HospitalInspections.org

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to ensure that patients received care in a safe setting. This deficient practice was evidenced by failing to perform every 15 minute observation checks on 14 (#3 - #16) of 17 (#1; #3 - #18) patients on the night shift of 03/20/2024, failing to monitor a patient ordered 1:1 observation for 1 (#2) of 3 (#1, #2, #3) patients reviewed, and failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for ligature risks and safety risks. (See findings in A-0144).

An Immediate Jeopardy situation was identified on 03/21/2024 at 5:07 p.m. and reported to S1CEO, S2CNO, and S3DBH. The Immediate Jeopardy situation was a result of the hospital failing to perform every 15 minute observation checks.

The Immediacy was lifted on 03/25/2024 at 10:19 a.m. when S1CEO, S2CNO, and S3DBH provided a written removal plan. The plan included the following:
1.) On 03/21/2024, S3DBH implemented a change in procedure whereby the nurse was to complete a patient check every 2 hours. Staff were educated on the need to perform Q15-minute observations on all patients as ordered. Completed 03/22/2024
2.) S3DBH met with staff to review Policy PC-1013: Levels of Patient Observation and Policy PC-1014: Patient Observation Record (15 Minute Check Sheet). Initiated 03/21/2024 all staff required before returning to work. Completed 03/21/2024
3.) Night shift staff were interviewed and counseled regarding their failure to ensure that the BHU patients received care in a safe setting. An Employee Conference Report was completed for each employee, indicating corrective action taken as a Final Written Warning. Completed 03/25/2024
4.) Administrative staff to perform random, in-person spot checks of the patient observation process to ensure that appropriate and accurate patient monitoring is occurring per policy. Initiated on 03/22/2024- to be completed for 72 hours
5.) Employee will conduct all rounds as ordered and document the truthfully and accurately while maintaining the correct ordered. Following an audit of the administrative rounds conducted by the House Supervisor it was found that employee had failed to meet the expected standard of rounding. S11RN was written up with a final warning disciplinary report. Completed 03/23/2024
6.) Following the random, in-person spot checks that occurred on 03/24/2024 it was found that an employee had inconsistencies in their Q-15 minute documentation despite education given to the employee on 03/22/2024 and 03/24/2024. S12MHT was terminated. Completed 03/24/2024
7.) A new Performance Improvement (PI) monitor will be implemented 03/22/2024 whereby licensed nursing staff will randomly audit Patient Observation Records in real time, at least 3 times per shift. Licensed nurse is expected to address any deficiencies on the spot and report the findings on the Q15 Audit Log, which is to be submitted to the Nurse Manager and Program Director at end of night shift. The Program Director is expected to address any fallouts with staff upon notification. Compliance with levels of observation will be monitored via PI monitor and results shall be reported to the PI Committee on a monthly basis. Initiated on 03/22/2024
8.) All staff will attend a retraining prior to their next shift. Ongoing
9.) Administrative staff reviewed security video footage of Q-15 monitoring and EMR documentation initiated 03/21/2024 for 72 hours. 03/21/2024


However, there was not enough evidence to determine sustainability of Compliance of the Condition of Patient Rights to be cleared. Noncompliance remains at the Condition level.

Based on observations, record reviews, and interviews, the hospital failed to provide care in a safe setting. This deficient practice was evidenced by:

1.) failing to perform every 15 minute observation checks on 14 (#3 - #16) of 17 (#1; #3 - #18) patients on the night shift of 03/20/2024;

2.) failing to monitor a patient ordered 1:1 observation for 1 (#2) of 3 (#1, #2, #3) patients reviewed; and

3.) failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for ligature risks and safety risks.

Findings:

1.) Failing to perform every 15 minute observation checks on 14 (#3 - #16) of 17 (#1; #3 - #18) patients on the night shift of 03/20/2024.

Review of the hospital's policy titled "PC-1013: Levels of Patient Observation" revised date of 07/31/2012, revealed in part, all patients admitted to the hospital will be assigned routine level of observation unless the physician orders a special level of observation. A) Routine levels of Observation: 1) All patients are monitored a minimum of once every 15 minutes.

Review of the video surveillance footage on 03/21/2024 at 2:05 p.m. with S3DBH and S2CNO revealed the hallway where patient rooms 200, 201, 202, 214, and 215 were located. The video surveillance footage began on 03/20/2024 at 11:47 p.m. On 03/21/2024 at 12:01 a.m. S4LPN was seen observing patients in the above stated rooms. At 12:53 a.m. S5MHT was seen observing patients. At 2:05 a.m. S4LPN was seen observing patients. At 2:13 a.m. S5MHT was seen observing patients. At 4:04 a.m. S5MHT was seen observing patients.
The patients were observed at 12:01 a.m. and not observed again until 12:53 a.m. (52 minutes)
The patients were observed at 12:53 a.m. and not observed again until 2:05 a.m. (72 minutes)
The patients were observed at 2:13 a.m. and not observed again until 4:04 a.m. (111 minutes)
There were 8 patients (#4, #5, #6, #7, #8, #13, #14, #15) assigned to the above stated rooms that were not observed every 15 minutes from 03/20/2024 at 11:47 p.m. - 03/21/2024 at 4:04 a.m.

Review of the video surveillance footage on 03/21/2024 at 2:44 p.m. with S3DBH and S2CNO revealed the hallway where patient rooms 205, 206, 207, 208, and 209 were located. The video surveillance footage began on 03/20/2024 at 11:47 p.m. At 11:53 p.m. S6MHT was seen observing patients in the above stated rooms. On 03/21/2024 at 12:03 a.m. S4LPN was seen observing patients. At 2:07 a.m. S4LPN was seen observing patients. At 4:04 a.m. S6MHT was seen observing patients.
The patients were observed at 12:03 a.m. and not observed again until 2:07 a.m. (124 minutes)
The patients were observed at 2:07 a.m. and not observed again until 4:04 a.m. (117 minutes)
There were 6 patients (#3, #9, #10, #11, #12, #16) assigned to the above stated rooms that were not observed every 15 minutes from 03/20/2024 at 11:47 p.m. - 03/21/2024 at 4:04 a.m.

In interviews during the reviews of video surveillance footage S3DBH and S2CNO verified the above stated findings.

2.) Failing to monitor a patient ordered 1:1 observation for 1 (#2) of 3 (#1, #2, #3) patients reviewed.

Review of the hospital's policy titled "PC-1013: Levels of Patient Observation" revised 07/31/2012, revealed in part, 2) One-to-One Supervision a) this is an extreme level of observation reserved for patients who are an imminent suicide risk or whose psychiatric state is such that control/safety cannot be maintained otherwise. b) a staff member is assigned to this patient and remains in physical proximity at all times. c) documentation in nursing progress notes must state that one-to-one supervision was provided throughout the shift. The staff member providing one-to-one supervision gives report to the on-coming staff.

Review of Patient #2's medical record revealed an admission date of 02/25/2024. Further review revealed a physician's order dated 03/01/2024 at 6:01 p.m. by S7MD for 1:1 observation.

Review of the self-report to State Office dated 03/05/2024 revealed in part, on 03/02/2024 Patient #2 was a LOS patient. Patient #2 was in the LOS room with nursing and tech supervision. Patient #2 was given a psych safe marker still under line of sight by staff. At approximately 11:23 a.m. Patient #2 exited her room to go to the day room where she approached S8MHT and showed her that she had stuck a marker into a spot in her arm that was soft skin from a previous wound. Although the wound was completely healed, it was new skin and much softer than the normal skin and tissue surrounding it. Patient #2 then was taken to nurse to be examined.

In an interview on 03/21/2024 at 10:55 a.m. S3DBH verified 1:1 observation is a staff member within arm's reach of the patient.

In an interview on 03/21/2024 at 11:11 a.m. S2CNO verified Patient #2 was ordered 1:1 observation from 03/01/2024 at 6:01 p.m. until discharge.

In an interview on 03/21/2024 at 12:32 p.m. S3DBH and S2CNO verified 1:1 observation was not identified and Patient #2 was able to insert a marker into her arm.

In an interview on 03/25/2024 at 3:12 p.m. S9RN stated 1:1 observation is a staff member sitting inside the line of sight room with the patient. S9RN verified Patient #2 was not on 1:1 observation prior to the incident.

In an interview on 03/25/2024 at 4:15 p.m. S10MHT stated there was not a staff member sitting with Patient #2 before the incident. S10MHT stated she was conducting Patient #2's 15 minute observation checks prior to the incident because there was not another staff member assigned to Patient #2.


3.) Failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for ligature risks and safety risks.

Review of the hospital's policy titled "PC-1020: Ligature Risk" effective date of 08/02/2023, revealed in part, this ligature risk policy aims to identify, assess, and mitigate potential hazards related to ligature points that could pose a risk of self-harm or harm to others. The policy applies to all areas within the hospital, including patient rooms, common areas, bathrooms, and outdoor spaces.

Observation on 03/20/2024 at 10:02 a.m. - 10:54 a.m. of the behavioral health unit revealed 12 out of 12 patient room doors had 3 separate hinges creating potential anchor points. Patient Room 206 had a fire sprinkler cover that was loosely attached to the ceiling and could be moved creating a potential anchor point. Patient Room 206 also had ceiling tiles that were not secured and could be moved creating numerous areas to conceal contraband.

In an interview during the observation S3DBH verified the above stated findings.

Observation on 03/21/2024 at 8:30 a.m. - 8:39 a.m. of Patient Room 201 revealed the bathroom door was a full door that created a potential anchor point when the door was closed. The bathroom ceiling tiles were not secured and could be moved creating numerous areas to conceal contraband.

In an interview during the observation, S3DBH verified 12 out of 12 bathroom doors in patient rooms were the same and created a potential anchor point when the door was closed. S3DBH verified the bathroom ceiling tiles were not secured and could be moved.

Based on record review and interview, the hospital failed to ensure the use of seclusion was in accordance with the order of a physician or other licensed independent practitioner who was responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This deficient practice was evidenced by failing to ensure secluded patients were monitored as per physician order for 1 (#3) of 2 (#2, #3) patients reviewed that were in seclusion.

Findings:

Review of Patient #3's medical record revealed Patient #3 was in seclusion on 03/24/2024 at 4:00 p.m. - 4:48 p.m. Review of the physician's order revealed in part, Note: Continual uninterrupted 1:1 monitoring is required if the patient is in restraints/seclusion.

Review of the video surveillance footage on 03/25/2024 at 1:53 p.m. with S3DBH and S2CNO revealed the seclusion room. The video surveillance footage began on 03/24/2024 at 4:00 p.m. On 03/24/2024 at 4:05 p.m. the seclusion room door opened and Patient #3 was seen placed in the seclusion room by staff and police officers. At 4:10 p.m. someone is seen at the window looking into the seclusion room and Patient #3 was standing at the window inside the seclusion room. At 4:18 p.m. Patient #3 was seen walking into the bathroom that was located inside the seclusion room. At 4:19 p.m. Patient #3 was seen walking out of the bathroom. During the time Patient #3 was in the bathroom in the seclusion room, Patient #3 was not able to be seen on video surveillance. At 4:22 p.m. Patient #3 was seen lying down on the bed in the seclusion room. At 4:45 p.m. the RN was seen to enter the seclusion room. At 4:47 p.m. Patient #3 was seen getting up from the bed, putting on his shoes, and walking out of the seclusion room. There was no staff member seen continuously observing Patient #3 through the window of the seclusion room door.

In an interview on 03/25/2024 at 2:07 p.m. S3DBH stated when a patient is in seclusion the patient is line of sight observation.

In an interview on 03/25/2024 at 2:48 p.m. S3DBH verified Patient #3 was unable to be observed by staff during the time Patient #3 was in the seclusion room bathroom.

Based on record review and interview, the hospital failed to ensure the Quality Assurance/Performance Improvement program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of services and quality of care. This deficient practice was evidenced by failing to identify Patient #2 was ordered 1:1 observation by S7MD and was able to insert a marker into her arm.

Findings:

Review of the hospital's policy titled "PC-1013: Levels of Patient Observation" revised 07/31/2012, revealed in part, 2) One-to-One Supervision a) this is an extreme level of observation reserved for patients who are an imminent suicide risk or whose psychiatric state is such that control/safety cannot be maintained otherwise. b) a staff member is assigned to this patient and remains in physical proximity at all times. c) documentation in nursing progress notes must state that one-to-one supervision was provided throughout the shift. The staff member providing one-to-one supervision gives report to the on-coming staff.

Review of Patient #2's medical record revealed an admission date of 02/25/2024. Further review revealed a physician's order dated 03/01/2024 at 6:01 p.m. by S7MD for 1:1 observation.

Review of the self-report to State Office dated 03/05/2024 revealed in part, on 03/02/2024 Patient #2 was a LOS patient. Patient #2 was in the LOS room with nursing and tech supervision. Patient #2 was given a psych safe marker still under line of sight by staff. At approximately 11:23 a.m. Patient #2 exited her room to go to the day room where she approached S8MHT and showed her that she had stuck a marker into a spot in her arm that was soft skin from a previous wound. Although the wound was completely healed, it was new skin and much softer than the normal skin and tissue surrounding it. Patient #2 then was taken to nurse to be examined.

In an interview on 03/21/2024 at 10:55 a.m. S3DBH verified 1:1 observation is a staff member within arm's reach of the patient.

In an interview on 03/21/2024 at 11:11 a.m. S2CNO verified Patient #2 was ordered 1:1 observation from 03/01/2024 at 6:01 p.m. until discharge.

In an interview on 03/21/2024 at 12:32 p.m. S3DBH and S2CNO verified 1:1 observation was not identified and Patient #2 was able to insert a marker into her arm.

Based on record review and interview, the hospital failed to identify opportunities for improvement. This deficient practice was evidenced by failing to track and/or trend 29 occurrences in the last 2 months that patients were in restraints and/or seclusion in the hospital's QAPI.

Findings:

Review of the report that S3DBH stated he sends to the managing company of the behavioral health unit revealed in part, there were 16 episodes of restraint and/or seclusion in January 2024. Further review revealed there were 13 episodes of restraint and/or seclusion in February 2024.

In an interview on 03/21/2024 at 10:22 a.m. S2CNO verified restraints and/or seclusion were not tracked and/or trended through the hospital's quality program. She stated restraints and/or seclusion were tracked and/or trended through the hospital's quality program for the emergency department but not for the behavioral health unit.

Based on record reviews and interviews, the hospital failed to maintain accurate medical records for each patient. This deficient practice was evidenced by failing to accurately document patient observations every 15 minutes on 13 (#3 - #15) of 17 (#1, #3- #18) patients on the night shift of 03/20/2024.

Findings:

Review of the hospital's policy titled "PC-1013: Levels of Patient Observation" revised date of 07/31/2012, revealed in part, all patients admitted to the hospital will be assigned routine level of observation unless the physician orders a special level of observation. A) Routine levels of Observation: 1) All patients are monitored a minimum of once every 15 minutes.

Review of the video surveillance footage on 03/21/2024 at 2:05 p.m. with S3DBH and S2CNO revealed the hallway where patient rooms 200, 201, 202, 214, and 215 were located. The video surveillance footage began on 03/20/2024 at 11:47 p.m. On 03/21/2024 at 12:01 a.m. S4LPN was seen observing patients in the above stated rooms. At 12:53 a.m. S5MHT was seen observing patients. At 2:05 a.m. S4LPN was seen observing patients. At 2:13 a.m. S5MHT was seen observing patients. At 4:04 a.m. S5MHT was seen observing patients. There were 8 patients (#4, #5, #6, #7, #8, #13, #14, #15) assigned to the above stated rooms that were not observed every 15 minutes from 03/20/2024 at 11:47 p.m. - 03/21/2024 at 4:04 a.m.

Review of the video surveillance footage on 03/21/2024 at 2:44 p.m. with S3DBH and S2CNO revealed the hallway where patient rooms 205, 206, 207, 208, and 209 were located. The video surveillance footage began on 03/20/2024 at 11:47 p.m. At 11:53 p.m. S6MHT was seen observing patients in the above stated rooms. On 03/21/2024 at 12:03 a.m. S4LPN was seen observing patients. At 2:07 a.m. S4LPN was seen observing patients. At 4:04 a.m. S6MHT was seen observing patients. There were 6 patients (#3, #9, #10, #11, #12, #16) assigned to the above stated rooms that were not observed every 15 minutes from 03/20/2024 at 11:47 p.m. - 03/21/2024 at 4:04 a.m.

Review of the observation sheets for Patients #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 dated 03/21/2024 at 12:00 a.m. - 4:00 a.m. revealed 15 minute observations were documented as being performed by the MHTs.

In interviews during the reviews of video surveillance footage S3DBH and S2CNO verified the MHTs did not perform every 15 minute observation checks on the above stated patients on 03/21/2024 at 12:00 a.m. - 4:00 a.m.

Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff and visitors.

Findings:

Observation on 03/20/2024 at 10:02 a.m. - 10:54 a.m. of the behavioral health unit revealed the following:
Patient Room 200: there were multiple ceiling tiles with stains.
Patient Room 206 Bathroom: there was a hole in one ceiling tile.
Patient Room 209 Bathroom: there was a hole in one ceiling tile.

In an interview during the observation S3DBH verified the above stated findings.

Based on observation and interview, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented. This deficient practice was evidenced by failing to maintain a sanitary environment.

Findings:

Observation on 03/20/2024 at 10:02 a.m. - 10:54 a.m. of the behavioral health unit revealed the following:
Patient Room 200: The air conditioner vent covers had rust.
Patient Room 208: The air conditioner vent covers had rust. The frame around the ceiling tiles in the bathroom and the frame of the bathroom door had rust.
Patient Room 206: The air conditioner vent covers had rust. The frame around the ceiling tiles in the bathroom had rust.
Patient Room 209: The air conditioner vent covers had rust. The frame around the ceiling tiles in the bathroom had rust.
All rust areas found in the patient rooms could not be disinfected.

In an interview during the observation S3DBH verified the above stated findings.