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333 HARRISBURG AVENUE

LANCASTER, PA 17603

PATIENT RIGHTS: CARE IN SAFE SETTING

Tag No.: A0144

Based on a review of medical records and facility documents, and interview with staff, the facility failed to consistently ensure that all patients received care in a safe setting. (MR1). Findings include:

Review of MR1 indicated the patient was readmitted to the facility on 3/23/19 with a history of Major Depression Recurrence Severe. Documentation indicated that the patient, due to past history in the facility and continued attempts to harm themselves or others, was ordered 1:1 supervision. According to the facility policy, "Patient Observation Rounds/Level of Supervision, a specified and dedicated staff member will stay within one arm's length of the patient on 1:1 observation at all times".

Documentation in MR1 and in the statement from the patient's caregiver, EMP1, revealed that during the evening shift on 3/31/19, the patient indicated to the caregiver the need to go to the bathroom. EMP1 took the patient to the bathroom and allowed the patient to close the curtain to offer privacy. Minutes later when the caregiver realized that there was no noise coming from the bathroom, the caregiver found the patient on the floor with two socks tied around the patient's neck. The patient was not breathing and a code was called.

On 4/10/19, interview with EMP2 revealed that the caregiver should have maintained direct observation of MR1 and not permitted the curtain to be pulled thus blocking the ability to continuously visualize the patient. Interview with other staff who provide direct care, EMP3 and EMP4, revealed that when staff are assigned to provide 1:1 supervision, they must stay at an arm's length at all times.

Further interview with staff, EMP3, on 4/10/19, revealed that all staff have been asked to carry walkie talkies when on duty. Walkie talkies are available at the nurses' station and are used as a means to communicate with other staff and/or if help is needed. According to EMP3, walkie talkies are typically used by staff but they are not always reliable. Staff have reported that the devices do not always hold the charge for the entire shift and little notice is given before the charge is gone. According to the interview with EMP1, this caregiver did not have a walkie talkie the evening of 3/31/19. Interview with EMP5 revealed that the facility did not have a policy regarding the use of walkie talkies and there was no evidence that the use of the devices or the consistency of the equipment was being monitored.

STAFFING AND DELIVERY OF CARE

Tag No.: A0392

Based on review of facility documentation and interview with staff, the facility failed to provide documentation that showed an accurate count of personnel who worked on each unit . Findings include:

On 4/10/19, interview with staff, EMP3 and EMP4, revealed that during the evening shift of 3/31/19, two staff members who had been assigned to Unit 3, needed to leave the facility to accompany patients to the hospital. In addition, a third staff member, EMP1, left the facility prior to the end of the shift. Review of the facility's assignment sheet for that unit on 3/31/19, revealed that this change in staffing pattern was not reflected on the sheet. According to EMP4, changes are not typically made to the sheet when a staff leaves or is added to the staffing complement. With three less staff for that shift, according to the assignment sheet, the remaining three staff, were responsible for the care of 22 patients.

Interview with EMP5 revealed that the facility did not have a policy on how to use the assignment sheets including what was necessary to be done if the staffing complement changed.