HospitalInspections.org
Bringing transparency to federal inspections
BUTLER HOSPITAL
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on surveyor observation, policy review, record review, and staff interview, it has been determined that the hospital failed to follow its own policy relative to the observation checks procedure for 2 of 4 patients observed who were on 5-minute observation checks, Patient ID #s 1 and 2.
Findings are as follows:
The hospital's policy titled "Checks Procedures" effective 7/18/2022 states and part,
" ...III. Policy. It is the policy of Butler Hospital to provide a safe and therapeutic environment at all times ...
...C. Steps
...5. The staff member is responsible for recording their visual observation of all patients according to the level of observation ordered
6. Each round of checks is recorded on the checks sheet concurrently as the patient is visually observed ..."
1. Record review for Patient ID #1 revealed an order for "Observation Safety Level B" dated 2/7/2023 at 12:13 AM which states,
"Observation Level- Five minute ...
Observe for- Intoxication ...
Risk Factors for Suicide- Substance Abuse ...
Current Potentiating Factors- Current Substance intoxication ...
Suicide Risk Category- Acute High Risk ..."
2. Record review for Patient ID #2 revealed an order for "Observation Safety Level B" dated 2/7/2023 at 1:35 AM which states,
"Observation Level- Five minute ...
Observe for- Risk of Self Injury Paranoia ...
Risk Factors for Suicide- Affective Disorder Substance Abuse ...
Suicide Risk Category- Acute Moderate Risk
Homicidal, violent thoughts, plan past 24 hrs- Yes ..."
During a surveyor observation on 2/7/2023 at 1:26 PM of Employee A, Mental Health Worker, who was performing observation checks of patients on Delmonico 3, was observed adding check marks to 5-minute time blocks at 1:00 PM, 1:05 PM, 1:10 PM, 1:15 PM, 1:20 PM, and 1:25 PM, for Patient ID #s 1 and 2 who were on 5-minute checks.
During a surveyor interview with Employee A, subsequently following the above-mentioned observation, when asked why the 5-minute time blocks were not checked off as completed for Patient ID #s 1 and 2, he stated he needed to "catch up" and acknowledged he had not completed the observation checks for both patients according to their level of observation.
During a surveyor interview on 2/7/2023 at 1:27 PM with the Delmonico 3 Nursing Director who was standing beside Employee A at the time of the observation, she stated that all patients are to be checked off on the checks board as they are seen and indicated that staff should not be catching up nor performing other tasks other than completing observation checks while assigned this task.