HospitalInspections.org

The hospital failed 2 of 2 Patients (Patient #1, and Patient #2) the right to receive care in a safe setting.

Findings Include:

During record review the Hospital Observation Sheet reflected, that roundings were conducted on Patient #1 by Staff #4 at 1330, 1345, and 1400.

During Video Footage review the footage indicates Staff #5 rounded on the unit prior to exiting the unit 1323. Footage reflects there is no other rounding until Staff #5 returns back on to the unit at 1341. During this time Patient #2 enters into Patient #1's room and the two patients are found in the bathroom unclothed at 1342. Staff #4 does not leave the nursing station until 1343 and only steps into the dayroom to hear what took place. Staff #4 never rounded the hall to ensure patients were actually on the unit and safe.

During interview with Staff #4, it was reported to the surveyor that rounding was completed and trained to do.

During interview with Staff #5, it was reported to the surveyor, that a proper hand-off was completed and the Observation Sheets were provided to the Staff #4.

During interviw with Staff #1, the surveyor was initially informed that the hospital staff were rounding as trained and the patients were observed. The surveyor requested the video footage and watched the video footage with Staff #1. Staff #1 was informed that the timeline appeared odd and Staff #5 documented that rounding was completed timely and as instructed. There were no actual rounds completed by hospital staff #4 during the times 1330, 1345 and 1400.

The hospital conducted a Root Cause Anaylsis meeting after the date of this investigation. The hospital indicated the following changes will be implemented by the end of August 2021.

" Observation Rounds Process and Documentation: The hospital will implement a quarterly refresher with attestation on observation rounds process, expectations, and documentation to start in August 2021. Hospital leadership is currently evaluating the observation round form to see if any changes would be helpful in the handoff and documentation processes. Once evaluated, any changes will be reviewed with staff to ensure a clear understanding of how to complete documentation. This education will be with all staff.

" Process for patients in rooms during treatment hours: Patients are not to be in their rooms during treatment hours to encourage participation in treatment. Patients refusing to go to groups will be in the dayroom rather than their rooms. If the patient needs to be in their room due to illness or other treatment related concerns, then the nurse will need to get a doctor's order for the patient to be in their room. Education will be provided to nurses and mhts on the procedure for getting patients out of their rooms and encouraging participation in groups, handoff when patients are staying in the unit, and patient's current status when handing off.

" Communication: Expectations for rounds hand offs and planning/delegating duties to ensure each person knows their role. Education to be provided to all staff.

" Closed patient rooms: All patient rooms must be closed if there are not patients in the room. When a staff member walks by an open door they need to check it to see if there is a patient in the room or bathroom and follow up to see if that patient is allowed to be in their room at this time. If there is no patient in the room or bathroom, the door must be closed. This education will be provided to all staff. Additional action item: Lead Tech will be assigned times to go to each unit and check rooms to ensure there are no patients in the rooms and doors are closed appropriately.

" Location for Round Sheets of patients on the unit: Nursing is identifying one location for round sheets to be placed on the unit if a patient remains on the unit. Once that location has been identified, all nursing staff will be educated on the procedure for consistency between all shifts.

" Nursing Staff presence in the hallway: Leadership is searching for an appropriate mobile desk that can be taken onto the hallway when the nurses have patients remaining on the unit during times when the techs are away from the unit. Thus, allowing the nurses to continue with their duties and providing improved monitoring in the hallway and dayroom areas. Once identified and acquired the full process will be educated to Nursing staff. In the meantime, the nursing staff will be educated that they must be on the hallway when they have patients remaining on the unit without a tech.

" Bed Board Reconciliation/Room Changes: Process to have nursing and intake reconcile the unit bed boards with the system bed board twice daily. Allows staff to ensure patients who may be on overflow are moved as early as possible depending on discharges to another unit.

POLICY
The hospital Policy on Observation/Rounding dated 09/09/2020 reflected, "An accurate record of the whereabouts and behavior of all patients will be maintained during each shift ..Levels of Observation: Level 3 (Every 15 minutes' observation): This moderately restrictive toward the patient and involves continuous monitoring every 15 minutes on the Patient Observation Record, with check marks documenting such. Nursing staff must also chart level of suicidal thought every shift to warrant the patient remaining on such observation or allowing the physician to discontinue the precautions based upon this assessment."

The hospital Policy on Sexually Acting Out and Sexual Victim Prevention dated 01/27/2020, reflected, "Perimeter Healthcare shall implement a policy for patients for protective measures. The facility shall advocate for those who are vulnerable to sexual victimization by other patients who are on sexual precautions and residing in the facility. Patients shall not have sexual contact with one another. Patients are assessed for risk of sexual acting out behavior or being sexually victimized ...Sexual Acting Out: Patients at risk for sexual acting out behavior may be placed on SAO (sexual acting out) precautions upon physician order.
a. The High Risk Notification Alert Sheet will identify whether the patient is on Sexual Acting Out or Sexual Victim
precautions after admission of the patient completed, with hand-off to receiving unit/department, and when a patient is
transferred from unit-to-unit or to another level of care within the same facility.
b. Sexual Acting Out precautions will be documented on
the Patient Observation Sheet, the Twelve (12) Hour Nursing Assessment and the Staffing Board."

The hospital Policy on Precautions dated 08/14/2020 reflected, "Patients admitted to Perimeter Behavioral Hospital will be assessed for risks and severity of those risks and will be placed on precautions as required per physician order. Staff members will be trained on the implementation of specified precaution interventions and the ongoing subjective and objective assessments required. Early recognition and reporting are embedded in the Prevention, Preparation, and Performance process ...Care provided at Perimeter Behavioral Hospital Centers around maintaining a safe environment. Patients admitted are universally a potential threat to their own safety or that of others due to their illness and symptomatology. The design, furnishing, and supplies of each patient care area established with the intent to mitigate risks collectively. Observation rounds are conducted routinely every 15minutes. However, with each identified precaution set there are other measures enacted to diminish the risk of adverse events."