. MHT #2 said after she got report she began conducting vital signs for the patients in the unit. While she was conducting vital signs in the day room, RN #1 came and told her to keep a close eye on Patient #1; that he was "unstable and paranoid." MHT #2 said she responded, "if this is the case, then I may need help then." RN #1 said he was going to go check on him. MHT #2 said she then heard "Code Blue" and responded to Patient #1's room where RN #1 was taking out toilet tissue from Patient #1's mouth that he "apparently stuck in his mouth." MHT #2 said she assisted from there with the code and that Patient #1 was nonresponsive.
MHT#2 further stated that she had only seen Patient #1 briefly while she was getting shift change report from MHT #1 and when she saw Patient #1, he was speaking to RN #1. MHT #2 said she heard Patient #1 talking to RN #1 about leaving the facility. MHT #2 says that Q 15-minute checks are supposed to be conducted every 15 minutes by "having eyes on the patient."
MHT #2 was asked about Policy # PC.3.02, for Patient Observation Rounds that states; "At the end of shift, the in-coming and the departing staff shall conduct a unit round together and confirm the location / status of patients and safety of unit, and sign-off on the same line on the Patient Observation sheet, confirming hand-off of unit and patients." MHT #2 responded by saying that she has not ever done that.
MHT #2 was asked about Patient #1's Patient Observation/MHT Rounds that documented at 6:30 PM as taking handoff from MHT #1 with documentation of M. (on the unit patio/smoke) and 24. Handwritten with "smoking." Staff initials including MHT #1 with handoff to MHT #2. In addition, at 6:45 PM, MHT #2 documented that Patient #1 was in C. in the TV Room and 10. With staff.
MHT #2 responded by saying that initially on 5/13/22, the 6:30 PM (1830) and 6:45 PM (1845) time slots were blank for Patient #1 and that those time slots should have been done by MHT #1 before she left her shift. MHT #2 said she was approached by the Psychiatrist/Doctor on 5/13/22 prior to leaving her shift early at 9:30 PM; stating the Q 15-minute checks had not been completed for 6:30 and 6:45 PM and that she needed to fill it out by putting where the patient was at these times. MHT #2 said she did not remember specifically as she only remembered that Patient #1 was talking to RN #2 and that was what she documented.
Note: This documentation does not correlate with the camera review that revealed Patient #1 was seen smoking at 6:15 PM and then going into his room at 6:37 PM and remained in his room during the 6:45 PM time.
Review of the facility's Training for Patient observation Guidelines revealed when conducting observation rounds, in part:
Round at least every 15 minutes.
Stagger order/time of rounds.
Document every 15 minutes (not ahead of time or after time has passed)
Hand-off must be documented by 2 staff initial on same line in space providing (staff giving AND staff receiving care of patient/forms)
RN must round twice a shift and sign-off on RN section of Q15's