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Based on review of records, observations, and interviews, the facility failed to ensure safe care for 1 of 1 patient (# G) on one-to-one observation for falls and agitation.

Findings include:

POLICY Number 2.4: One-to-One or Two-to-One Supervision of Patients (Arm's length and Direct Observation)

One-to-One or Two-to-One Supervision of Patient is close observation of patients that have been identified as an imminent danger to themselves or others.

PROCEDURE:

Staff Responsibilities included:
1. Document the patient's behavior/ activity every 15 minutes on S/R Event Monitoring,
2. While on duty the assigned staff may not leave the patient unattended under any circumstances.
3. Keep within arm's length of patient at all times unless distance supervision is ordered.
4. Stay Alert.
5. Avoid distractions at all times
6. To provide safety and care for the patient, you are expected to observe, and care for the patient at all times.

During a tour 02/21/24 at 10:55 am the dayroom was entered by one surveyor and employee (#1), Director of Clinical Performance. Unlicensed Mental Health Technician (MHT) (staff #20) was seated by a window in the dayroom approximately 10 feet past the nursing station counter watching the dayroom television where she remained until interviewed.

When interviewed at 11:35 she was asked was asked what she was doing. She responded she was doing 1:1 observation on a patient in bed. She then pointed to a room several yards behind her. The room interior and patient therein were not visible where staff # 20 was seated.

Patient #G was assessed as moderate/high fall risk and had a medical order dated 11/29/23 for fall precautions. On 12/01/23 for 1:1 monitoring as ordered. Both orders remained in place on 02/21/24.

Staff #20's every 15-minute documentation was checked at 11:30 am. It indicated she had checked the patient in the patient room while still sitting in the dayroom at 11:00, 11:15 and 11:30 am.

When interviewed 12/21/24 at 11:45 employee (#1), Director of Clinical Performance confirmed patient # 20 was not visible to the staff assigned to monitor her 1:1.