HospitalInspections.org

Based on review of facility documents, medical records (MR), observations, and staff interview (EMP), it was determined the facility failed to ensure staff documented once their assessment was completed and care was rendered for two of two applicable medical records reviewed (MR1, MR3).

Findings include:

Review on December 15, 2021, of facility policy, "Suicide Precautions" revised August 2020, revealed "Purpose: To outline a mechanism for observation and protection of patients who are assessed to be at risk for suicide, or have expressed suicidal ideations. Policy: 1. A physician's order must be obtained for suicide precautions and a psychiatric consult obtained. 2. Suicide precautions must be re-ordered daily. 3. A patient monitor is assigned until the patient is either transferred to an appropriate facility or is determined to be no longer at risk and discontinued. ...11. The patient monitor must be an employee/contractor of the hospital and must have attended the patient monitoring class provided by the Professional Development Department and have current CPR certification. ...13. The patient monitor is to be located within line of sight, inside the doorway and in direct proximity of the patient. If the patient is in a hallway bed, the patient monitor is to be seated at the foot of the patient's bed (beyond arm's length but in direct proximity of the patient). 14. The patient monitor will report any potentially unsafe behaviors to the assigned nurse. 15. The patient monitor must accompany the patient at all times. 16. While utilizing the bathroom, the door must remain ajar and the patient monitor must keep the patient in sight at all times. 17. The patient monitor is to remain with the patient when visitors are present. 18. The patient monitor may not leave the room of the patient until they are relieved. 20. The patient monitor or other hospital personnel must document patient observation checks every 15 minutes on the Patient Observer Monitoring Checklist Form ...21. The nurse assigned should review the documented observations made by the patient monitor each shift. ..."

Review on December 15, 2021, of facility policy, "General Documentation Guidelines Assessment/Reassessment," revised September 2020, revealed "Purpose: To establish an accurate and precise means of documentation. ...General Documentation Guidelines: 1. Documentation should be entered once the assessment is completed and care is rendered. ..."

Review on December 15, 2021, of video surveillance from December 11, 2021, at 1902 revealed MR1's 1:1 patient monitor walked down the hallway away from MR1 leaving MR1 alone. Video surveillance from December 11, 2021, at 2014 revealed a new 1:1 patient monitor arrived at MR1's room.

Interview on December 15, 2021, with EMP3, at approximately 0900 confirmed video surveillance from December 11, 2021, at 1902 revealed MR1's 1:1 patient monitor walked down the hallway away from MR1 leaving MR1 alone. Video surveillance from December 11, 2021, at 2014 revealed a new 1:1 patient monitor arrived at MR1's room.

Review on December 15, 2021, of MR1 revealed MR1's Suicide Patient Observer Monitoring Checklist revealed a staff member documented observations on the patient from 1900 to 2015.

Interview on December 15, 2021, with EMP1 confirmed MR1's Suicide Patient Observer Monitoring Checklist revealed a staff member documented observations on the patient from 1900 to 2015. EMP1 confirmed facility policy was not followed.

Review on December 15, 2021, of video surveillance from December 12, 2021, revealed at 1447 MR3 was in a room in the crisis area with a crisis staff member and a visitor. No 1:1 patient monitor present. At 1448, the crisis staff member left the room and the visitor and patient were in room alone and at 1449 the visitor left the room. No 1:1 patient monitor present. At 1452, the visitor returns to MR3's room. No 1:1 patient monitor present. The patient monitor returned to MR3's room at 1454 and walked back to the nurses station at 1459 leaving MR3 alone. At 1507, the 1:1 patient monitor returns to MR3's room.

Interview on December 15, 2021, with EMP3, at approximately 0910 confirmed video surveillance from December 12, 2021, revealed at 1447 MR3 was in a room in the crisis area with a crisis staff member and a visitor. No 1:1 patient monitor present. At 1448, the crisis staff member left the room and the visitor and patient were in room alone and at 1449 the visitor left the room. No 1:1 patient monitor present. At 1452, the visitor returns to MR3's room. No 1:1 patient monitor present. The patient monitor returned to MR3's room at 1454 and walked back to the nurses station at 1459 leaving MR3 alone. At 1507, the 1:1 patient monitor returns to MR3's room.

Review on December 15, 2021, of MR3 revealed MR3's Suicide Patient Observer Monitoring Checklist revealed a staff member documented observations from 1445 to 1500.

Interview on December 15, 2021, with EMP1, at approximately 1145 confirmed MR3's Suicide Patient Observer Monitoring Checklist revealed a staff member documented observations from 1445 to 1500. EMP1 confirmed facility policy was not followed.