HospitalInspections.org

Based on a review of documentation and interview, the facility failed to protect and promote each patient's rights, as evidenced by:

* The facility failed to appropriately and effectively address voluntary requests for discharge at the facility. *Refer to A0129*

* The facility failed to ensure the patients' right to care in a safe setting, as they failed to monitor patients at the level of monitoring most recently ordered by their physician. *Refer to A0144*

* The facility failed to ensure the patients' right to be free from all forms of abuse or harassment, as they failed to ensure that sexual contact between patients was appropriately documented, addressed per policy, and effect monitoring was in place to prevent further sexual abuse between patients. *Refer to A0145*

Based on a review of documentation and interview, the facility failed to ensure the patients were able to exercise their rights as evidenced by failing to appropriately and effectively address voluntary requests for discharge at the facility as well as monitor patients at the observation level most recently ordered by their physician.

Findings:

Based on a review of documentation and interview, the facility failed to ensure that if a hospital is informed that a voluntary patient desires to leave the hospital or a voluntary patient or the patient's LAR requests that the patient be discharged, the hospital shall, in accordance with Texas Health and Safety Code, §572.004: if necessary and as soon as possible, assist the patient in creating a written request for discharge and present it to the patient for the patient's signature.

Facility based policy entitled, "DISCHARGE, AMA (Against Medical Advice)" stated in part,

"All patients voluntarily admitted to inpatient services for treatment of mental illness or chemical dependency or the person who requested admission on the individual's behalf have the right to request discharge. Any such person expressing a request for release shall be given an explanation of the process for requesting release and afforded the opportunity to request release in writing.

·When a written request for release is presented to any direct care staff of the hospital, it should be signed, dated, and timed by the individual or a person legally responsible for the individual.

·If an individual informs a person associated with or employed by the hospital of the individual's desire to leave, the employee or person shall, as soon as possible, assist the individual in creating the written request and present it to the individual to sign, date, and time. Without regard to whether the individual agrees to sign paperwork requesting discharge from services, the request will be documented and processed by staff. The refusal or inability of the individual to sign the request for discharge will be documented on the unsigned written request.

All written or prepared requests for discharge will be timed, dated, and signed by the staff member; who shall provide information -to the individual that pursuant to law, during the ensuing period of up to 24 hours, the individual will be observed and evaluated to determine the clinical appropriateness of seeking an involuntary commitment to services. The form and format for requesting release and the information to be provided may be prescribed by the department."


Review of the medical record for Patient #4 revealed this patient made multiple verbal appeals to be discharged before a request for discharge form was completed. This patient was admitted voluntarily on 12/18/20.


AMA Documentation for this patient:

Notes requesting release included the following:

* On 12/19/20 at 0530 nursing note stated in part, "Patient angry and wants to leave AMA ...and he wants to see practitioners ...Brother called at 1040 to state patient want to leave AMA. Supervisor notified."

* On 12/22/20 Physician Assistant note stated in part, "Pt appears discharge oriented. States sadness due to not being able to spend holiday with family."

* On 12/23/20 a Nurse Practitioner note stated in part, "59 y.o. male seen today stating 'I want to go home' ..."

* On 12/30/20 a nursing note at 0900 stated in part, "Asking to go AMA ..."


The patient completed an initial Request to Leave Against Medical Advice (AMA) on 12/21/20 at 2:02. This form indicated the physician determination was "discharge patient within 4 hours of request". An order to "Discharge pt home" was written on 12/31/20 at 1610.

The patient did complete an initial Request to Leave Against Medical Advice (AMA) on 12/21/20 at 2:02. There was no documentation this form was offered to the patient prior to this date despite multiple verbal requests for discharge home. This delayed this patient's discharge for almost 11 days after their first request to leave the facility AMA.

The above findings were verified on 01/13/21 with staff member #3.


Based on a review of documentation and interviews, the facility failed to ensure that voluntary inpatient persons were informed by the physician of the intent to file an application for court-ordered mental health services.

Facility based policy entitled, "DISCHARGE, AMA" stated in part,

"All patients voluntarily admitted to inpatient services for treatment of mental illness or chemical dependency have the right to be discharged within four hours of a request for release unless the individual's treating physician (or another physician if the treating physician is not available) determines that there is cause to believe that the individual might meet the criteria for court-ordered mental health services or emergency detention.

o Each patient detained beyond four hours has the right to be examined in person by a physician and assessed for discharge readiness within 24 hours of the filing of a request for release, with results of the assessment and recommendation resulting documented in the medical record and disclosed to the individual. Patients have the right not to be detained beyond the completion of the in-person examination unless:...

*the patient, in the physician's clinical judgment, meets the criteria for involuntary commitment outlined in the Texas Health and Safety Code, §573.022, and an application for court-ordered mental health services, chemical-dependency services or emergency detention will be filed and an order obtained not later than 4 p.m. on the next succeeding business day after the date on which the examination occurs and the individual is detained under the provisions of the relevant statute; ...

PROCEDURE ...

o The attending physician must determine if patient will be discharged or if meets criteria for court order to continue care. Determination must occur within four hours of patient's AMA request. Physician will document rationale for decision to hold or discharge patient ...

o If the attending/covering physician assesses the patient to be harmful to self or others, or is unable to meet basic needs due to psychiatric condition, the physician may initiate a Certificate of Medical Examination (CME) within 24 hours of patient's AMA request."

Review of medical records revealed the following 2 of 3 patients (#3,4, and 8) requesting to be discharged while voluntarily at the facility did not have documentation present to reflect that the physician notified these patients of the intent to file an application for court-ordered mental health services:


Patient #3 Record Review:

This patient signed in voluntarily on 05/28/20.

AMA Documentation for this patient:

* The patient completed an initial Request to Leave Against Medical Advice (AMA) on 06-03-20 at 1700.

* The area for the date and time notification of the physician and physician notification area of the form was blank.

* This form indicated the physician determination was "continue to observe and evaluate for clinical appropriateness of seeking an involuntary commitment based on the following concerns(s):" due to "concern for pt safety".

* An Application for Emergency Detention was filed on this patient on 06/04/20 at 1745. A Warrant for Emergency Detention was obtained on 06/04/20.

No physician notes indicated the patient was informed of the physician's intent to file for an Emergency Detention on the patient. The only physician note regarding the EDO was on 06/05/20 which stated in part, "The patient was placed on an EDO yesterday at 5:45 PM because the patient was asking to leave against medical advice."

Nursing notes included:

* On 06/04/20 at 2225, "Pt requested an answer to his request for AMA she signed yesterday ...She was placed on EDO. She was informed of the order. She was disappointed but took the news well."

* On 06/05/20 at 2246, " ...She asked to know about how the AMA request works and why she got an EDO, said nobody explained to her. She was satisfied with explanation staff gave her."

Based on the above information, it does not appear the physician notified this patient of the intent to file an application for court-ordered mental health services.


Patient #8 Record Review:

This patient signed in voluntarily on 05/06/20.

AMA Documentation for this patient:

* The patient completed an initial Request to Leave Against Medical Advice (AMA) on 05/07/20 at 1830. The nurse notified the physician on 05/07/20 at 1830. This form indicated the physician determination was "continue to observe and evaluate for clinical appropriateness of seeking an involuntary commitment based on the following concerns(s):" The area to list concerns was blank on this form with no clinical behavior to hold beyond the four hours noted. The physician signed this on 10/10/20. The bottom of the form was signed by a nurse on 05/07/20 at 1830.

* There was no order to hold the patient or any Application for Emergency Detention completed on 05/07/20.

* The patient signed to withdraw this initial request to leave AMA on 05/08/20 at 1300.

* The patient completed a second initial Request to Leave Against Medical Advice (AMA) on 05/09/20 at 7:20 (indicated by the patient on the form). The nurse notified the physician on 05/09/20 at 1830. This form indicated the physician determination was "continue to observe and evaluate for clinical appropriateness of seeking an involuntary commitment based on the following concerns(s):" The area to list concerns was blank on this form with no clinical behavior to hold beyond the four hours noted. No physician signature was present on the form. The bottom of the form was signed by a nurse on 05/07/20 at 1830.

* A physician note on 05/08/20 stated in part that the patient's chief complaint was "I would like to go. I think this pandemic is not a good idea for me to be here." There was no documented reason to not discharge the patient or any mention of the patient withdrawing their request to leave.

* There was a physician order on 05/09/20 at 0325, "Per [physician name] place patient on 24 hour hold for further evaluation".

* An Application for Emergency Detention was completed on 05/09/20 at 1732. A Warrant for Emergency Detention signed on 05/09/20 by a judge.

No physician notes indicated that the patient was informed of the physician's intent to file for an Emergency Detention on the patient. Based on the above information, it does not appear the physician notified this patient of the intent to file an application for court-ordered mental health services.

The above findings were verified on 01/13/21 with staff member #3.


Based on a review of documentation, the facility failed to ensure that if a written request for discharge from a voluntary patient or the patient's LAR was made known to a hospital, the hospital within four hours after the request was made known to the hospital, notified the treating physician or, if the treating physician is not available during that time period, notify another physician who is a hospital staff member of the request.

Facility based policy entitled, "DISCHARGE, AMA" stated in part,

"All patients voluntarily admitted to inpatient services for treatment of mental illness or chemical dependency or the person who requested admission on the individual's behalf have the right to request discharge. Any such person expressing a request for release shall be given an explanation of the process for requesting release and afforded the opportunity to request release in writing.

·When a written request for release is presented to any direct care staff of the hospital, it should be signed, dated, and timed by the individual or a person legally responsible for the individual.

·If an individual informs a person associated with or employed by the hospital of the individual's desire to leave, the employee or person shall, as soon as possible, assist the individual in creating the written request and present it to the individual to sign, date, and time. Without regard to whether the individual agrees to sign paperwork requesting discharge from services, the request will be documented and processed by staff. The refusal or inability of the individual to sign the request for discharge will be documented on the unsigned written request.

·All written or prepared requests for discharge will be timed, dated, and signed by the staff member; who shall provide information -to the individual that pursuant to law, during the ensuing period of up to 24 hours, the individual will be observed and evaluated to determine the clinical appropriateness of seeking an involuntary commitment to services. The form and format for requesting release and the information to be provided may be prescribed by the department."


Review of medical record revealed 1 of 3 patients requesting voluntary discharge did not have the notification (time and date) of the physician noted on their AMA form.


Patient #3 AMA Documentation:

The patient completed an initial Request to Leave Against Medical Advice (AMA) on 06-03-20 at 1700.
The area for the date and time notification of the physician and physician notification area of the form was blank.

The above findings were verified with staff member #3 on 01/13/21.


Based on a review of documentation and interview, the facility failed to ensure that if the hospital intends to detain a patient to file an application and obtain a court order for further detention of the patient, a physician documents the reasons for the decision to detain the patient in the patient's medical record.

Facility based policy entitled, "DISCHARGE, AMA" stated in part,

"All patients voluntarily admitted to inpatient services for treatment of mental illness or chemical dependency have the right to be discharged within four hours of a request for release unless the individual's treating physician (or another physician if the treating physician is not available) determines that there is cause to believe that the individual might meet the criteria for court-ordered mental health services or emergency detention.

o Each patient detained beyond four hours has the right to be examined in person by a physician and assessed for discharge readiness within 24 hours of the filing of a request for release, with results of the assessment and recommendation resulting documented in the medical record and disclosed to the individual. Patients have the right not to be detained beyond the completion of the in-person examination unless:...

*the patient, in the physician's clinical judgment, meets the criteria for involuntary commitment outlined in the Texas Health and Safety Code, §573.022, and an application for court-ordered mental health services, chemical-dependency services or emergency detention will be filed and an order obtained not later than 4 p.m. on the next succeeding business day after the date on which the examination occurs and the individual is detained under the provisions of the relevant statute; ..."

Review of medical records revealed the following 1 of 3 patients requesting to be discharged while voluntarily at the facility did not have clearly documented reasons for the decision to detain the patient in the patient's medical record.


Patient #8 Record Review:

This patient signed in voluntarily on 05/06/20.

AMA Documentation for this patient:

* The patient completed an initial Request to Leave Against Medical Advice (AMA) on 05/07/20 at 1830. The nurse notified the physician on 05/07/20 at 1830. This form indicated the physician determination was "continue to observe and evaluate for clinical appropriateness of seeking an involuntary commitment based on the following concerns(s):" The area to list concerns was blank on this form with no clinical behavior to hold beyond the four hours noted. The physician signed this on 10/10/20. The bottom of the form was signed by a nurse on 05/07/20 at 1830.

* There was no order to hold the patient or any Application for Emergency Detention completed on 05/07/20.

* The patient signed to withdraw this initial request to leave AMA on 05/08/20 at 1300.

* The patient completed a second initial Request to Leave Against Medical Advice (AMA) on 05/09/20 at 7:20 (indicated by the patient on the form). The nurse notified the physician on 05/09/20 at 1830. This form indicated the physician determination was "continue to observe and evaluate for clinical appropriateness of seeking an involuntary commitment based on the following concerns(s):" The area to list concerns was blank on this form with no clinical behavior to hold beyond the four hours noted. No physician signature was present on the form. The bottom of the form was signed by a nurse on 05/07/20 at 1830.

* There was a physician order on 05/09/20 at 0325, "Per [physician name] place patient on 24 hour hold for further evaluation".

* An Application for Emergency Detention was completed on 05/09/20 at 1732. A Warrant for Emergency Detention signed on 05/09/20 by a judge.

Based on the above information, it does not appear the physician consistently documented the reasons for the decision to detain the patient in the patient's medical record.

The above findings were verified on 01/13/21 with staff member #3.

Based on a review of clinical records, observation and an interview with staff, the facility failed to ensure the patients' right to care in a safe setting, as 22 of 29 patients had not/were not monitored at the monitoring level most recently ordered by their physician.

Findings were:

Patient #5 was admitted to the facility on 5-14-20. According to physician's orders, the patient was to be observed at the following precaution/observation levels during their stay:

* 5-14-20 upon admission - Q 5 minutes

* 5-19-20 at 2:30 pm - 1:1 (for safety)

* 5-20-20 (during 3pm to 11pm shift) - order written by RN House Supervisor that stated to discontinue 1:1 order for "administrative override"; order was not given by a physician, nor was it dated or timed.

* 5-22-20 at 12:30 pm - discontinue q 5 minute checks, start q 15 minute checks

A review of observation sheets as well as unit staffing sheets completed during the patient's stay revealed that the patient was observed and monitored at the following levels:

* Q 5 from 5-14-20 at 2:25 pm to 5-19-20 at 1:55 pm

* Q 15 from 5-19-20 at 2:15 pm to 3:00 pm

* Q 5 from 5-19-20 at 2:55 pm to 5-22-20 at 12:45 pm (patient was then discharged)

** On 5-21-20 from 6:15 am to 7:10 am, there was no documentation that the patient had been monitored at all. There was also no documentation that the patient had ever been monitored on a 1:1 observation level, although an order to do so had been written on 5-19-20 at 2:30 pm and not discontinued by the physician until 5-22-20 at 12:30 pm.**

During a tour of the adult and specialty units, the records for 28 current patients were reviewed. Review of the physician's orders and observations sheets for these 28 patients revealed that 7 of 10 patients on the adult unit (patients #11, #13, #4, #15, #17, #18 and #20) and 14 of 18 patients on the specialty unit (patients #21 - #27, #29 - #32 and #36 - #38) were all being observed at a monitoring level less frequent than the monitoring level most recently ordered by their physician. All 21 current patients (not being monitored at the appropriate level) were to be monitored q 5 minutes, but the observation sheets revealed that all 21 were being monitored q 15 minutes.

Facility policy titled "Observations, Patient" stated, in part:

"Policy:

In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN. Level of observation can be increased by the RN any time there is a concern but only a psychiatric practitioner may decrease the level.

Procedure:

The psychiatric practitioner will order one of three levels of observation at time of admission and as the patient's condition warrants a change:

* 15 minute

* 5 minute

* One-to-one
...

The RN may increase the level of observation if the patient's condition changes. The psychiatric practitioner will be contacted [as] soon as possible for notification of the change in condition and to obtain an order for the observation level.

The RN may not decrease the level of observation, i.e. change from 1:1 to Q15 [minutes] without an order by the psychiatric practitioner.

Documentation of Observations:

Staff documents all levels of observation on each patient's observation form which becomes a part of the patient record. Each entry is to include the following:

* Level of observation

* Precaution

* Location

* Behavior

* Activity

* Time

* Staff initial and signature
...

Q 15/Q 5 Minute Rounds:

All patients are monitored at a minimum once in every 5 or 15 minute block of time. In order to minimize the change that [the] patient may anticipate the timing of the rounds, the staff are instructed to vary the order in which patients are observed within each 5 or 15 minute period. During the rounds staff are to:

* Make direct visual contact; look for signs of danger or distress.

* Observe sleeping patients close enough to confirm they are breathing and not in any physical distress such as bleeding, lying on the floor, very restress, etc.

* Remain vigilant for specific risks for patients on special precautions.

* Allow reasonable privacy for dressing and bathing.

* If awake, address the patient - 'good morning, how are you today', etc.

* Observe the patient's environment for potential hazzards(sic) that can be corrected (e.g., clutter on the floor, belongings that were not returned to storage etc)

1:1 Observation:

* 1:1 is the highest level of observation and is reserved for patients who are so unpredictable that without a dedicated staff member there is a risk of patient harming self or others."

The above findings were verified on 01/13/21 with staff member #3.

Based on a review of documentation and interview, the facility failed to ensure patients' right to be free from all forms of abuse or harassment, as evident by failing to ensure that sexual contact between patients was appropriately documented, addressed per policy, and effect monitoring was in place to prevent further sexual abuse between patients.

Findings:

Facility based policy entitled, "ABUSE AND NEGLECT" stated in part, "Patient-to-Patient Abuse

o The registered nurse will place the patient committing the offense on Line of Sight or 1:1 observation and notify the attending/covering physician.

o The registered nurse will complete a nursing assessment of the patient who was abused to evaluate the patient's physical and mental condition.

o The registered nurse will notify the designated family contact and/or legal representative of the patient who was abused."


In July 2020, two adolescent patients (Patients # 1 Male and # 2 Female) were identified as having reported sexual contact with each other.

According to the facility-based investigation:

"Patient [#2] was discharged 7/3/2020 and readmitted on 7/4/2020. [Patient #2] reported to a Mental Health Tech she was worried she was pregnant. Patient was asked if she had intercourse while she was at home. Patient proceeded to say she snuck into a boy's room [Patient #1] during last stay and had oral and intercourse. Risk Manager questioned [Patient #1] and he confirmed. Patients report [Patient #2] was able to sneak into his room either on 7/1/2020 and 7/2/2020 while they were getting ready for hygiene and between Q-15 checks. Neither patient is reporting coercion. Patients were put on Q-5 immediately."


Review of the medical records for patients #1 and 2 reveal that neither patient had details of the sexual contact, nursing assessment, evaluation, or family contact documented in detail.

The only notes addressing the sexual contact between the 2 adolescent patients in Patient #1's record were the following:

* A physician note on 07/09/20 which stated in part, "As far as recent incident, the patient states that he regrets what he did and that he kept saying no, but eventually gave in because he was repeatedly asked. He admits that he should not have done it. The patient is advised to think about how his actions affect him and the people around him and to consider this in his decision making."

* The discharge summary on 07/13/20 stated in part, "The pt also was engaged in sexual activity was another patient towards the end of this hospital stay."


The only notes addressing the sexual contact between the 2 adolescent patients in Patient #2's record were the following:

* A physician note on 07/09/20 which stated in part, "Her mother was glad also that she shared about the incident that happened with [Patient #1] instead of staying quiet."

* The discharge summary on 07/13/20 stated in part, "Despite the discussion of safety and boundaries and appropriate behavior with the patient repeatedly, she engaged in sexual activity with other male patient and incident was reported to her mother."


Neither patient was placed on Line of Sight or 1:1 observation after the sexual contact outcry was made, per facility policy. Documented Patient Observation was at Q 5 or Q 15 minutes, also it was not clear that Sexually Acting Out precautions were being enforced as monitored.


Patient Observations, Orders and Documentation for Patient #1 included the following:

* On 07/07/20 at 1717, "SAO [Sexually Acting Out] precaution" was ordered.

* The Patient Observation sheet for 07/08/20 for this patient indicated "check every 15 minutes" with elopement and assault indicated as the reason for the observation; this was completed from 0000-2345. It is unknown if this patient was being monitored for sexually acting out as ordered after 1717 on 07/07/20.

* On 07/08/20 at 1430, Q 5 observation was ordered.

* The Patient Observation sheet for 07/08/20 for this patient indicated "check every 15 minutes" for elopement, assault, and sexual acting out, this was completed from 0000-2345; there was no documentation that the monitoring was increased to 5 minutes as ordered. It is unknown if this patient was being monitored every 5 minutes as ordered after 1430 on 07/08/20.
The Observations sheet was not changed to reflect every 5-minute observations staring at noon on 07/09/20. There was no precaution sheet from 0000 to 1145 for 07/09/20; therefore, it is unknown what level the patient was being observed at for that period.


Patient Observations, Orders and Documentation for Patient #2 included the following:

* On 07/08/20 at 1430, "SAO precaution Q 5 Observation" was ordered.

* The Patient Observation sheet for 07/08/20 for this patient indicated "check every 5 minutes" with suicide indicated as the reason for the observation; this was completed from 0000-2345. It is unknown if this patient was being monitored for sexually acting out as ordered after 1430 on 07/08/20.


On 01/13/20 the above findings were verified in an interview with staff members #2 and 4.

Based on a review of documentation and an interview with staff, the director of the nursing service failed to effectively discharge her oversight responsibilties for the operation of the service, as evidenced by the fact that nursing staff failed to follow facility policy regarding patient observation or admission assessment.

Findings:

Patient #5 was admitted on 5-14-20. According to physician's orders, patient #5 was to be observed at the following precaution/observation levels during her stay:

* 5-14-20 upon admission - Q 5 minutes

* 5-19-20 at 2:30 pm - 1:1 (for safety)

* 5-20-20 (during 3pm to 11pm shift) - order written by staff #5 (RN House Supervisor) that stated to discontinue 1:1 order for "administrative override"; order was not given by a physician, nor was it dated or timed.

* 5-22-20 at 12:30 pm - discontinue q 5 minute checks, start q 15 minute checks


A review of observation sheets as well as unit staffing sheets completed during the patient's stay revealed that patient #5 was observed and monitored at the following levels:

* Q 5 from 5-14-20 at 2:25 pm to 5-19-20 at 1:55 pm

* Q 15 from 5-19-20 at 2:15 pm to 3:00 pm

* Q 5 from 5-19-20 at 2:55 pm to 5-22-20 at 12:45 pm (patient was then discharged)

**On 5-21-20 from 6:15 am to 7:10 am, there was no documentation that the patient had been monitored at all. There was also no documentation that the patient had ever been monitored on a 1:1 observation level, although an order to do so had been written on 5-19-20 at 2:30 pm and was not discontinued by the physician until 5-22-20 at 12:30 pm.**


Attempts to perform the admission nursing assessment for patient #5 were documented as follows:

* 5-15-20 at 9:00 am

* 5-17-20 at 9:00 am

* 5-21-20 at 2:00 pm

* 5-22-20 at 12:00 pm


The Nursing Assessment form stated "If unable to complete the assessment because the patient is unable or unwilling, document DAILY attempts. Add additional lines as needed."

Facility policy titled "Observations, Patient" stated, in part:

"Policy:

In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN. Level of observation can be increased by the RN any time there is a concern but only a psychiatric practitioner may decrease the level.

Procedure:

The psychiatric practitioner will order one of three levels of observation at time of admission and as the patient's condition warrants a change:

* 15 minute

* 5 minute

* One-to-one
...

The RN may increase the level of observation if the patient's condition changes. The psychiatric practitioner will be contacted [as] soon as possible for notification of the change in condition and to obtain an order for the observation level.

The RN may not decrease the level of observation, i.e. change from 1:1 to Q15 [minutes] without an order by the psychiatric practitioner.


Documentation of Observations:

Staff documents all levels of observation on each patient's observation form which becomes a part of the patient record. Each entry is to include the following:

* Level of observation

* Precaution

* Location

* Behavior

* Activity

* Time

* Staff initial and signature

...
Q 15/Q 5 Minute Rounds:

All patients are monitored at a minimum once in every 5 or 15 minute block of time. In order to minimize the change that [the] patient may anticipate the timing of the rounds, the staff are instructed to vary the order in which patients are observed within each 5 or 15 minute period. During the rounds staff are to:

* Make direct visual contact; look for signs of danger or distress.

* Observe sleeping patients close enough to confirm they are breathing and not in any physical distress such as bleeding, lying on the floor, very restress, etc.

* Remain vigilant for specific risks for patients on special precautions.

* Allow reasonable privacy for dressing and bathing.

* If awake, address the patient - 'good morning, how are you today', etc.

* Observe the patient's environment for potential hazzards(sic) that can be corrected (e.g., clutter on the floor, belongings that were not returned to storage etc)

1:1 Observation:

* 1:1 is the highest level of observation and is reserved for patients who are so unpredictable that without a dedicated staff member there is a risk of patient harming self or others."


Facility policy titled "Assessment/Reassessment" stated, in part:

"Policy:

All patients admitted to the hospital will receive a thorough assessment and evaluation. Results of assessments are reviewed and integrated by the multidisciplinary team to prioritize identified problems within the Interdisciplinary Treatment Plan.
...

Nursing Assessment:

A comprehensive nursing assessment is performed by a Registered Nurse within eight (8) hours of admission."


The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 1-13-21.