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Based on observations and interview, the hospital failed to ensure that patients received care in a safe setting. This deficient practice was evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients on the hospital's Acute Care Psychiatric Units "A" and "B". There were currently 64 patients receiving treatment at the time of the observations.

Findings:

On 10/09/17 at 9:35 a.m., the following observations were made on the hospital's Acute Care Psychiatric Unit "B":

a. Patient room entry doors (Rooms "a", "b", "c", "d", "e", "f", "g", "h", "i", "j", "k", "l", "m", "n", "o", "p", "q", "r", and "s") with 3 hinges separated widely enough to facilitate potential ligature risk.

b. Non-tamper resistant screws in the window frames and door faceplates in all patient rooms. S2DON indicated all patient window frames and door hardware would be the same in all patient rooms.

c. The seclusion room entry door and the seclusion room bathroom had doors with 3 hinges separated widely enough to facilitate potential ligature risk.


On 10/09/17 at 9:45 a.m. the following observations were made on the hospital's Acute Care Psychiatric Unit "A":

a.The seclusion room entry door, the bathroom door, and both rooms off of the vestibule of the seclusion room had doors with 3 hinges separated widely enough to facilitate potential ligature risk. Further observation revealed the window frames and door hardware had non-tamper resistant screws. S2DON confirmed all patient room window frames also had the same hardware. Two patients (Patient #1 and Patient #R10 - both with ordered every 15 minute observation checks) were in the seclusion rooms, unattended by staff, during the observation. S2DON reported Patient #1 and Patient #R10 were not in ordered seclusion. He said they were in the rooms for quiet time. S2DON reported there were cameras in the seclusion room. S2DON confirmed there was no staff member assigned to continuously monitor the feed from the cameras in the seclusion room to monitor patients, such as Patient #1 and Patient #R10, who were there for quiet time and not on ordered seclusion (patients on ordered seclusion would have staff present observing them).

In an interview on 10/09/17 at 9:50 a.m., with S2DON, he confirmed, during the observations, that the above environmental findings presented safety risks for the patients in the hospital.

Based on record review, observation, and interview, the hospital failed to ensure that the registered nurse (RN) supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failure of the RN to ensure the MHTs were documenting patient observation checks every 15 minutes, as ordered, for 7 (Patient #2, #R1, #R2, #R3, #R4, #R5, #R6) of 7 patients (assigned to S4MHT) that were reviewed for documentation of staff supervision out of a total of 3 (#1, #2, #5) current sampled patients and 10 (#R1- #R10) current random sampled patients.

Findings:

Review of the hospital policy titled,"Patient Observation", policy number PC-032, revealed in part:
Purpose: This policy is to ensure staff has guidelines for the monitoring of psychiatric patients via staff observation due to their mental or physical conditions.
Scope: This policy applies to all of the nursing staff of this hospital.
Responsibility: It is the responsibility of the Nursing Director and/or designee to implement this policy and procedure and to disseminate this information to employees under their direction.
Policy: It is the policy of this hospital to observe patients for safety based on initial and reassessment of their health and behavioral conditions.
Definitions: 1. Standard Observation: Visual contact is made between staff member and patient at least every 15 minutes.
Procedure: 1. All patients admitted to the hospital are automatically placed on standard observation (q 15 minute checks), unless deemed necessary for a higher level of precaution by the admitting physician or charge nurse.

Patient #2
Review of Patient #2's medical record revealed an admission date of 10/7/17 with an admission diagnosis of Major Depressive Disorder. Further review revealed the patient's legal status was PEC due to being a potential danger to self and being unable to seek voluntary admission. Additional review revealed the patient had MD orders, dated 10/7/17, for suicide precautions. The orders included an instruction to check the patient every 15 minutes.

Patient #R1
Review of Patient #R1's medical record revealed an admission date of 10/4/17 with an admission diagnosis of Schizoaffective Disorder, Bipolar Type. Further review revealed the patient's legal status was CEC due to being a potential danger to self or others, altered mood, substance abuse, and being unable to seek voluntary admission. Additional review revealed the patient had MD orders, dated 10/4/17, for suicide precautions. The orders included an instruction to check the patient every 15 minutes and to keep the patient's bedroom door open.

Patient #R2
Review of Patient #R2's medical record revealed an admission date of 10/6/17 with an admission diagnosis of Major Depressive Disorder recurrent, moderate. Further review revealed the patient's legal status was PEC due to being a potential danger to self or others, altered mood, and being unable to seek voluntary admission. Additional review revealed the patient had MD orders, dated 10/6/17, for suicide precautions. The orders included an instruction to check the patient every 15 minutes and to keep the patient's bedroom door open.

Patient #R3
Review of Patient #R3's medical record revealed an admission date of 10/7/17 with an admission diagnosis of Bipolar Disorder. Further review revealed the patient's legal status was PEC due to being a potential danger to self. Additional review revealed the patient had MD orders, dated 10/7/17, for suicide precautions. The orders included an instruction to check the patient every 15 minutes.

Patient #R4
Review of Patient #R4's medical record revealed an admission date of 10/5/17 with an admission diagnosis of Major Depressive Disorder, recurrent, moderate. Further review revealed the patient's legal status was Formal Voluntary Admission due to being a potential danger to self and altered mood. Additional review revealed the patient had MD orders, dated 10/5/17, for suicide precautions. The orders included an instruction to check the patient every 15 minutes.

Patient #R5
Review of Patient #R5's medical record revealed an admission date of 10/9/17 with an admission diagnosis of Opiod Abuse. Further review revealed the patient's legal status was PEC due to being a potential danger to self, altered mood, and substance abuse. Additional review revealed the patient had MD orders, dated 10/9/17, for suicide precautions. The orders included an instruction to check the patient every 15 minutes.

Patient #R6
Review of Patient #R6's medical record revealed an admission date of 10/4/17 with an admission diagnosis of Alcohol Abuse. Further review revealed the patient's legal status was CEC due to being a potential danger to self and substance abuse. Additional review revealed the patient had MD orders, dated 10/4/17, for suicide precautions. The orders included an instruction to check the patient every 15 minutes.

On 10/9/17 at 9:35 a.m. an observation was made of the hospital's Acute Care Psychiatric Unit "B". The observation checklist sheets for Patient #2, Patient #R1, Patient #R2, Patient #R3, Patient #R4, Patient #R5, and Patient #R6 were collected for review at 9:35 a.m. The observation checklist sheets were used by the hospital staff to document observation of patients' location, activities, and behaviors in 15 minute intervals around the clock. All of the above referenced patients were on q (every) 15 minute observation checks. Review of the referenced patients' every 15 minute observation checklists revealed no entries had been documented on any of the observation sheets since 7:30 a.m. (a total of 2 hours and 5 minutes with no documented entries).

In an interview on 10/9/17 at 1:11 p.m. with S2DON, he confirmed Patients #2, #R1, #R2, #R3, #R4, #R5, and #R6's observation checklist sheets had not been completed every 15 minutes, as ordered, for 2 hours and 5 minutes on 10/9/17. He also confirmed the patient observation documentation should have been up to date and completed in real time at the time they were collected for review on 10/9/17 at 9:35 a.m. S2DON indicated S4MHT had been assigned the above referenced patients on the day shift of 10/9/17. S2DON also indicated it was the unit nurses' responsibility to review the MHTs' patient observation checklists every 3 hours and to sign off on them after verifying accuracy.

In an interview on 10/10/17 at 9:21 a.m. with S1Adm, he indicated he had reviewed the video footage of Acute Care Psychiatric Unit "B" on 10/9/17 from 7:30 a.m. - 9:30 a.m. S1Adm indicated he had seen S4MHT going outside for a smoke break and when she returned she had been observed interacting with the patients, but had failed to document her assigned patients' q 15 minute checks as ordered.

In an interview on 10/10/17 at 9:11 a.m. with S4MHT, she indicated she had been educated on documenting observations in real time and ensuring observations were conducted q 15 minutes as ordered. She confirmed the hospital policy was to hand off patient assignments to another tech or to a nurse if they were doing another task or went on break. S4MHT reported when she had taken her smoke break on 10/9/17 she had forgotten to take her "q's" (observation sheets). S4MHT indicated S1Adm had talked to her on 10/9/17 about her failure to document her q 15 minute observations on her assigned patients.

In an interview on 10/10/17 at 2:05 p.m. with S5RN, he indicated any RN could check the patient observation sheets to ensure they were accurately documented. He said the nurses checked the MHTs' patient observation sheets for accuracy every 2 hours. S5RN confirmed the MHTs were to "hand off" their assigned patients if they were performing other tasks or leaving the unit for lunch/breaks. He confirmed the staff members who had patients "handed off" to them were responsible for observing/documenting on the patients.