HospitalInspections.org

Based on observation, staff interviews, medical record review, and review of facility documents, it was determined the facility failed to protect and promote the rights of each patient.

Findings include:

1. The facility failed to ensure the patient's right to privacy by ensuring staff do not photograph patients without their consent;
2. The facility failed to ensure patients at risk for elopement, self harm, or harm to others are evaluated by a physician to determine the need for a higher level of observation, in accordance with facility policy and procedure;
3. The facility failed to ensure staff maintain continuous visual observation of patients placed on line-of-sight observation and remain within arm's length distance of patients placed on one-to-one observation;
4. The facility failed to ensure physician orders for line-of-sight observation and one-to-one observation are renewed every 24 hours;
5. The facility failed to ensure the behavior of the patient placed on line-of-sight observation, or one-to-one observation, is documented every 15 minutes and initialed by the observer;
6. The facility failed to ensure clinical staff performing line-of-sight observation receive training regarding line-of-sight observation.

(Cross refer to Tags A-142, A-144).

Based on observation, staff interviews, medical record review, and review of facility policies and procedures, it was determined the facility failed to maintain a patient's right to privacy. This deficient practice was identified for 1 of 1 patient (Patient #1) who was photographed without consent.

Findings include:

Facility policy, "Personal Use of Cellular & Electronic Devices," dated 4/5/2019, states,"... Policy ... 6. Patient information cannot be transmitted via test/sms/mms on any personal/work provided mobile device. ... 1. Employees ... b. Camera/Recording equipped Cellular Devices: To ensure the privacy of patients, visitors and employees, as well as to ensure the confidentiality of all records, etc., camera-equipped and recording devices (including audio) belonging to employees must be turned off during working hours and may not be used at any time on [Facility Name] premises. ... ."

Facility policy, "Photography/Videotaping," revised 12/2015, states, "Policy: 1. Photographs are not permitted without written consent and completion of the Patient Release Form ... ."

During the entrance conference on 5/25/22 at 9:50 AM, Administrative Staff #1 confirmed that on the morning of 5/24/22, Patient #1 fell to his/her death from the window of their room. Staff #1 stated the patient was able to collect and tie together sheets and blankets to make a makeshift rope, tamper with the window in his/her room to get it to open, and attempted to elope by climbing down the rope from his/her window, but fell.

During an interview on 5/25/22 at 11:21 AM, Housekeeping Staff #8 stated, "On the day that this happened, I came in before 6:00 AM. I sometimes cook for [Patient #1 name] and was taking [him/her] some food when the aide [name of aide] came running out the room saying [Patient #1 name] jumped out the window. I took a peek in the room, but no one was in there. Just [name of aide] coming out. I see the rope through the window and I said 'whoa.' I looked outside but I didn't see [him/her]. My instinct was to run outside to try to catch [him/her], because I thought I would see [him/her] walking away. [He/She] always wanted to leave. When I got outside at first I didn't see [him/her], but then I looked in the bushes and saw [him/her]. Me and a respiratory therapist guy found [him/her] first." Staff #8 then showed the survey team a picture on his/her cell phone of a person lying on the ground being tended to by another individual. Staff #8 confirmed the person in the picture, laying on the ground, was Patient #1. Staff #8 confirmed he/she took the picture of Patient #1 after the fall.

During a follow-up interview on 5/26/22 at 1:45 PM, Staff #8 was asked if he/she had shown the cell phone picture of Patient #1 to anyone. Staff #8 stated, "I only showed you and I showed [Staff #1 name] yesterday. [He/She] told me to erase it. I told [him/her] I will." Staff #8 was asked if he/she erased the picture. Staff #8 stated, "I will." Staff #8 was asked why he/she took a picture of the patient. Staff #8 stated, "I took the picture not to show people, but just if people investigate. A rapid response lady took pictures too. On the day of the incident, when I came back to the floor, I showed the girls [staff members working on the unit housing Patient #1] the picture. But a lot of them didn't want to see it. I didn't show anyone else."

During an interview on 5/26/22 at 2:25 PM, Staff #1 confirmed that Staff #8 showed him/her the cell phone picture of Patient #1 after his/her fall. Staff #1 stated the facility has policies prohibiting staff from taking pictures of patients. Staff #1 stated, "[Staff #8 name] should not have done that." Staff #1 stated he/she was unaware of any other staff member taking pictures of Patient #1.

During a telephone interview on 5/26/22 at 4:06 PM, Staff #25, identified as a Registered Nurse on the Rapid Response Team, indicated he/she took pictures of the patient after the patient's fall. Staff #25 stated, "After they called the rapid response and said the patient jumped out the window, it took 10-15 minutes for us to find the body. I only took pictures to share with security so they could know how to find us and will know the side of the building we were on. I did not share the pictures with anyone. I still have them. There were a lot of other people who were there taking videos. It was change of shift and a lot of staff were there with their phones out."

There was no evidence in the medical record of a Patient Release Form signed by the patient indicating that he/she granted consent to have his/her picture taken by staff.

Based on observation, review of eight (8) of ten (10) medical records (Medical Records #1, 2, 4, 6, 7, 8, 9, 10), staff interviews, and review of facility policies and procedures, it was determined the facility failed to ensure: 1) patients at risk for elopement, self harm, or harm to others are evaluated by a physician to determine the need for a higher level of observation, in accordance with facility policy and procedure; 2) staff maintain continuous visual observation of patients placed on line-of-sight observation and remain within arm's length distance of patients placed on one-to-one observation; 3) physician orders for line-of-sight observation and one-to-one observation are renewed every twenty-four (24) hours; 4) the behavior of the patient placed on line-of-sight observation or one-to-one observation is documented every fifteen (15) minutes and initialed by the observer; 5) clinical staff performing line-of-sight observation receive training regarding line-of-sight observation.

Findings include:

1) Facility policy, "Elopements" dated 8/29/2019 states, "... Elopement Attempt ... If a voluntary/involuntary patient is stopped by staff in an attempt to elope, the patient will be escorted safely back to the unit. The attending psychiatrist/provider will evaluate the patient to determine if the patient needs to be placed on closer observation (1:1 or LOS) [one-to-one or line-of-sight observation]."

Facility policy, "Patient Watch for Behavioral Indication," last revised 4/2017 states, "Purpose ... Patient Watch observation shall be utilized to prevent self-injury or injury to others in those patients whose behavior is impulsive and unpredictable as to require presence of a staff member. ... For patients exhibiting behaviors that present a danger to self or others as evidenced by grossly psychotic behavior that demonstrates a lack of insight or ability to process reality to the degree that it impairs the patient's or others' safety, a One to One Observation is necessary. ... Line of Sight: The patient has an altered mental status and/or compromised physical condition and whose behavior places the patient at risk for self or other injury... For the patient who has periods of memory loss, confusion, or impaired judgment that places the patient at risk for injury, elopement, and/or wandering, an Every 15 Minute Check is necessary. Patients placed on this watch are observed at least once every 15 minutes throughout the duration of the order."

Review of Medical Record #1 revealed the 72 year-old patient was admitted to the ED on 5/29/20 at 2:44 AM with a chief complaint of an assault by unknown persons. A CT scan of the head revealed the patient sustained a subdural and subarachnoid hemorrhage, and the patient was transferred to the intensive care unit (ICU) at 9:34 AM. Nursing and physician progress notes indicate the patient was combative and attempting to get out of bed. An initial order for LOS observation was entered on 5/29/20 at 11:56 AM. The patient remained an inpatient in the facility until 8/8/21, when the patient eloped from the facility. The patient was brought back to the facility by the police on 8/10/21 at 11:58 AM and readmitted to the facility while awaiting permanent placement by his/her guardianship.

During the entrance conference on 5/25/22 at 9:55 AM, Staff #1 stated, "Throughout [his/her] stay, the patient was on multiple units in the hospital. [He/She] was on line-of-sight (LOS) observation which is different than one-to-one. One-to-one means you have to be within arms length of the patient and LOS means that you just have to have visual observation of the patient at all times."

Review of Medical Record #1 on 5/26/22 revealed the following:

A nurse's note dated 1/18/21 at 2:12 PM states, "pt expresses that [he/she] needs to leave hospital [he/she] has been here for 5 months and lawyer has cleared [him/her] to leave facility. pt made aware that [he/she] is unable to leave facility because we are waiting on placement, pt became more agitated, stating [he/she] will hit the nurse in the face with the call bell, pt gathers all belongings and attempts to leave unit security alert called... security restrain pt and nurse administer 0.5 mg Lorazepam IM, pt still agitated attempts to physically and verbally attack nurse." There was no evidence that the psychiatrist or physician assessed the patient to determine the patient's need for closer observation.

A nurse's note dated 4/25/21 at 9:35 PM states, "Around 5pm patient packed up belongings and attempter [sic] to leave through the back stairwell. Code gray patient elopement called. ... Patient said we could call security but warned us the last time during this admission security was called [he/she] fought with them... Patient then said [he/she] would stay but if [he/she] saw [name of physician] or [name of psychiatrist] [he/she] wants to punch them in the face. Patient expresses much anger and states [he/she] does not want to eat the food or take any meds. [He/She] stated that [he/she] will call [his/her] lawyer tomorrow and will try to leave again to go to court to sue the hospital for keeping [him/her] almost a year. Day nurse [name of nurse] and night shift [name of nurse] speaking to patient who said this is like prison and that '[he/she] would find a way out of here even if [he/she] has to jump out of a window; being dead is better than being trapped in here forever.' ... Call placed to [name of psychiatrist] to notify of the elopement and that [he/she] did mention once about jumping out a window. Awaiting call back." There was no evidence that the psychiatrist or physician assessed the patient to determine the patient's need for closer observation after the patient's elopement attempt.

A nurse's note dated 4/26/21 at 2:07 AM states, "Made supervisor aware of the conversation with RN [name of RN] at shift change who left a message for [name of psychiatrist]. Supervisor aware of attempt of elopement and pt stated that [he/she] would jump at [sic] of a window [he/she] had to [sic] and rather be dead than staying here for the rest of [his/her] life. ... No further orders placed at this time." There was no evidence that the psychiatrist or physician assessed the patient to determine the patient's need for closer observation.

A nurse's note dated 4/26/21 at 9:55 AM states, "patient refuses to have vital signs taken and refuses all AM medications. ... [name of psychiatrist] aware of pt's distress and desire to leave unit." There was no evidence that the psychiatrist or physician assessed the patient to determine the patient's need for closer observation.

A nurse's note dated 8/9/21 at 11:20 AM states, "pt was code gray yesterday... 8/8/21... about 3:49 PM... [he/she] was not he [sic] [his/her] room at 3PM and there after when the na (nursing assistant) [name of nursing assistant] was making rounds... [he/she] walks around... upon searching the unit, including the shower and toilet... pt not found... code called... nursing supervisor [name of nursing supervisor] notified... [he/she] came to the unit... updated on the case and scenario, then [name of nursing supervisor] notified the necessary personnel... search done of other areas... pt not found."

Upon interview on 5/26/22 at 1:25 PM, Staff #1 stated, "The doctors did not think the patient was competent, so [he/she] was placed on LOS (line-of-sight) observation." There was no evidence of a physician's order for one-to-one observation, LOS observation, every 15 minute checks, or the implementation of any additional interventions to prevent elopement, until the patient's successful elopement on 8/8/21, despite the patient's elopement ideation, repeated verbalizations that he/she desired to leave the facility, and numerous elopement attempts.

Review of Medical Record #1 on 5/27/22, for the patient's re-admission from 8/10/21 to 5/24/22, revealed the following:

A nurse's note dated 1/1/22 at 5:34 PM states, "Patient was extremely irate to be moved to 2 SA. Patient sat and security was called because patient stated [he/she] was going to take 5 security to move [him/her]. Upon security arriving they found blankets tied and stapled together, a metal bar and two pieces of wire. [He/She] stated that these items are for [him/her] to get out with ... Called [sic] placed and message left for on call psychiatrist on call [sic] and left message with PMD (Psychiatric Medical Doctor]. Nurse on incoming unit notified and nursing superior [sic] notified." There was no evidence the patient was evaluated by a psychiatrist or a physician for a higher level of observation until 1/6/22 at 7:00 PM, five days after the incident, when a physician's order for LOS observation was written.

During the entrance conference on 5/25/22 at 9:50 AM, Administrative Staff #1 confirmed that on the morning of 5/24/22, Patient #1 fell to his/her death from the window of his/her room. Staff #1 stated the patient was able to collect and tie together sheets and blankets to make a makeshift rope, tamper with the window in his/her room to get it to open, and attempted to elope by climbing down the rope from his/her window, but fell.

2) Facility policy, "Patient Watch for Behavioral Indication," last revised 4/2017 states, "... 1. One to One Observation: requires that a patient be visually observed by a staff member who remains with the patient at all times. 2. Line of Sight: is defined as a staff member observing a maximum of 4 patients, all of whom are within the same physical space and/or room as the 'observer' and within the same visual field of the 'observer' at all times. ... One-to-One Observation ... Staff should be at an arm's length apart from the patient when performing a one-to-one observation unless there is a Physician order stating otherwise."

During the entrance conference on 5/25/22 at 9:50 AM, Staff #1 confirmed Patient #1 was initially admitted to the facility on 5/29/20 with a chief complaint of an assault by unknown persons. The patient's assault resulted in head injuries that required the patient to be admitted to the ICU. Staff #1 stated, "[Patient #1] came in two years ago and was here for 13 or 14 months before [he/she] eloped on 8/8/21. The police brought [him/her] back on 8/10/21. [He/She] had been on multiple med/surg (medical/surgical) units since [he/she] was re-admitted, but [he/she] was most recently on 3 South Annex for a few months. [He/She] was on LOS observation the entire time [he/she] was on 3 South Annex because of [his/her] previous elopement." Staff #1 confirmed that on the morning of 5/24/22, Patient #1 was able to collect and tie together sheets and blankets to make a makeshift rope, tamper with the window in his/her room to get it to open, and attempt to elope by climbing down the rope from his/her window, but fell. Staff #1 confirmed Patient #1 was on LOS observation at the time of his/her death.

During the entrance conference on 5/25/22 at 9:55 AM, Staff #1 stated, "Throughout [his/her] stay, the patient was on multiple units in the hospital. [He/She] was on line-of-sight (LOS) observation which is different than one-to-one. One-to-one means you have to be within arms length of the patient and LOS means that you just have to have visual observation of the patient at all times."

Upon interview on 5/25/22 at 11:55 AM, Staff #7 stated that Patient #1 was placed on LOS observation during his/her entire admission from 8/10/21 to 5/23/22. On 5/27/22 at 1:00 PM, Staff #1 confirmed Patient #1 was placed on LOS observation for his/her entire admission, from 8/10/21 to 5/23/22, after his/her successful elopement from the facility on 8/8/21.

A tour was conducted of 3 South Annex on 5/25/22 at 11:03 AM, in the presence of Staff #1 and Staff #2. Observation of the patient's room revealed that the room was a negative pressure isolation room designed for single occupancy. Upon entering the door to the patient's room, surveyors first entered a narrow ante-room (small area typically used for staff to don or doff PPE and perform hand hygiene, before and after entering the room of a patient on isolation precautions), which led to an additional door that separated the ante-room from the patient's hospital room. Upon interview at 11:20 AM, Staff #1 and Staff #2 indicated that both doors to the patient's room were kept open at all times while the patient was on LOS observation.

During a tour of 3 South Annex on 5/25/22 at 11:20 AM, Staff #11, a Nurse's Aide, was observed performing LOS observation in a patient room immediately adjacent to Patient #1's room. Upon interview at 12:14 PM, Staff #11 indicated LOS observation means the patient must be watched closely at all times, including when the patient goes into the bathroom. Staff #11 stated per facility policy, one staff member is permitted to observe four patients on LOS observation at one time. Staff #11 was asked if Patient #9, the current patient in the room adjacent to Patient #1's room, was on LOS observation on 5/23/22 and 5/24/22. Staff #11 stated, "Yes. Usually that room (room adjacent to Patient #1's room) is used for other LOS patients so we don't have to use another staff member. Since we know that [Patient #1's name] was on LOS observation, they would use one staff member to do LOS observation for both rooms." Staff #11 was asked if he/she ever performed LOS observations simultaneously for patients located in rooms adjacent to one another. Staff #11 stated, "Yes I have. I wasn't there the night of the incident, but I've done both rooms before." Staff #11 was asked how he/she observed the patients in both rooms simultaneously. He/she stated, "We sit at a table in the hallway. We place the table between both rooms so we can observe both patients." The survey team stood in the hallway between Patient #1's room and and the room immediately adjacent to it, in the location Staff #11 indicated staff sit when they are performing LOS observation for patients in both rooms. From the hallway, the survey team was only able to visualize a narrow portion of the right side of Patient #1's room that included: a wall mounted television, the wardrobe closet, a portion of the right window, and a portion of the foot of the bed. Visualization of the rest of Patient #1's room was occluded, due to the design of the room. This surveyor asked Staff #11 how he/she was able to maintain continuous visual observation of Patient #1 inside his/her room from the hallway. Staff #11 stated, "You can't. You can't see inside the room from the hallway. Our only option is to sit at the table because we have to watch both patients. Usually, when a nurse goes into the other room (the room adjacent to Patient #1's room), we will go in and check on [Patient #1's name] while the nurse is with the other patient."

Upon interview on 5/25/22 at 11:55 AM, Staff #7 stated, "Nursing Assistants primarily perform LOS observations, but if they need relief, then the nurse will take over. Sometimes, they may have to observe two people on LOS. If [Patient #1's name] goes in the bathroom, the person watching [him/her] must let someone know so they can observe [him/her]." Staff #7 confirmed that the room adjacent to Patient #1's room is where other LOS patients are placed so that the staff member performing LOS observation can observe both rooms.

During a telephone interview on 5/26/22 at 4:42 PM, Staff #3 stated he/she was scheduled to perform LOS observation for Patient #1 and Patient #9 on 5/23/22 from 11:00 PM to 7:00 AM. Staff #3 stated Patient #1 and Patient #9 were in rooms immediately adjacent to one another. Staff #3 stated he/she sat in the hallway between both rooms with the doors open to view each patient. Staff #3 stated that during "the early part of the night," he/she accompanied Patient #9 to the bathroom, leaving Patient #1 out of his/her sight. Staff #3 stated that he/she then left Patient #9 unattended in the bathroom and went into Patient #1's room to "check on [him/her]." Staff #3 confirmed Patient #9, who was on LOS observation, was left unattended and unobserved in the bathroom while he/she left the room to check on Patient #1. Staff #3 was asked how he/she maintained continuous visual observation of Patient #1 and Patient #9 simultaneously. Staff #3 stated, "You can't see [his/her] (Patient #1) full body because there's a piece of wall there, but we can see [he/she] was sleeping." Staff #3 was asked how he/she knew the patient was sleeping without seeing the patient. Staff #3 stated, "We can see [his/her] feet. From the hallway, we can see the bottom part of the bed and we see [his/her] feet in the bed. When [he/she] is watching TV we can see [his/her] black slippers." Staff #3 confirmed he/she was unable to maintain continuous visual observation of Patient #1 at all times.

During a telephone interview on 5/26/22 at 2:06 PM, Staff #4 identified him/herself as the nurse assigned to Patient #1 on 5/23/22 from 11:00 PM to 7:00 AM. Staff #4 indicated Staff #3, a Nurse's Aide, was assigned to perform LOS observation on Patient #1 and Patient #9. Staff #4 stated, "[Staff #3] was sitting in the hallway between both rooms so [he/she] can see both rooms." Staff #4 was asked how staff are able to maintain continuous visual observation of both patients at the same time from the hallway. He/she stated, "If [he/she] (Patient #1) is in [his/her] room, we can't see [him/her], but we can see [his/her] feet when [he's/she's] in the bed. If [he/she] goes to the bathroom, we can't see [him/her]. You have to go into [his/her] room if you want to see [him/her]. You have to go into [his/her] room, look at [him/her], and come back out."

Facility document, "Care of the Asymptomatic COVID-19 Positive Patient in the Inpatient Behavioral Health Setting ... (October 2020)" states, " ... If the patient is a line of sight or one to one, the staff will follow the policy/procedure of line of sight or one to one as appropriate."

During a tour of the Behavioral Health Unit (CC3) on 5/25/22 at 1:45 PM, in the presence of Staff #1, Staff #18 stated there were currently two patients who were on LOS observation for "COVID." At 1:53 PM, Staff #17 was observed viewing a video monitor outside of a patient room. Upon interview, Staff #17 stated Patient #2 was COVID positive and on LOS observation. Staff #17 stated he/she was observing the patient from the "baby monitor" since staff are not always physically in the room. Staff #17 was asked if he/she was able to maintain continuous visual observation of the patient on LOS while viewing the video monitor. Staff #17 stated that if the patient goes in the bathroom, they are out of camera view. He/she stated, "If they are in there (the bathroom) for an unusual amount of time, then I will go check on the patient." Staff #17 confirmed that he/she was unable to maintain continuous visual observation of patients on LOS when they are in the bathroom.

During an interview at 1:59 PM, Staff #19 stated he/she was observing a COVID positive LOS patient (Patient #3) via video monitor. Staff #19 was asked if he/she was able to maintain continuous visual observation of the patient on LOS while viewing the video monitor. Staff #19 confirmed he/she was unable to see the patient when they were in the bathroom. Staff #19 stated he/she will make sure patients "are ok" but does not always maintain continuous visual observation of patients on LOS observation.

On 5/25/22, Staff #1 and Staff #2 were notified that the above findings resulted in an Immediate Jeopardy (IJ). A copy of the completed IJ template was provided to the facility on 5/25/22 at 4:35 PM. An acceptable IJ removal plan was received from the facility on 5/27/22. Removal plan interventions include staff re-education on the facility's policy regarding LOS observation, policy change to limit LOS observation ratio to two patients who must be in the same room or space, and a revision of the facility's policy regarding LOS observation for behavioral health patients with COVID. An on-site verification of the implementation of the IJ removal plan was conducted on 5/27/22. The IJ was lifted on 5/27/22.

3) Facility policy, "Patient Watch for Behavioral Indication," last revised 4/2017 states, " ... Policy ... A physician's order is required to initiate, change, or discontinue a patient watch ... the patient watch order will be renewed daily by the physician ... ."

Review of Medical Record #1 revealed that on 8/10/21 at 12:30 PM, a physician's order for "Patient Watch Line of Sight" was initiated. A nurse's progress note, dated 8/25/21 at 10:19 PM states, "... line of sight continue patient is not aggressive or disoriented but pt (patient) tried to escape from the hospital couple days ago. Line of sight is to keep pt safe." There was no evidence of a physician's order for LOS observation for 8/25/21.

A nurse's progress note, dated 8/26/21 at 11:24 AM states, "... pt have no guardianship in new jersey and [he/she] tried to escape from the hospital. Therefore, pt is on line of sight until care coordinator find the right placement." There was no evidence of a physician's order for LOS observation for 8/26/21.

A nurse's progress note, dated 9/2/21 at 11:57 AM states, "... line of sight continue patient is not aggressive or disoriented." There was no evidence of a physician's order for LOS observation for 9/2/21.

A nurse's progress note, dated 11/3/21 at 11:31 PM states, "Line of sight watch maintained ... ." There was no evidence of a physician's order for LOS observation for 11/3/21.

A nurse's progress note, dated 1/23/22 at 8:02 PM states, "Receive patient x4 (times four) on line of sight. Patient continues to refuse vitals, meds, IV access, and telemetry. Will continue to monitor." There was no evidence of a physician's order for LOS observation for 1/23/22.

A nurse's progress note, dated 4/5/22 at 8:36 AM states, "Patient alert and oriented x4. Voices no complaints. LOS present. Patient refused AM medications." There was no evidence of a physician's order for LOS observation for 4/5/22.

Upon interview on 5/27/22 at 1:00 PM, Staff #1 stated Patient #1 was placed on LOS observation for his/her entire admission, from 8/10/21 to 5/23/22, after his/her successful elopement from the facility on 8/8/21. Staff #1 stated it is the facility's policy that physician orders for LOS observation are renewed every 24 hours.

Upon interview on 5/27/22 at 4:30 PM, Staff #1, Staff #2, and Staff #29 confirmed physician orders for LOS observation were not renewed every 24 hours, in accordance with facility policy. Staff #1, Staff #2, and Staff #29 confirmed that of the two hundred eighty-six (286) days the patient was on LOS observation, from 8/10/21 to 5/23/22, forty-one (41) physician orders for LOS observation were entered on the following days: 8/10/21, 8/12/21, 8/14/21, 8/16/21, 8/20/21, 8/21/21, 8/22/21, 8/23/21, 8/29/21, 8/30/21, 9/09/21, 9/12/21, 9/14/21, 9/22/21, 9/24/21, 9/27/21, 9/28/21, 9/30/21, 10/1/21, 10/2/21, 10/3/21, 10/4/21, 10/7/21, 10/9/21, 10/11/21, 10/22/21, 10/27/21, 10/28/21, 10/30/21, 10/31/21, 11/1/21, 11/6/21, 1/5/22, 1/7/22, 1/8/22, 1/9/22, 1/11/22, 1/25/22, 2/19/22, 2/27/22, and 3/3/22.

4) Facility policy, "Patient Watch for Behavioral Indication," last revised 4/2017 states, "Purpose ... Patient Watch observation shall be utilized to prevent self-injury or injury to others in those patients whose behavior is impulsive and unpredictable as to require presence of a staff member. ... Guidelines for completion of 'The Patient Watch Observation Sheet'... For patients placed on One-to-One Observation, Line of Sight, and Every 15 Minute Check: a. The sheet is initiated for any type of a patient watch that is ordered and maintained by the staff member assigned to the watch. b. The staff member assigned to the patient watch will document the behavior of the patient on the check sheet every 15 minutes as indicated using the activity code at the bottom of the form. ... ."

Review of Medical Record #1 on 5/27/22 revealed Patient Watch Observation Sheets that lacked documentation of the patient's activity code and the observer's initials every fifteen (15) minutes, on the following dates: 8/16/21, 8/30/21, 9/5/21, 9/13/21, 9/18/21, 9/19/21, 9/22/21, 9/23/21, 9/24/21, 9/26/21, 9/28/21, 10/1/21, 10/3/21, 10/8/21, 10/14/21, 10/17/21, 10/20/21, 10/22/21, 10/23/21, 10/26/21, 10/28/21, 11/1/21, 11/3/21, 11/6/21, 11/10/21, 11/21/21, 11/18/21, 11/19/21, 11/21/21, 11/26/21, 11/28/21, 12/5/21, 12/3/21, 12/12/21, 12/15/21, 1/7/22, 1/10/22, 1/27/22, 2/5/22, 2/10/22, 2/12/22, 2/16/22, 2/25/22, 2/28/22, 3/1/22, 3/12/22, 3/22/22, 3/26/22, 3/30/22, 3/31/22, 4/1/22, 4/14/22, 4/15/22, 4/18/22, 4/21/22, 4/26/22, 4/27/22, 5/6/22, 5/7/22, 5/8/22, 5/16/22, 5/17/22, and 5/18/22.

The Patient Watch Observation Sheet, dated 4/21/21, lacked documentation of the observer's initials and the patient's activity code, from 2:15 AM to 3:00 AM. The word "Break" was written in the margin of the Patient Watch Observation Sheet during the time of 2:15 AM - 3:00 AM. Upon interview on 5/27/22 at 9:55 AM, Staff #1 stated that staff members performing LOS observations should be relieved by another staff member for breaks. Staff #1 confirmed there was no way to verify the observer was performing LOS observation if he/she did not initial the Patient Watch Observation Sheet.

Review of Medical Record #4, on 5/27/22, revealed the patient was on one-to-one observation. The Patient Watch Observation Sheets lacked documentation of the patient's activity code and the observer's initials every 15 minutes, on the following dates: 5/24/22 and 5/25/22.

Review of Medical Record #7, on 5/27/22, revealed the patient was on LOS observation. The Patient Watch Observation Sheets lacked documentation of the patient's activity code and the observer's initials every 15 minutes, on the following dates: 5/24/22 and 5/25/22.

Review of Medical Record #8, on 5/27/22, revealed the patient was on LOS observation. The Patient Watch Observation Sheets lacked documentation of the patient's activity code and the observer's initials every 15 minutes, on the following dates: 5/11/22, 5/12/22, 5/14/22, 5/17/22, 5/18/22, 5/22/22, and 5/24/22. There was no evidence in the medical record, of documentation on Patient Watch Observation Sheets, despite physician's orders for LOS observation, for the following date: 5/13/22.

Review of Medical Record #9, on 5/27/22, revealed the patient was on LOS observation. The Patient Watch Observation Sheets lacked documentation of the patient's activity code and the observer's initials every 15 minutes, on the following dates: 4/10/22, 4/11/22, 4/28/22, 4/29/22, 4/30/22, 5/2/22, 5/6/22, 5/8/22, 5/15/22, 5/17/22, 5/18/22, and 5/25/22.

Review of Medical Record #10, on 5/27/22, revealed the patient was on LOS observation. The Patient Watch Observation Sheets lacked documentation of the patient's activity code and the observer's initials every 15 minutes, on the following dates: 5/21/22 and 5/23/22.

On 5/27/22, Staff #1 and Staff #24 confirmed the The Patient Watch Observation Sheets on the above dates and times lacked evidence of documentation of the patient's acitivity code and the observer's initials every 15 minutes.

5) Facility policy, "Patient Watch for Behavioral Indication," last revised 4/2017 states, "Purpose ... Patient Watch observation shall be utilized to prevent self-injury or injury to others in those patients whose behavior is impulsive and unpredictable as to require presence of a staff member. ... Guidelines for completion of 'The Patient Watch Observation Sheet'... For patients placed on One-to-One Observation, Line of Sight, and Every 15 Minute Check: a. The sheet is initiated for any type of a patient watch that is ordered and maintained by the staff member assigned to the watch. b. The staff member assigned to the patient watch will document the behavior of the patient on the check sheet every 15 minutes as indicated using the activity code at the bottom of the form. ... ."

Upon interview on 5/25/22 at 11:20 AM, Housekeeping Staff #8 stated he/she had a strong rapport with Patient #1 and would occasionally escort Patient #1 from his/her room to the solarium, located on 3 South Annex, to eat. Staff #8 confirmed there were no other staff members present when he/she would escort Patient #1 to the solarium.

Review of Medical Record #1 on 5/25/22, revealed the patient eloped from the facility on 8/8/21, and was brought back to the facility by the police on 8/10/21. Upon interview on 5/25/22, Staff #1 confirmed Patient #1 was on LOS observation during his/her admission from 8/10/21 to 5/23/22, due to his/her previous elopement.

On 5/25/22 at 4:00 PM, a review of Housekeeping Staff #8's personnel file revealed his/her job title as, "cleaner, union." A review of his/her job description did not include any requirement for patient care duties. There was no evidence of education or training to perform line-of-sight observation, or any patient watch observations.

On 5/25/22 at 4:38 PM, Staff #1 confirmed environmental services staff are not trained to perform patient watch observations. He/she stated, "They don't do that stuff."

On 5/27/22 at 4:30 PM, Staff #1, Staff #2, and Staff #29 confirmed Staff #8 did not receive training on performing patient watch observations, and therefore, should not have solely escorted Patient #1 to the solarium.

Based on staff interview, medical record review, and review of facility policies and procedures, it was determined the facility failed to ensure that 1 of 2 long-term patients (Patient #1) receives a plan of care within eight hours of admission.

Findings include:

Facility policy titled, "Interdisciplinary Plan of Care," last revised 4/2009 states, "... Policy: 1. Planning of the patient's care begins on admission. Appropriate resources are identified, and referrals made as needed. 2. The Registered Nurse is responsible for initiation and coordination of the plan of care. ... 3. A. The plan of care will be initiated within eight hours from the time of admission. ... The plan of care is to be filed in the medical record under the tab 'Plan of Care.'"

Review of Patient #1's medical record on 5/27/22, in the presence of Staff #1, revealed the following:

Review of Medical Record #1 revealed the 72 year-old patient was admitted to the Emergency Department (ED) on 5/29/20 at 2:44 AM with a chief complaint of an assault by unknown persons. A CT scan of the head revealed the patient sustained a subdural and subarachnoid hemorrhage, and the patient was transferred to the intensive care unit (ICU) at 9:34 AM. Nursing and physician progress notes indicate the patient was combative and attempting to get out of bed. An initial order for LOS observation was entered on 5/29/20 at 11:56 AM. The patient remained an inpatient in the facility until 8/8/21, when the patient eloped from the facility. The patient was brought back to the facility by the police on 8/10/21 at 11:58 AM. There was no evidence in the medical record of a plan of care initiated within eight hours of the patient's admission on 8/10/21.

On 5/27/22 at 1:30 PM, Staff #1 confirmed there was no plan of care documented within eight hours for Patient #1's admission on 8/10/21.