HospitalInspections.org

Based on document review, staff interview and observation it was determined the hospital failed to follow their own policy for Close Observation/Line of Sight. This deficient practice was identified in one (1) of one (1) records reviewed (patient #2). This failure has the potential to adversely affect the rights of all patients.

Findings include:

1. A review of the hospital policy titled "Emergency Department- Suicide Precautions Plan", revised 11/2017, revealed it states, in part: "Statement of Purpose: To ensure a safe environment for potentially self-destructive patients and to establish specific guidelines for staff observation of these patients. Close Observation/Line of Sight: This is very restrictive for the patient and involves continuous visual monitoring at all times. Staff must be within visual contact at all times with exception of toileting and showering, during which staff shall be present outside a door left ajar, but remain in audible contact with the patient. Staff will document patients' behavior every thirty (30) minutes."

2. A tour of the Emergency Department (ED) was conducted on 1/22/18 at 10:30 a.m. The Assistant Director of Nursing accompanied the surveyors on the tour. He stated any patient who is violent or on suicide watch will be located in a seclusion room. He reported any patient in the seclusion rooms will be under close observation. Patient #2 was located in seclusion Room 17. The door to Room 17 was closed, blinds were slightly open, head of stretcher was lowered, feet of stretcher was elevated, side rails were up in locked position and no one was with patient #2. Patient #2 was standing on the floor at the bottom of stretcher, with his hands on the stretcher, when the Assistant Director of Nursing entered the room. He stated patient #2 was put in Room 17 due to being violent at home. The Assistant Director of Nursing stated, "When there is no one in the seclusion room with patient #2, the patient is being monitored by a video camera. Monitors for the video cameras are located at the nurse's station and are monitored by a monitor technician." Upon further tour, it was observed that no staff was located at the monitoring station. The Assistant Director of Nursing stated the monitoring technician was pulled to do another task and the monitoring of the video cameras is the responsibility of the Charge Nurse. The ED Charge Nurse was not watching the video camera monitors upon this surveyor's arrival at the nurse's station.

3. A review of the medical record for patient #2 revealed the patient arrived to the ED by ambulance at 8:53 a.m., was triaged at 8:54 a.m. and a mental health assessment was completed at 9:31 a.m. The mental health assessment documented patient #2 was angry, hostile, suspicious, impulsive, irritable, disorganized, disoriented and delusional. Precautions needed were documented as close observation. Further review revealed no thirty (30) minute nursing documentation between 10:23 a.m. and 11:32 a.m.

4. An interview was conducted with the Vice President of Quality and Safety on 1/22/18 at 11:20 a.m. He stated any patient presenting in the ED with violet behaviors, suicidal ideations or altered mental status and put in the seclusion room are monitored under the policy titled "Emergency Department - Suicide Precaution Plan". He concurred the ED staff did not follow policy.

Based on observation, document review and staff interview it was determined the hospital failed to follow their own policy to maintain a sanitary environment to avoid sources and transmission of infection and communicable diseases. This failure has the potential to adversely affect all patients.

Findings include:

1. A tour of the Emergency Department was conducted on 1/22/18 at 10:30 a.m. The Assistant Director of Nursing accompanied the surveyors on the tour. All beside commodes (BSC) were located in the soiled utility room. The Assistant Director of Nursing stated clean and dirty BSC are stored in the soiled utility room. There was a lack of evidence to prove any BSC in the ED had been cleaned; no BSC was tagged as cleaned and properly stored. All cleaned intravenous (IV) poles and pumps were stored in the ambulance (bay) entrance. The Assistant Director of Nursing stated all IV poles and pumps when cleaned are put in the bay until needed. One (1) IV pole and pump located in the bay was not marked as cleaned. Clean IV poles and pumps were exposed to the outside elements. One (1) pair of used latex examination gloves was located in the ambulance (bay) entrance on the floor.

2. Review of the hospital policy titled "Infection Prevention and Control: Nursing", revised 8/20/13, revealed it stated, in part: "Toiletry articles are to be cleaned appropriately with a hospital approved germicidal solution after each use. Any reusable piece of equipment, such as a potty chair, will be properly cleaned with a hospital approved germicide between usages by patients. Any reusable equipment, such as IV pumps, gomcos, cool mist therapy tents, etc., will be returned to the Central Service Department for decontamination and reprocessing, or sent to the next unit with the patient."

3. An interview with the Vice President of Quality and Safety was conducted on 1/24/18 at 2:00 p.m. He concurred with the above findings.