HospitalInspections.org

Based on review of facility documents and staff interviews it was determined the facility failed to ensure the hospital worked cooperatively with the designated OPO (Organ Procurement Organization), tissue bank and eye bank in educating staff on donation and includes quality improvement activities for one of one agreement reviewed.

Findings included:

Review of the facility's current written agreement with the OPO revealed section G. Activity Data Review, Reporting and Quality Assessment (QA) and Improvement (QI) stated "G.1 At least annually, the Foundation shall provide Donor Hospital specific data with the appropriate Donor Hospital personnel for the purposes of quality assessment (QA) and improvement (QI), process evaluation, and to analyze outcomes of potential referral/donor situations, allowing for a collaborative plan of corrective action when indicated."

Staff education on organ procurement roles and processes, as outlined in the contract, was not evidenced.

Requested evidence to ensure integration into the hospital's QAPI (Quality Assurance Performance Improvement) program was not provided during survey. Review of the facility's Board Quality and Patient Safety Committee meeting minutes revealed the last meeting in which specific data was provided to the committee was 1/19/2017. Review of requested documentation revealed the OPO provided data for calendar years 2017 and 2018. There was no evidence the data was provided to the facility's Board Quality and Patient Safety Committee for integration into the hospital's QAPI program.

On 3/20/2024 at 2:06 PM the Director of Clinical Services was interviewed. She stated she was not aware of who the facility designee was for communication with the OPO. On 3/20/2024 at 3:44 PM she stated the designee of the facility was the Director of Risk Management.

On 3/21/2024 at 10:16 AM the Director of Risk Management was interviewed. She confirmed she was assigned the role but had not yet received the necessary education.

Based on review of staffing schedules, medical record review, policies, video review and staff interviews it was determined the facility failed to maintain sufficient staffing levels to adequately supervise a patient ordered one to one observation for one (#12) of twenty-four patients sampled.

Findings included:

Review of the facility staffing sheets revealed that on 03/18/2024 at 11:00 PM, night shift (11:00 PM- 7:30 AM), there was one Mental Health Tech (MHT) assigned to Dolphin Bay Unit (Acute unit). The census was 10 patients with physician ordered observation status of every 15 minutes and one patient with physician ordered observation status of 1:1 (continuous staff observation to safeguard patient from self-harm or harm to others.)

Review of the facility staffing sheets for 03/19/2024 night shift (11:00 PM- 7:30 AM) revealed one Mental Health Tech (MHT) assigned for Dolphin Bay Unit (Acute unit). The census was 10 patients with physician ordered observation status of every 15 minutes and one patient with physician ordered observation status of 1:1.

Review of the Medical records for Patient #12 the Physician orders revealed on 03/14/2024 at 10:00 PM observation status changed to a 1:1 observation.
Review of the Medical Records for Patient #2 the Physician orders revealed on 02/28/2024 at 10:00 PM observation status as an every 15 minutes observation.

Review of the Medical Records the Patient observation record for Patient # 12 and Patient #2 revealed the patient room on opposite ends of the hall and the MHT signing their initial both 1:1 observation and every 15 minutes observation.

Review of the facility policy and procedure title, "Level of Observation/ Patient Safety Rounds", #PC-53, revised 04/2023. Policy: It is the policy of Suncoast Behavior Health Center (SBHC) to use Levels of Observation based on the assessment of patient's need for observation in order to provide for safety, security and interaction. At a minimum, all patients are observed every 15 minutes ...every 15 minutes safety observation are placed when they need routine observation cheeks ... 1:1 observation when a patient need arm's length supervision due to suicidal, homicidal, elopement risk or disorganization problems ...

Review of the video for 03/18/2024 at 10:00 PM through 03/19/2024 2:00 AM revealed that patient #12 was not in constant supervision of staff.

An interview was conducted with Staff RN I, on 03/20/2024 at 8:01 AM. Staff RN I said an order for patient #12 for a 1:1 (one staff with one patient for close observation) and they did not have the staff to have the 1:1.

An interview was conducted with the Chief Medical Officer (CMO) on 03/20/2024 at 11:14 AM. The CMO said that if he ordered a patient to be 1:1 observation then his expectation is that the Mental Health Tech (MHT) to be with the patient at all times.

An interview was conducted with Staff MHT H on 03/21/2024 at 8:01 AM. Staff MHT H disclosed that they have a 1:1 patient he disclosed that the RN told him to just check the patient every 5 minutes because he was the only MHT on the unit.

An interview was conducted with The Chief Executive Officer (CEO) on 03/21/2024 8:35 AM. The CEO reviewed the facility policy, staffing sheets, and the medical records and disclosed that it was unacceptable not to have the staffing for patient #12 on the 1:1 observation per the physician orders.

Video evidence provided.