HospitalInspections.org

Based on document reviews, interviews, and observations, St. Mary's Regional Medical Center failed to ensure patients' right to receive care in a safe setting by failing to ensure that 15-minute checks were being conducted on an 18 bed Inpatient Psychiatric Unit (C4) as evidenced by:

Findings:

-St Mary's Regional Medical Center's policy titled, "Close Observation, SML Behavioral Health," last revised 12/2022 states in part:

" ...It is the policy of St. Mary's Regional Medical Center to initiate and provide close observation for patients exhibiting behavior warranting increased supervision ..."

And

" ...Type of Close Observation includes, but is not limited to:
suicide precautions (SP)
behavioral assessment precautions (BA)
fall precautions
elopement precautions
reassurance

Frequency:
Intermittent Observation: staff checks every 15 minutes ..."

-At 12:11 PM on 11/29/2023 an interview was conducted with DIRECTOR OF ADULT BEHAVIORAL SERVICES which revealed the following information:

DIRECTOR OF ADULT BEHAVIORAL SERVICES stated the purpose of the 15-minute checks is to, "make sure the patients are alive and breathing."

DIRECTOR OF ADULT BEHAVIORAL SERVICES stated that 15-minute checks are the primary task technicians perform on C4.

-A document titled, "Evidence for Tag A0144 Internal Correspondence," containing email correspondence was reviewed and revealed the following information:

"Evidence for Tag A0144 Internal Correspondence," contains an email sent to DIRECTOR OF ADULT BEHAVIORAL SERVICES at 7:10 PM on 09/09/2023 which reads in part:

"...Hey, [DIRECTOR OF ADULT BEHAVIORAL SERVICES],

[TECHNICIAN #1] was our only tech on the floor today and we had an admission from C2. It was discovered that this patient did not have 15 minute checks completed for 11 rounds (2.5 hours)..."

"Evidence for Tag A0144 Internal Correspondence," contains an email sent to DIRECTOR OF ADULT BEHAVIORAL SERVICES at 10:55 AM on 11/01/2023 which reads in part:

"...The front door to the unit was not shut completely and was noticeably open for a unknown amount of time. When asking [TECHNICIAN #1] if all the pt's were accounted for and when the last set of rounds took place. Was informed that [he/she] did not do checks for 30 min. As [he/she] took over the CVO [Constant Visual Observation] we have on the floor, so the tech could use the bathroom. Was informed no other techs were on the floor..."

"Evidence for Tag A0144 Internal Correspondence," contains an email sent to DIRECTOR OF ADULT BEHAVIORAL SERVICES at 11:38 AM on 11/29/2023 which reads in part:

"...Checks were not done today 11/29/23 for one hour and thirty minutes. When spoken to [TECHNICIAN #1] [he/she] states [he/she] handed checks off for one hour to give a patient a shower. Spoke with the 2 other techs [TECHNICIAN #2 and TECHNICIAN #3], was told [TECHNICIAN #1] did not had off checks to anyone..."

-At approximately 11 AM on 11/29/2023 observations were conducted on the Adult Psychiatric Inpatient Unit (C4) which revealed the following:

Surveyor observed RN #1 talking with TECHNICIAN #1 who was holding paperwork to do 15-minute safety checks.

RN #1 then returned to the nursing station and stated, "[TECHNICIAN #1] is not doing [his/her] 15-minute checks today."

Surveyor observed staff doing 15-minute checks for the next hour. At the end of the hour, Surveyor asked TECHNICIAN #1 if 15-minute checks were missed on his/her current shift.

TECHNICIAN #1 confirmed 15-minute checks had been missed from 10am to 11am on 11/29/2023.

-At 9:34 AM on 11/29/2023 an interview was conducted with TECHNICIAN #3 which revealed the following information:

At 9:35 AM on 11/29/2023 TECHNICIAN #3 made the following statement, "Some of the 15-minute checks are being falsified because there is no way that you can do all of the checks and all of the patient care."

Based on document reviews, observations and interviews, St. Mary's Regional Medical Center failed to ensure that Registered Nurses ("RN") performed hand hygiene prior to medication administration and/or following patient contact during four (4) out of five (5) observed medication passes. ( #1, #2, #3, #4).

Findings:

St. Mary's Regional Medical Center policy titled, "Medication Administration," last revised 08/2023 states in part:

"...Hand hygiene is performed before handling medications..."

St. Mary's Regional Medical Center policy titled, "Hand Hygiene," last revised 09/2023 states in part:

"...Clean hands before and after routine patient care activities, including entering and exiting the patient care environment and after hand-contaminating activities. Clean hands before handling medication or preparing food..."

And

"...Hand hygiene indications include:
1. Before touching a patient
2. Before clean/aseptic procedure
3. After body fluid exposure
4. After touching a patient
5. After touching the patient's surroundings (patient care area)..."

St. Mary's Regional Medical Center policy titled, "Standard Precautions, 1016 (was 13.01)," last revised 03/2022 states in part:

"...Gloves:

a. Wear gloves when touching blood, body fluids, secretions or excretions and contaminated items. Clean gloves are donned before touching mucous membranes and non-intact skin. Change gloves during patient care if the hands will move from a contaminated body site (e.g., perineal area) to a clean body site (e.g., face).

b. Remove gloves after contact with a patient and/or surrounding environment (including medical equipment), using proper technique to prevent hand contamination.

c. Do hand hygiene immediately after removal of gloves to avoid transfer of microorganisms to other patients or environments. Note that gloves are an adjunct, not a substitute, for hand hygiene. Utility gloves are disinfected for re-use if the integrity is not compromised...."

At approximately 9:06 AM on 11/29/2023, during observation of medication pass #1, RN #2 failed to wash or sanitize his/her hands prior to medication administration. RN #2 failed to wash or sanitize his/her hands following medication administration.

At approximately 9:10 AM on 11/29/2023, during observation of medication pass #2, RN #3 failed to wash or sanitize his/her hands prior to medication administration.

At approximately 9:10 AM on 11/29/2023, following the observation of medication pass #3, RN #3 assisted the patient with getting dressed. RN #3 failed to wash or sanitize his/her hands following patient contact.

At approximately 9:30 AM on 11/29/2023, during observation of medication pass #4, RN #4 failed to wash or sanitize his/her hands prior to medication administration. Surveyors observed that the patient had removed their own intravenous catheter (IV), and the IV was on the floor. RN #4 was observed to have picked up the IV catheter and dressing off of the floor without gloves. RN #4 failed to perform hand hygiene after picking up the IV catheter and dressing with his/her bare hands and proceeded to administer medications.