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Based on a review of clinical records and an interview with staff, the patients on the adolescent unit failed to receive care in a safe setting, as the nursing staff member assigned to the 1:1 observation of a patient was noted to be observing multiple patients at the same time. This placed the patient on the 1:1 observation level (as well as the other patients) at risk.

Findings were:

Clinical records for 12 patients were reviewed. Patient #4 exhibited inappropriate behaviors on 1-10-16, 1-12-16 and 1-14-16 (requiring patient #4 to be placed on 1:1 observation status) and observation sheets for all 12 patients were examined for those dates. On the listed dates, patient #4's observation level ordered by the physician was as follows:
· 1-10-16 - placed on 1:1 observation at 12:54 pm
· 1-12-16 - 1:1 observation level was briefly discontinued at 3:00pm but was again ordered at 4:01pm
· 1-14-16 - patient was on 1:1 observation level

On 1-10-16, staff #2 was assigned to serve as the 1:1 staff for patient #4. Patients #1, #2, #3, #4, #5, #6, #7 and #8 were all patients on the unit on 1-10-16. In addition to the 1:1 observation of patient #4, a review of observation sheets also revealed that staff #2 had also performed observation at different times during the day on patients #1, #2, #3, #5, #6, #7 and #8.

On 1-12-16, staff #3 was assigned to serve as the 1:1 staff for patient #4. Patients #1, #3, #4, #5, #6, #7, #8 and #11 were all patients on the unit on 1-12-16. In addition to the 1:1 observation of patient #4, a review of observation sheets also revealed that staff #4 had also performed observation at different times during the day on patients #3, #5, #6, #7, #8 and #11.

On 1-14-16, staff #1 was assigned to serve as the 1:1 staff for patient #4. Patients #3, #4, #5, #6, #7, #8, #9, #10, #11 and #12 were all patients on the unit on 1-14-16. In addition to the 1:1 observation of patient #4, a review of observation sheets also revealed that staff #1 had also performed observation at different times during the day on patients #3, #5, #6, #7, #8, #9, #10, #11 and #12.

While assigned to the care of a patient on a 1:1 observation status, staff are not to perform any duties other than observe the assigned 1:1 patient.

The above was confirmed in an interview with staff #4 on the afternoon of 3-9-16 in the facility conference room.

Based on a review of clinical records, facility documentation and an interview with staff, the director of the nursing service was not responsible for the operation of the service, as the director did not ensure that a nursing staff member only supervised one patient when assigned to a 1:1 observation. This had the potential to place the patient on the 1:1 (as well as the other patients on the unit) at risk.

Findings were:

Clinical records for 12 patients were reviewed. Patient #4 exhibited inappropriate behaviors on 1-10-16, 1-12-16 and 1-14-16 (requiring patient #4 to be placed on 1:1 observation status) and observation sheets for all 12 patients were examined for those dates. On the listed dates, patient #4's observation level ordered by the physician was as follows:
· 1-10-16 - placed on 1:1 observation at 12:54 pm
· 1-12-16 - 1:1 observation level was briefly discontinued at 3:00pm but was again ordered at 4:01pm
· 1-14-16 - patient was on 1:1 observation level

On 1-10-16, staff #2 was assigned to serve as the 1:1 staff for patient #4. Patients #1, #2, #3, #4, #5, #6, #7 and #8 were all patients on the unit on 1-10-16. In addition to the 1:1 observation of patient #4, a review of observation sheets also revealed that staff #2 had also performed observation at different times during the day on patients #1, #2, #3, #5, #6, #7 and #8.

On 1-12-16, staff #3 was assigned to serve as the 1:1 staff for patient #4. Patients #1, #3, #4, #5, #6, #7, #8 and #11 were all patients on the unit on 1-12-16. In addition to the 1:1 observation of patient #4, a review of observation sheets also revealed that staff #4 had also performed observation at different times during the day on patients #3, #5, #6, #7, #8 and #11.

On 1-14-16, staff #1 was assigned to serve as the 1:1 staff for patient #4. Patients #3, #4, #5, #6, #7, #8, #9, #10, #11 and #12 were all patients on the unit on 1-14-16. In addition to the 1:1 observation of patient #4, a review of observation sheets also revealed that staff #1 had also performed observation at different times during the day on patients #3, #5, #6, #7, #8, #9, #10, #11 and #12.

A review of the daily assignment sheets for 1-12-16 and 1-14-16 revealed that staff #6 had made regular rounds on the adolescent unit on those dates. When asked if the observation sheets had been checked for completeness and accuracy during the rounds, staff #6 stated that they had not.

While assigned to the care of a patient on a 1:1 observation status, staff are not to perform any duties other than observe the assigned 1:1 patient.

The above was confirmed in an interview with staff #4 on the afternoon of 3-9-16 in the facility conference room.