The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

BAPTIST MEDICAL CENTER SOUTH 2105 EAST SOUTH BOULEVARD MONTGOMERY, AL 36116 Jan. 24, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of facility policies, medical records, Station Census, Emergency Medical Service (EMS) Patient Care reports, emergency room medical records, video footage, and interviews with facility staff, it was determined the facility failed to ensure it was in compliance with 482.13, Patient Rights

The facility failed to ensure:

1. The staff followed the hospital policy for Search, Seizure and Disposition of Drugs, Weapons, and Potentially harmful substances and Patient Belongings. This deficient practice affected Patient Identifier (PI) # 1 and had the potential to negatively affect all patients admitted to the facility.

2. The ordered Q (every) 15 minute checks were completed on the night shift (11 PM to 7 AM). This deficient practice affected 4 of 4 patients, Patient Identifier (PI) #s 1, 2, 3 and 4 and had the potential to negatively affect all patients admitted to the facility

Findings include:

Refer to 482.13(c)(2) (A144) for findings.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policies, medical records, Station Census, Emergency Medical Service (EMS) run reports, emergency room medical records, video footage and interviews with facility staff, it was determined:

1. The staff failed to follow the hospital policy for Search, Seizure and Disposition of Drugs, Weapons, and Potentially harmful substances and Patient Belongings. This deficient practice affected Patient Identifier (PI) # 1 and had the potential to negatively affect all patients admitted to the facility.

2. Q (every) 15 minutes checks were not completed on the night shift (11 PM to 7 AM), as evidence by video review, but, were documented as having been completed by Employee Identifier (EI) #'s 1 and 2. This deficient practice affected 4 of 4 patients; Patient Identifier (PI) #s 1, 2, 3 and 4 and had the potential to negatively affect all patients admitted to the facility

Findings include:

A. Policy/Procedure

Title: Nursing Admission Procedures
Policy No.: CS.009
Date Issued: 5/2010
Date Reviewed/Revised: 5/2010, 5/2012

Procedure:

... A Mental Health Technician and a witness will be responsible for the patient's physical search, obtaining Vital Signs, height and weight as well as the completion of Valuable/Belongings list upon entry to the unit...

Procedure:

A. Assessment
1. The RN is responsible for overseeing the admission of all patients to Crossbridge Behavioral Health. This includes orientation to the program and Unit, preparation of environment, checking of personal belongings brought onto the unit, and makes room assignments...

3. When a patient arrives on the unit, he/she will be met by the assigned staff member who introduces self and a safety check is done immediately after arrival on the unit.

4. The following occurs:
... c) Upon explaining the unit's safety policy, the assigned staff member checks the patient's belongings in his/her presence for restricted items and does not allow patient to keep such items. All personal belongings are indicated on the Patient's Possession List...

... 7. The assigned staff member explains to the patient the necessity for checking belongings, and determines if the patient is able to be responsible for personal property, an itemized list is developed and placed with the belongings in a secure area on the unit, is sent home with family members, or is locked in the hospital safe...

B. Policy/ Procedure

Title: Search, Seizure, and Disposition of Drugs, Weapons, and Potentially harmful substances

Policy No: RM.004

Date Issued: 05/2010

Date Reviewed/Revised: 3/2012

Purpose: To provide a safe, therapeutic milieu for all patients and a safe environment for the staff and others.

Policy:
Nursing personnel have the responsibility for maintaining a safe and therapeutic milieu for patients, visitors and staff members. When there is a reasonable cause to suspect that a chemical substance, weapon, or harmful object is present on the unit, nursing personnel on duty evaluate the situation and take necessary measures to remove those objects which compromise the health and safety of the patient or those in contact with the patient. An internal body search is done only by a physician.

Procedure:

1. Admission
a. All newly admitted patients will be searched for contraband immediately upon arrival on the unit, even if the remainder of the admission process is going to be delayed...

... c. Patients will be searched by two staff members. The charge nurse may request Security's assistance in accomplishing the search, if the patient is resistant/aggressive, etc. The search must be done regardless of the patient's resistance/refusal.

d. The patient is given a gown and asked to remove his/her clothing. Both male and female patients are asked to stand with their feet approximately two feet apart in case contraband has been hidden in the perineal area.

e. All clothing must be checked before returning to the patient, pockets should be turned inside out... Shoestrings and belts are removed and stored per Crossbridge Behavioral Health policy.

f. The charge nurse and or the admitting RN (Registered Nurse) are apprised of any contraband found on the patient...

4. Nursing staff is responsible for informing patients on admission about items that are not allowed to be kept with patients. These are, but not limited to:

....shoe laces... belts...

C. Policy/ Procedure

Suicidal Patient, Care of
Policy No: RM.002
Issue date 5/10
Revision dates: 5/12, 11/13

Purpose: To provide guidelines to ensure the suicidal patient's safety and treatment.

Procedure:

1. The RN will complete the Suicide Risk Assessment as part of the Nursing Assessment, on the patient at admission and level noted (see overall risk)...

Levels of Risk/Interventions Required

Low Risk

Q 15 minute Flowsheet check list...

Moderate Risk

10 minute Flowsheet check list...

High Risk

... LOS (line of sight) or 1:1 observation (document on Q 10 minute Flowsheet Check list)...

D. Policy/ Procedure

Title: Nursing Rounds
Policy No: RM.011
Date Issued: 05/2010
Date Reviewed/Revised: 3/2012

Purpose: To ensure a safe environment

Rounds are made every fifteen (15) minutes...

... Rounds are completed by assigned staff.

Procedures:

A. The designated staff member writes each patient's name on the Rounds Sheet so it is prepared in time for appropriate rounds and dates the Rounds Sheet.

B. The Charge Nurse designates the staff member(s) responsible for each set of rounds.

C. The assigned staff member(s) personally locates each patient listed visually and documents the patient's location on the Rounds Sheet under the appropriate time column. The staff member places his/her initials by the appropriate time patient visualized.

D. While making rounds, the staff member observes the environment for unsafe conditions.

E. ... environmental problems are reviewed and reported to the Charge Nurse immediately.

F. Once patients are prepared for bed time, the doors of their rooms are left open at least 12 inches, without hindering the patient's privacy.

G. The staff member must enter the room to observe the condition of the patient visually.

A review of the Station Census dated 01/16/14 at 06:17 (6:17 AM) revealed there were two patients assigned to room 214, (PI # 1 and # 2) and two patients assigned to room 213, (PI # 3 and # 4).

1. Patient Identifier (PI) # 1 was voluntarily admitted on [DATE] with diagnoses including Accidental overdose of Alcohol and sedatives to Crossbridge Behavioral Health, the Prospective Payment System (PPS) unit, which is located off of the main hospital campus. PI # 1 was assigned to room 214. A review of the Patient's Possession List dated 1/16/14 at 2:00 AM revealed Employee Identifier (EI) # 1, Mental Health Technician (MHT) # 1 documented the patient had a pair of Zebra print pajama pants.

PI # 1 was assessed by a Registered Nurse (RN) on 1/16/14 at 3:20 AM. The RN's assessment documented PI # 1's mood was depressed with feelings of guilt. PI #1's concentration was normal with some generalized anxiety and no signs of homicidal ideations were identified. PI #1's suicide risk factors were identified as alcohol and drug use and abuse and PI # 1 stated no plan to harm herself/himself. A review of the Inpatient Suicide Risk Assessment completed by the RN on 1/16/14 at 3:20 AM (part of the admission assessment) documented, "(1) Did the patient attempt suicide within 48 hours prior to Crossbridge admission? Yes, per nurse; No, per patient." The RN intake assessment identified PI # 1 , using the SADPERSONS Scale scoring system, as low risk with every 15 minute checks to be performed.

A second RN assessed PI # 1 on 1/16/14 at 8:00 AM and documented PI # 1 had no suicidal or homicidal ideations, no auditory or visual hallucinations and her/his behaviors as appropriate, agitated and isolative.

The Licensed Professional Counselor (LPC) assessed PI # 1 on 1/16/14 at 8:40 AM and documented PI # 1 was currently having depression, anxiety and poor impulse control. The LPC documented PI # 1 denied auditory, visual, command, tactile olfactory hallucinations, delusions and paranoid ideations. The LPC commented PI # 1 had a history of depression.

The physician assessed PI # 1 on 1/16/14 at 10:25 AM and documented PI # 1 was alert, calm, relaxed, comfortable, coherent, with normal eye contact. The physician also documented PI # 1's speech was at a normal rate, volume, coherent, and goal-directed. The physician documented PI # 1's mood as, "fine ...needs to go home and take care of (his/her) family." During the physician assessment it was documented PI # 1's affect showed a full range of emotion, including consternation and humor with no psychotic material or evidence of syndromal mood disorder. The physician documented PI # 1 had an episodic abuse of alcohol and sedatives and she/he requested to be discharged .

The plan of care for PI # 1 was to discharge home.

The Interdisciplinary Progress Notes dated 1/16/14 at 12:30 PM revealed documentation the Social Worker was notified PI # 1's mother was aware of the discharge and the mother had petitioned the court for inpatient commitment. The physician was aware of the petition according to the documentation in the medical record.

A review of the Legal Status Form revealed PI # 1's admission status was changed from voluntary to involuntary on 1/16/14 at 12:00 PM and PI # 1 was notified of the legal status change at that time.

PI # 1 was found by a facility staff member on 1/16/14 at 2:33 PM in the shower with a pink ribbon tied around his/her neck and hanging from the shower head. Cardiopulmonary Resuscitation (CPR) and emergency transport to the Emergency Department at Baptist Medical Center South was completed. After arrival at Baptist Medical Center South PI # 1 was coded per ACLS (Advanced cardiac life support) protocol two times. At 7:17 PM on 1/16/14, PI # 1 expired.

On 1/22/14 at 8:00 AM, the surveyor reviewed video footage in the presence of Employee Identifier (EI) # 13, Director/Treatment Manager, which revealed the following events concerning PI # 1 on 1/16/14:

At 2:09:49 AM (2:09 AM and 49 seconds) - the patient entered an exam room with the Employee Identifier (EI) # 1, Mental Health Technician (MHT) # 1 and at 2:10:14 AM (2:10 AM and 14 seconds), EI # 2, MHT # 2 entered the same exam room, which was 15 seconds after EI # 1 and the patient entered the exam room. PI # 1 was wearing a pair of zebra striped pants, hospital gown with a blanket wrapped around the shoulders. At 2:18:33 AM (2:18 AM and 33 seconds), EI # 1, PI # 1 and EI # 2 exited the exam room. PI # 1 was wearing a pair of zebra print pants, hospital gown with a blanket wrapped around the shoulders.

A review of the Physician's Orders dated 1/16/14 at 3:00 AM revealed the patient's admitting diagnosis was documented as Suicidal Ideations and there were physician orders for observations to be completed every 15 minutes.

A review of the 15 Minute Check Sheet, that was undated, revealed 15 minute checks were documented as having been completed every 15 minutes by Employee Identifier (EI) # 1, Mental Health Technician (MHT) # 1 and EI # 2, MHT #2 from 2:00 AM to 7:15 AM (This document's time ended at 7:15 AM). A review of the 15 Minute Check Sheet dated 1/16/14 to 1/17/14 revealed 15 minute checks were documented as having been completed every 15 minutes by EI # 1 from 7:30 AM to 8:00 AM. (This document's time began at 7:30 AM).

Review of the video footage dated 1/16/15 of PI # 1 revealed the following discrepancies involving the above documented Q 15 minute safety checks:

At 4:01 AM, both EI #s 1 and 2 walked to room 214, EI # 1 peered into room, then walked back down the hallway out of view of the video camera.

At 6:15 AM, EI # 2 entered room 214 with a rolling blood pressure machine and exited the room at 6:20 AM and closed the door to the point at which a person is unable to see into the room. According to the video footage, this was 2 hours and 14 minutes since the last time (4:01 AM) someone went to room 214.

At 7:16 AM, EI # 1 opened the door to room 214, peered into the room, then closed the door to the point at which a person is unable to see into the room and continued to walk down the hallway to the next room. According to the video footage, this was 49 minutes since the last time (6:15 AM) someone went to room 214.

At 8:05 AM, EI # 11, MHT # 3 entered room 214 and exited at 8:07:08 AM, walked down the hallway out of view of the video camera. At 8:07:49 AM, EI # 11, MHT # 3 returned to room 214 with a hospital gown and exited the room at 8:07:57 AM. At 8:11 AM, PI # 1 exited room 214 wearing zebra striped pants and 2 hospital gowns and walked down the hallway out of view of the video camera. According to the video footage, this was 51 minutes since the last time (7:16 AM) someone went to room 214.

Review of the video footage dated 1/16/14 of PI # 1 revealed the following:

From 8:13 AM to 9:09 AM, PI # 1 was in the dining room, interacting with facility staff members and other patients. From 9:10 AM to 10:19 AM, PI # 1 was sitting on the floor or the chair outside of the Nurses Station, interacting with multiple staff members and other patients. From 10: 25 AM to 10:38 AM, PI # 1 was at the Nurses Station area, interacting with multiple staff members.

Review of the Physician's Orders dated 1/16/14 at 10:24 AM revealed orders for the patient to be discharged on [DATE], the same day PI # 1 was admitted .

Review of the video footage dated 1/16/14 of PI # 1 revealed the following:

From 10:38 AM to 10:46 AM, PI # 1 was in room 214. From 10:46 AM to 11:08 AM, PI # 1 was with EI # 11, MHT. PI # 1 and EI # 11 gathered the patient's clothes from the Personal Property room and returned to room 214.

From 11:10 AM to 11:57 AM, PI # 1 was in the Dayroom, interacting with other patients and the MHTs. From 11:52 AM, PI # 1 was in the Dining Room, sitting at a table with two other patients and the MHTs. At 11:57 AM, EI # 5, Court Liaison, entered, spoke with the patient, then both PI # 1 and EI # 5 exited the Dining room and entered the Dayroom at 11:58 AM.

From 12:00 PM to 12:10 PM, PI # 1 was in the Dining Room, interacting with other patients and facility staff.

Review of the Petition for Involuntary Commitment dated 1/16/14 revealed the patient's admission status was changed from voluntary to involuntary due to, "1 ... has been treated in the past for personality disorder and may have further mental issues ... is presently at Crossbridge for what is believed to be an overdose. 2 ... broke into the petitioner's medicines and took them... alternates between passing out and acting out. 3 ... is self mutilating, and is making threats against (his/her) mother and to (his/her) self..."

Review of the video footage dated 1/16/14 of PI # 1 revealed the following:

From 12:12 PM to 2:06 PM, PI # 1 sat in a chair or stood in the hallway at the Nurses Station, multiple patients and staff members interacted with the patient.

At 2:06 PM, PI # 1 was standing in the doorway entrance to the Nurses Station with EI # 10, MHT # 4. PI # 1 was talking on the telephone. At 2:09 PM, PI # 1 lifted the end of the blue shirt and touched the strings/ribbons that were attached to the zebra striped pants. PI # 1 touched the strings multiple times during the telephone conversation, then placed the blue shirt back over the top of the zebra striped pants in the presence of EI # 10, MHT # 4. After the telephone conversation ended, PI # 1 walked away from the Nurses Station and down the hallway out of view of the video footage.

At 2:10 PM, PI # 1 entered room 214 wearing the blue long sleeved shirt and zebra striped pants. At 2:16 PM, EI # 11 looked into room 214, but, did not enter, then walked down the hallway out of view of the video footage. The door to room 214 was opened at that time and a person could easily see into the room. At 2:23 PM, EI # 11 closed the door to room 214 to the point at which a person is unable to see into the room, then walked down the hallway out of view of the video footage. After EI # 11 walked away the door opened of it's own accord.

At 2:33:52 PM, EI # 3, Housekeeping staff member entered room 214. At 2:34:05 PM, EI # 3 ran out of room 214 to the Nurses Station. Multiple staff members, including physicians followed EI # 3 to room 214 and entered. At 2:35 PM, a staff member entered the room with the emergency cart. This was 10 minutes after EI # 11 closed the door to room 214.

At 2:43 PM, six Fire Department (FD) personnel entered the room. At 2:49 PM, a Emergency Medical Services (EMS) staff member entered the room, a stretcher was located in the hallway. At 2:49 PM a blue back board was given to someone in room 214, then the second EMS staff member entered the room. At 2:51 PM, PI # 1 was carried out of room 214 on the back board and placed on the stretcher and MFD personnel resumed chest compressions. At 2:52 PM, EMS wheeled PI # 1 down the hallway out of view of the video camera.

Review of the EMS Patient Care Report dated 1/16/14 revealed EMS arrived at the patient's side at 2:46 PM. Review of the EMS Patient Care Report dated 1/16/14 revealed, "... Health care staff at Crossbridge stated last time anyone saw pt (patient) was approximately 30 minutes earlier. Staff state pt was discovered hanging by neck from shower head with pink nylon ribbon. Staff pulled pt down to floor and started CPR (cardiopulmonary resuscitation). Upon our arrival MFD (Montgomery Fire Department) were performing CPR and had establish OPA (oropharyngeal airway) with BVM (Bag-valve-mask) and Oxygen to ventilated pt. Pt was unresponsive. Pt's airway remained patent, breath sounds were absent except with ventilation, circulation was absent... Pt remained unresponsive, CPR was performed continuously during transport to Baptist South - ER (emergency room ). One attempt to intubate by MFD was performed but pt's tongue ring interfered. Pt was ventilated with OPA and BVM with Oxygen..." Further review of the EMS Patient Care Report dated 1/16/14 revealed the patient arrived at the Emergency Department (ED) at 2:55 PM.

PI # 1 was transported to the ED located at the main campus. Review of PI # 1's ED medical record revealed the Code Blue Flowsheet dated 1/16/14 documented the following:

3:00 PM - heart rhythm was documented as PEA (pulseless electrical activity)

3:02 PM - heart rhythm continued as PEA, one ampoule of Epinephrine was administered at that time and at 3:04 PM the patient's heart rhythm was sinus tach (tachycardia - rapid heartbeat).

A second Code Blue was performed in the ED on PI # 1. Review of the Code Blue Flowsheet dated 1/16/14 revealed the following:

7:05 PM - heart rhythm - sinus bradycardia (slow heart rate) at 30 beats per minute, 1 ampoule of Epinephrine was administered at that time.

7:07 PM - heart rhythm - ventricular fibrillation (very rapid, uncoordinated, ineffective series of contractions throughout the lower chambers of the heart), 1 ampoule of Sodium Bicarbonate was administered at that time.

7:10 PM - heart rhythm - PEA, 1 ampoule Calcium Chloride was administered

7:11 PM - hearth rhythm - PEA, 2 grams Magnesium and 1 ampoule Epinephrine were administered

7:13 PM - heart rhythm - none

Review of the emergency room Report dated 1/16/14 at 7:36 PM revealed, "... Pronounced dead per nursing notes... Impression and Plan: Cardiopulmonary Arrest, patient expired..." This document was signed and dated by two physicians on 1/16/14.

On 1/22/14 at 8:00 AM, the surveyor reviewed video footage in the presence of Employee Identifier (EI) # 13, Director/Treatment Manager, who verified the above concerning the safety checks not completed every 15 minutes, even though the MHTs documented having completed them. EI # 13 stated that EI # 10, MHT # 4 had been interviewed and EI # 10 stated that she had an opportunity to remove the strings from PI # 1's pants, but, got busy and forgot. An interview was conducted on 1/23/14 at 8:10 AM with EI # 13, who stated EI # 1 and 2, MHT were placed on administrative leave and not on rotation to work.

An interview was conducted on 1/22/14 at 2:15 PM with Employee Identifier (EI) # 10, MHT # 4. The surveyor asked EI # 10 about her interaction with PI # 1. EI # 10 stated she did not have PI # 1 as a patient that morning, but, that after lunch PI # 1 wanted to make a phone call and it was not phone time. EI # 10 stated that she stood there with PI # 1 during the phone conversation. PI # 1 was telling the person on the phone visitation time and to bring clothes. EI # 10 stated she told PI # 1 to tell the person on the phone not to bring clothes with strings. EI # 10 stated that PI # 1 held up shirt and PI # 1 had a string on pajama pants. EI # 10 stated that she got busy with another patient and failed to obtain the string from PI # 1 or to inform the nurse about the string on the patient's pajama pants.

The surveyor asked EI # 10 who was responsible for checking patients for contraband (items not allowed). EI # 10 replied, "All of us".

An interview was conducted on 1/22/14 at 3:19 PM with EI # 11 (MHT # 3). EI # 11 verified she was assigned to PI # 1 on 1/16/14. EI # 11 stated that PI # 1 had seen the physician and that she was to be discharged on [DATE]. EI # 11 verified she retrieved the patient's personal belongings from the Personal Belongings room. Then PI # 1 and EI # 11 went to room 214 (patient's room) and the patient got a shower. EI # 11 stated after lunch she was making rounds and around 2:12 PM - 2:15 PM she looked into PI # 1's room and the patient's roommate (PI # 2) was in bed asleep and PI # 1 was standing in the far corner of the room. EI # 11 stated there were a lot of people in the hallway and she looked back in the room (PI # 2) in bed asleep, but did not see PI # 1. EI # 11 made no attempt to visualize PI # 1 at that time. EI # 11 stated she closed the door because of the noise in the hallway.

An interview was conducted on 1/23/14 at 7:35 AM with EI # 1 (MHT # 1), who stated that she checked PI # 1 into the facility. EI # 1 verified EI # 2 (MHT # 2) was present in the room when PI # 1 was admitted and checked for contraband (items not allowed on the unit). EI # 1 stated PI # 1 had on a pair of zebra striped pajama pants and hospital gowns at admission. EI # 1 stated she had lifted the hospital gowns up. EI # 1 verified that MHTs are responsible for checking the patient's for contraband. EI # 1 stated she told PI # 1 that he/she would have to remove the pants or take the string out. EI # 1 stated that normally one MHT checks the patient's vital signs and the other MHT removes items not allowed. EI # 1 stated that she assumed the EI # 2 (MHT # 2) was going to remove the string.

EI # 1 verified the following procedures for patient safety checks: Every patient has to be checked every 15 minutes, some patients are checked every 10 minutes - if staff feel the patient is a threat to themselves, some patients are line of sight (meaning patient has to be within your line of sight at all times) and some are one to one (arm length away from the staff member).

An interview was conducted on 1/23/14 at 8:34 AM with EI # 2 (MHT # 2). EI # 2 verified she was on the hall when PI # 1 was admitted . EI # 2 stated that when she entered the exam room, EI # 1 had almost completed checking PI # 1, but denied having checked the patient for contraband. EI # 2 stated that when she entered the only thing she saw that the patient was wearing was a hospital gown. EI # 2 denied recalling that PI # 1 was wearing pajama pants. EI # 2 stated usually there are two people in the exam room for safety reasons and that one person (MHT) does the searching for items not allowed on the unit.

The surveyor asked EI # 2 what was the procedure for safety checks and EI # 2 stated that safety checks were done every 15 minutes. The surveyor asked if there were times when safety checks were done more frequently. EI # 2 replied, "No, usually every 15 minutes."

Following the incident with PI # 1, the following measures were put in place to protect the health and safety of the patients in the unit:

1. On 1/23/14, Employee Identifier (EI) # 1, Mental Health Technician (MHT) and EI # 2, MHT were placed on administrative leave pending the completion of the facility's investigation of the events in which the Q 15 minutes checks were not completed during the night shift (11 PM to 7 AM). EI #'s 1 and 2 had also completed the initial search of PI # 1 for items/belongings that might pose a hazard to the patient or other patients and failed to remove the pink ribbon from PI # 1's pants that PI # 1 used to harm his/herself.

2. On 1/16/14, a thorough recheck of every patient's belongings to ensure there were no other items that could potentially cause harm to patients or others was performed.

3. The search Policy and Procedure (Policy No. RM.004) was updated to include:
"... e. All property including the clothing the patient is wearing must be checked ... Shoestrings, belts and any other items not allowed are to be removed and stored in the property room in a paper bag labeled DO NOT USE or sent home with permission from the patient.
f. "Items Not Allowed" form is to be filled out by the staff member completing the search.
g. The admitting RN (Registered Nurse) is to recheck the property and sign the "Items Not Allowed" form.
h. Any items brought to the patient after they are admitted will be checked in using the process outlined in "e" above. A new "PROPERTY SHEET" and "ITEMS NOT ALLOWED" sheet should be completed, signed by the admitting Tech and RN and placed in the chart..."

4. Beginning 1/17/14, all staff were to review and study the revised Search Policy and Procedure, which included the implementation of a new checklist for "Items Not Allowed".

5. Management Team would review every admission for the "Items Not Allowed" forms through March 2104 with a review of 5 new admissions per week through June 2014.

6. Reeducation on the importance of timely rounding and Environment of Safety rounds. Review of the Agenda for the mandatory meetings included:
"I. Check in...
II. Personal Accountability,
III. Safety reminders: a. Environment of Care rounds for patient safety, b. 15 minute rounding... c. Property and Searches and new "Items Not Allowed Form",
IV. Video Surveillance Random Audits and
V. Summary and Next Steps".

7. Addendum 1/23/14 for Q (every) 15 minutes check not being completed revealed a detailed written instruction tool to be developed for staff, which will outline specifically how/when the rounds are to be completed and also outline the assignment of duties by Charge Nurse. A review of the Q 15 minute Check Sheet Instruction Form revealed this was a detailed instruction sheet, including, "... (7) Observations cannot be completed from the Nurses Station or "down the hall". During waking hours you must observe each patient from arms length even during "nap" times. During night hours, while patients are asleep, doors should be left open 12 inches. Flashlights may be used to observe patients... (8) Flow sheets must be completed. Location codes and activity must be documented every 15 minutes. ANY change in behavior must be reported to the RN. These behaviors include but are not limited to: excessive time in the room, pacing or walking, isolating, crying/tearful..."

8. The Q 15 Minute flow sheet is to be reevaluated and revised to include a column to address behaviors, as well as every 2 hour safety checks to be completed by the RN. Compliance with the Q 15 minute rounds policy will be monitored by the Director on a weekly basis for each shift for each of the three units, for three months, then monthly thereafter.

Based on the nursing assessments, Licensed Professional Counselor assessment, physician assessment, review of the security video footage and staff interviews, there was no information or indication to show PI # 1 would harm himself/herself. The hospital took immediate action to put measures in place to protect other patients in the unit. Survey staff conducted patient safety inspections with hospital staff, reviewed inservice training records, the revised policy and observed patient care. There was no immediate threat to patient safety identified during the survey.

2. PI # 2 was admitted to the facility on [DATE] with Depressive disorder with suicidal risk and assigned to room 214. Review of the 15 Minute Check Sheet dated 1/15/14 to 1/16/14 revealed 15 minute checks were documented as having been completed every 15 minutes by EI #s 1 and 2 from 4:00 AM to 7:15 AM (This document's time ended at 0715). Review of the 15 Minute Check Sheet dated 1/16/14 to 1/17/14 revealed 15 minute checks were documented as having been completed every 15 minutes by EI # 1 from 7:30 AM to 8:00 AM (This document's time began at 730 AM).

EI # 1 and # 2 had shared responsibilities for the completion of every 15 minute patient safety checks.

Review of security video footage:

On 1/22/14 at 8:00 AM, the surveyor reviewed video footage in the presence of Employee Identifier (EI) # 13, Director/Treatment Manager, which revealed the following:

At 4:01:47 AM, EI #s 1 and 2 walked to room 214, EI # 1 peered into room, then walked back down the hallway out of view of the video camera.

At 6:15 AM, EI # 2 entered room 214 with a rolling blood pressure machine and exited the room at 6:20 AM and closed the door to the point at which a person is unable to see into the room. According to the video footage, this was 2 hours 14 minutes since the last time (4:01 AM) someone went to room 214.

At 7:16 AM, EI # 1 opened the door to room 214, peered into the room, then closed the door to the point at which a person is unable to see into the room and continued to walk down the hallway to the next room. According to the video footage, this was 49 minutes the last time (6:20 AM) since someone went to room 214.

At 8:05 AM, EI # 11 - MHT # 3 entered room 214. According to the video footage, this was 51 minutes since the last time (7:16 AM) someone went to room 214.

Summary: EI #s 1 and 2 documented having completed Q 15 minute checks on PI # 2 during the night shift (11 PM to 7 AM), but, according to the security video footage, EI #s 1 and 2 failed to complete Q 15 minute checks on PI # 2 from 4:01 AM to 6:15 AM, from 6:15 AM to 7:16 AM and then from 7:16 AM to 8:05 AM.

3. Review of PI # 3's 15 Minute Check Sheet dated 1/15/14 to 1/16/14 revealed 15 minute checks were documented as having been completed every 15 minutes by EI #s 1 and 2 from 4:00 AM to 7:15 AM (This document's time ended at 0715). Review of the 15 Minute Check Sheet dated 1/16/14 to 1/17/14 revealed 15 minute checks were documented as having been completed every 15 minutes by EI # 1 from 7:30 AM to 8:00 AM (This document's time began at 730 AM).

Review of security video footage:

On 1/22/14 at 8:00 AM, the surveyor reviewed video footage in the presence of Employee Identifier (EI) # 13, Director/Treatment Manager, which revealed the following events:

At 2:27 AM revealed EI # 2 - MHT # 2 walked to room 213, peered into the room, then walked down the hallway peering into rooms and then out of view of the video camera. At 3:01 AM, EI # 2 walked to room 213 and peered into room, then walked back down the hallway out of view of the video camera. According to the video footage, this was 34 minutes since the last time (2:27 AM) someone went to room 213.

At 3:19 AM, EI # 1 - MHT # 1 walked to room 213, peered into the room, then walked back down the hallway out of view of the video camera. At 4:01 AM, EI # 2 - MHT # 2 walked to room 213, peered into room, then walked back down the hallway out of view of the video camera. According to the video footage, this was 42 minutes since the last time (3:19 AM) someone went to room 213.

At 6:21 AM, EI # 2 - MHT # 2 entered room 213 with a rolling blood pressure machine and exited the room at 6:25 AM. According to the video footage, this was 2 hours 20 minutes since the last time (4:01 AM) someone went to room 213.

Summary: According to the video footage, EI #'s 1 and 2 failed to complete Q 15 minute checks during the night shift (11 PM to 7 AM), on PI # 3 from 2:27 AM to 3:01 AM, from 3:19 AM to 4:01 AM, then from 4:01 AM to 6:21 AM.

4. Review of PI # 4's 15 Minute Check Sheet dated 1/15/14 to 1/16/14 revealed 15 minute checks were documented as having been completed by EI #s 1 and 2 from 4:00 AM to 7:15 AM (Th
VIOLATION: NURSING SERVICES Tag No: A0385
This condition level deficiency is cited based on review of facility policies, medical records, Station Census, video footage and interviews with facility staff, it was determined the facility failed to ensure the Registered Nurse (RN) supervised the Mental Health Technician, who failed to:

1. Follow the hospital policy for Search, Seizure and Disposition of Drugs, Weapons, and Potentially harmful substances and Patient Belongings. This deficient practice affected Patient Identifier (PI) # 1 and had the potential to negatively affect all patients admitted to the facility.

2. Complete the Q (every) 15 minutes checks on the night shift (11 PM to 7 AM), as evidence by video review, but, were documented as having been completed by Employee Identifier (EI) #'s 1 and 2. This deficient practice affected 4 of 4 patients Patient Identifier (PI) #s 1, 2, 3 and 4 and had the potential to negatively affect all patients admitted to the facility.

Findings include:

Refer to 482.23(b)(3) (0395) for findings.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policies, medical records, Station Census, video footage and interviews with facility staff, it was determined the Registered Nurse (RN) failed to ensure:

1. The staff followed the hospital policy for Search, Seizure and Disposition of Drugs, Weapons, and Potentially harmful substances and Patient Belongings. This deficient practice affected Patient Identifier (PI) # 1 and had the potential to negatively affect all patients admitted to the facility.

2. Q (every) 15 minutes checks were completed on the night shift (11 PM to 7 AM), as evidence by video review, but, were documented as having been completed by Employee Identifier (EI) #'s 1 and 2. This deficient practice affected 4 of 4 patients Patient Identifier (PI) #s 1, 2, 3 and 4 and had the potential to negatively affect all patients admitted to the facility

Findings include:

A. Policy/Procedure

Title: Nursing Admission Procedures
Policy No.: CS.009
Date Issued: 5/2010
Date Reviewed/Revised: 5/2010, 5/2012

... Policy:
The RN (Registered Nurse) in charge is responsible for overseeing the admission of all patients to Crossbridge Behavioral Health. This includes the supervision of staff delegated to orient the patient to the program and Unit, preparation of the environment, completion of the personal search and checking of personal belongings brought onto the unit...

B. Policy/ Procedure

Title: Nursing Rounds
Policy No: RM.011
Date Issued: 05/2010
Date Reviewed/Revised: 3/2012

Purpose: To ensure a safe environment

Policy: The Charge Nurse is responsible for assigning nursing staff to make unit rounds in order to account for all patients' whereabouts and ensure a safe environment.

Procedures:

... B. The Charge Nurse designates the staff member(s) responsible for each set of rounds.

A review of the Station Census dated 01/16/14 at 6:17 AM revealed there were two patients assigned to room 214, (PI # 1 and # 2) and two patients assigned to room 213, (PI # 3 and # 4).

1. Patient Identifier (PI) # 1 was voluntarily admitted on [DATE] with diagnoses including Accidental overdose of Alcohol and sedatives to Crossbridge Behavioral Health, the Prospective Payment System (PPS) unit, which is located off of the main hospital campus. PI # 1 was assigned to room 214.

Review of the Patient's Possession List dated 1/16/14 at 2:00 AM revealed Employee Identifier (EI) # 1, Mental Health Technician (MHT) # 1 documented the patient had a pair of Zebra print pajama pants.

A review of the Physician's Orders dated 1/16/14 at 3:00 AM revealed the patient's admitting diagnosis was documented as Suicidal Ideations and there were physician orders for observations to be completed every 15 minutes.

A review of the Psychiatric Assessment completed by the Registered Nurse (RN) dated 1/16/14 at 3:20 AM revealed the RN documented on the Suicide Risk and Management sheet, the patient's Level of Risk for suicide was Low Risk and the interventions required included: Every 15 minute checks.

On 1/22/14 at 8:00 AM, the surveyor reviewed video footage in the presence of Employee Identifier (EI) # 13, Director/Treatment Manager, which revealed the following events concerning PI # 1 on 1/16/14:

At 2:09:49 AM (2:09 AM and 49 seconds) - the patient entered an exam room with the Employee Identifier (EI) # 1, Mental Health Technician (MHT) # 1 and at 2:10:14 AM (2:10 AM and 14 seconds), EI # 2, MHT # 2 entered the same exam room, which was 15 seconds after EI # 1 and the patient entered the exam room. PI # 1 was wearing a pair of zebra striped pants, hospital gown with a blanket wrapped around the shoulders. At 2:18:33 AM (2:18 AM and 33 seconds), EI # 1, PI # 1 and EI # 2 exited the exam room. PI # 1 was wearing a pair of zebra print pants, hospital gown with a blanket wrapped around the shoulders.

A review of the 15 Minute Check Sheet, that was undated, revealed 15 minute checks were documented as having been completed every 15 minutes by Employee Identifier (EI) # 1, Mental Health Technician (MHT) # 1 and EI # 2, MHT #2 from 2:00 AM to 7:15 AM (This document's time ended at 7:15 AM). A review of the 15 Minute Check Sheet dated 1/16/14 to 1/17/14 revealed 15 minute checks were documented as having been completed every 15 minutes by EI # 1 from 7:30 AM to 8:00 AM. (This document's time began at 7:30 AM).

Review of the video footage dated 1/16/14 of PI # 1 revealed the following discrepancies involving the above documented Q 15 minute safety checks:

PI # 1 entered room 214 at 3:39 AM. At 4:01 AM, both EI #s 1 and 2 walked to room 214, EI # 1 peered into room, then walked back down the hallway out of view of the video camera. According to the video footage, neither EI # 1 or EI # 2 returned to room 214 until 6:15 AM, when EI # 2 entered room 214 with a rolling blood pressure machine. This was 2 hours and 14 minutes since the last time (4:01 AM) someone went to room 214.

According to the video footage, neither EI # 1 or EI # 2, returned to room 214 until 7:16 AM, when EI # 1 opened the door to room 214 and peered into the room. This was 49 minutes since the last time (6:15 AM) someone went to room 214.

According to the video footage, neither EI # 1 or EI # 2, returned to room 214 until 8:05 AM, EI # 11, MHT # 3 entered room 214. This was 51 minutes since the last time (7:16 AM) someone went to room 214.

At 8:11 AM, PI # 1 exited room 214 wearing zebra striped pants and 2 hospital gowns.

At 2:06 PM, PI # 1 was standing in the doorway entrance to the Nurses Station with EI # 10, MHT # 4. PI # 1 was talking on the telephone. At 2:09 PM, PI # 1 lifted the end of the blue shirt and touched the strings/ribbons that were attached to the zebra striped pants. PI # 1 touched the strings multiple times during the telephone conversation, then placed the blue shirt back over the top of the zebra striped pants in the presence of EI # 10, MHT # 4. After the telephone conversation ended, PI # 1 walked away from the Nurses Station and down the hallway out of view of the video footage.

At 2:10 PM, PI # 1 entered room 214 wearing the blue long sleeved shirt and zebra striped pants. PI # 1 continued to wear the zebra striped pants throughout the entire video footage.

At 2:16 PM, EI # 11 looked into room 214, but, did not enter, then walked down the hallway out of view of the video footage. The door to room 214 was opened at that time and a person could easily see into the room. At 2:23 PM, EI # 11 closed the door to room 214 to the point at which a person is unable to see into the room, then walked down the hallway out of view of the video footage. After EI # 11 walked away the door opened of it's own accord.

PI # 1 used the drawstring from the pants to hang self in the shower in room 214.

At 2:33:52 PM, EI # 3, Housekeeping staff member entered room 214. At 2:34:05 PM, EI # 3 ran out of room 214 to the Nurses Station. Multiple staff members, including physicians responded to a Code Blue in room 214, initiated and performed CPR (cardiopulmonary resuscitation) on PI # 1, who was transported to the ED located at the main campus of this facility.

Review of PI # 1's medical record revealed he/she was transported to the main campus Emergency Department (ED). The ED medical record dated 1/16/14 revealed PI # 1 was coded per ACLS (Advanced cardiac life support) protocol two times. At 7:17 PM on 1/16/14, PI # 1 expired.

On 1/22/14 at 8:00 AM, the surveyor reviewed video footage in the presence of Employee Identifier (EI) # 13, Director/Treatment Manager, who verified the above concerning the safety checks not completed every 15 minutes, even though the MHTs documented having completed them. EI # 13 stated that EI # 10, MHT # 4 had been interviewed and EI # 10 stated that she had an opportunity to remove the strings from PI # 1's pants, but, got busy and forgot. An interview was conducted on 1/23/14 at 8:10 AM with EI # 13, who stated EI # 1 and 2, MHT were placed on administrative leave and not on rotation to work.

An interview was conducted on 1/22/14 at 2:15 PM with Employee Identifier (EI) # 10, MHT # 4. The surveyor asked EI # 10 about her interaction with PI # 1. EI # 10 stated that after lunch, PI # 1 wanted to make a phone call and it was not phone time. EI # 10 stated that she stood there with PI # 1 during the phone conversation. PI # 1 was telling the person on the phone visitation time and to bring clothes. EI # 10 stated she told PI # 1 to tell the person on the phone not to bring clothes with strings. EI # 10 stated that PI # 1 held up shirt and PI # 1 had a string on pajama pants. EI # 10 stated that she got busy with another patient and failed to obtain the string from PI # 1 or to inform the nurse about the string on the patient's pajama pants.

The surveyor asked EI # 10 who was responsible for checking patients for contraband (items not allowed). EI # 10 replied, "All of us".

An interview was conducted on 1/22/14 at 3:19 PM with EI # 11 (MHT # 3). EI # 11 verified she was assigned to PI # 1 on 1/16/14. EI # 11 stated after lunch she was making rounds and around 2:12 PM - 2:15 PM she looked into PI # 1's room and the patient's roommate (PI # 2) was in bed asleep and PI # 1 was standing in the far corner of the room. EI # 11 stated there were a lot of people in the hallway and she looked back in the room (PI # 2) in bed asleep, but did not see PI # 1. EI # 11 made no attempt to visualize PI # 1 at that time. EI # 11 stated she closed the door because of the noise in the hallway.

An interview was conducted on 1/23/14 at 7:35 AM with EI # 1 (MHT # 1), who stated that she checked PI # 1 into the facility. EI # 1 verified EI # 2 (MHT # 2) was present in the room when PI # 1 was admitted and checked for contraband (items not allowed on the unit). EI # 1 stated PI # 1 had on a pair of zebra striped pajama pants and hospital gowns at admission. EI # 1 stated she had lifted the hospital gowns up. EI # 1 verified that MHTs are responsible for checking the patient's for contraband. EI # 1 stated she told PI # 1 that he/she would have to remove the pants or take the string out. EI # 1 stated that normally one MHT checks the patient's vital signs and the other MHT removes items not allowed. EI # 1 stated that she assumed the EI # 2 (MHT # 2) was going to remove the string.

EI # 1 verified the following procedures for patient safety checks: Every patient has to be checked every 15 minutes, some patients are checked every 10 minutes - if staff feel the patient is a threat to themselves, some patients are line of sight (meaning patient has to be within your line of sight at all times) and some are one to one (arm length away from the staff member).

An interview was conducted on 1/23/14 at 8:34 AM with EI # 2 (MHT # 2). EI # 2 verified she was on the hall when PI # 1 was admitted . EI # 2 stated that when she entered the exam room, EI # 1 had almost completed checking PI # 1, but denied having checked the patient for contraband. EI # 2 stated that when she entered the only thing she saw that the patient was wearing was a hospital gown. EI # 2 denied recalling that PI # 1 was wearing pajama pants. EI # 2 stated usually there are two people in the exam room for safety reasons and that one person (MHT) does the searching for items not allowed on the unit.

The surveyor asked EI # 2 what was the procedure for safety checks and EI # 2 stated that safety checks were done every 15 minutes. The surveyor asked if there were times when safety checks were done more frequently. EI # 2 replied, "No, usually every 15 minutes."

Summary: The RN failed to ensure staff followed the facility's policy to provide a safe environment by not removing clothing that presented as a hazard, in that, PI # 1 was admitted wearing zebra striped pants that had a removable drawstring and continued to wear the same pants the entire time. PI # 1 used the drawstring from the pants to hang self in the shower in room 214. The RN failed to ensure Q 15 minute checks were performed on PI # 1 by EI #s 1 and 2 from 4:01 AM to 6:15 AM, from 6:15 AM to 7:16 AM and from 7:16 AM to 8:05 AM, which were documented by EI #s 1 and 2 as having been completed every 15 minutes.

2. PI # 2 was admitted to the facility on [DATE] with Depressive disorder with suicidal risk and assigned to room 214. Review of the 15 Minute Check Sheet dated 1/15/14 to 1/16/14 revealed 15 minute checks were documented as having been completed every 15 minutes by EI #s 1 and 2 from 4:00 AM to 7:15 AM (This document's time ended at 7: 15 AM). Review of the 15 Minute Check Sheet dated 1/16/14 to 1/17/14 revealed 15 minute checks were documented as having been completed every 15 minutes by EI # 1 from 7:30 AM to 8:00 AM (This document's time began at 7:30 AM).

EI # 1 and # 2 had shared responsibilities for the completion of every 15 minute patient safety checks.

Review of the video footage dated 1/16/14 revealed the following discrepancies involving the above documented Q 15 minute safety checks:

At 4:01 AM, both EI #s 1 and 2 walked to room 214, EI # 1 peered into room, then walked back down the hallway out of view of the video camera. According to the video footage, neither EI # 1 or EI # 2 returned to room 214 until 6:15 AM, when EI # 2 entered room 214 with a rolling blood pressure machine. This was 2 hours and 14 minutes since the last time (4:01 AM) someone went to room 214.

According to the video footage, neither EI # 1 or EI # 2, returned to room 214 until 7:16 AM, when EI # 1 opened the door to room 214 and peered into the room. This was 49 minutes since the last time (6:15 AM) someone went to room 214.

According to the video footage, neither EI # 1 or EI # 2, returned to room 214 until 8:05 AM, EI # 11, MHT # 3 entered room 214. This was 51 minutes since the last time (7:16 AM) someone went to room 214.

Summary: The RN failed to ensure Q 15 minute checks were performed on PI # 2 by EI #s 1 and 2 from 4:01 AM to 6:15 AM, from 6:15 AM to 7:16 AM and from 7:16 AM to 8:05 AM, which were documented by EI #s 1 and 2 as having been completed every 15 minutes.

3. Review of PI # 3's 15 Minute Check Sheet dated 1/15/14 to 1/16/14 revealed 15 minute checks were documented as having been completed every 15 minutes by EI #s 1 and 2 from 4:00 AM to 7:15 AM (This document's time ended at 7:15 AM). Review of the 15 Minute Check Sheet dated 1/16/14 to 1/17/14 revealed 15 minute checks were documented as having been completed every 15 minutes by EI # 1 from 7:30 AM to 8:00 AM (This document's time began at 7:30 AM).

On 1/22/14 at 8:00 AM, the surveyor reviewed video footage in the presence of Employee Identifier (EI) # 13, Director/Treatment Manager, which revealed the following events:

At 2:27 AM revealed EI # 2 - MHT # 2 walked to room 213, peered into the room, then walked down the hallway peering into rooms and then out of view of the video camera. According to the video footage, neither EI # 1 or EI # 2, returned to room 213 until 3:01 AM, when EI # 2 walked to room 213 and peered into room, then walked back down the hallway out of view of the video camera. This was 34 minutes since the last time (2:27 AM) someone went to room 213.

According to the video footage, neither EI # 1 or EI # 2, returned to room 213 until 3:19 AM, when EI # 1 - MHT # 1 walked to room 213, peered into the room, then walked back down the hallway out of view of the video camera. According to the video footage, neither EI # 1 or EI # 2, returned to room 213 until 4:01 AM, when EI # 2 - MHT # 2 walked to room 213, peered into room, then walked back down the hallway out of view of the video camera. This was 42 minutes since the last time (3:19 AM) someone went to room 213.

According to the video footage, neither EI # 1 or EI # 2, returned to room 213 until 6:21 AM, when EI # 2 - MHT # 2 entered room 213 with a rolling blood pressure machine and exited the room at 6:25 AM. This was 2 hours 20 minutes since the last time (4:01 AM) someone went to room 213.

Summary: The RN failed to ensure Q 15 minute checks were performed on PI # 3 by EI #'s 1 and 2 from 2:27 AM to 3:01 AM, from 3:19 AM to 4:01 AM, then from 4:01 AM to 6:21 AM, which were documented by EI #s 1 and 2 as having been completed every 15 minutes.

4. Review of PI # 4's 15 Minute Check Sheet dated 1/15/14 to 1/16/14 revealed 15 minute checks were documented as having been completed by EI #s 1 and 2 from 4:00 AM to 7:15 AM (This document's time ended at 7:15 AM). Review of the 15 Minute Check Sheet dated 1/16/14 to 1/17/14 revealed 15 minute checks were documented as having been completed by EI # 1 from 7:30 AM to 8:00 AM (This document's time began at 7:30 AM).

Review of security video footage:

On 1/22/14 at 8:00 AM, the surveyor reviewed video footage in the presence of Employee Identifier (EI) # 13, Director/Treatment Manager, which revealed the following events:

At 2:27 AM revealed EI # 2 - MHT # 2 walked to room 213, peered into the room, then walked down the hallway peering into rooms and then out of view of the video camera. According to the video footage, neither EI # 1 or EI # 2, returned to room 213 until 3:01 AM, when EI # 2 walked to room 213 and peered into room, then walked back down the hallway out of view of the video camera. This was 34 minutes since the last time (2:27 AM) someone went to room 213.

According to the video footage, neither EI # 1 or EI # 2, returned to room 213 until 3:19 AM, when EI # 1 - MHT # 1 walked to room 213, peered into the room, then walked back down the hallway out of view of the video camera. According to the video footage, neither EI # 1 or EI # 2, returned to room 213 until 4:01 AM, when EI # 2 - MHT # 2 walked to room 213, peered into room, then walked back down the hallway out of view of the video camera. This was 42 minutes since the last time (3:19 AM) someone went to room 213.

According to the video footage, neither EI # 1 or EI # 2, returned to room 213 until 6:21 AM, when EI # 2 - MHT # 2 entered room 213 with a rolling blood pressure machine and exited the room at 6:25 AM. This was 2 hours 20 minutes since the last time (4:01 AM) someone went to room 213.

According to the video footage, neither EI # 1 or EI # 2, returned to room 213 until 7:14 AM, when EI # 11 - MHT # 3 approached room 213, stood at the doorway and peered into the room. This was 49 minutes since the last time (6:25 AM) someone went to room 213.

According to the video footage, neither EI # 1 or EI # 2, returned to room 213 until 8:05 AM, when EI # 10 - MHT # 4 entered room 213. According to the video footage, this was 51 minutes since the last time (7:14 AM) someone went to room 213.

Summary: The RN failed to ensure Q 15 minute checks were performed on PI # 4 by EI #'s 1 and 2 from 2:27 AM to 3:01 AM, from 3:19 AM to 4:01 AM, from 4:01 AM to 6:21 AM, then from 7:14 AM to 8:05 AM, which were documented by EI #s 1 and 2 as having been completed every 15 minutes.

Employee Identifier (EI) # 1, Mental Health Technician (MHT) and EI # 2, MHT were placed on administrative leave pending the completion of the facility's investigation of the events in which the Q 15 minutes checks were not completed during the night shift (11 PM to 7 AM).