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SOLDIERS AND SAILORS MEMORIAL HOSPITAL 32-36 CENTRAL AVENUE WELLSBORO, PA June 17, 2014
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure patient's safety and security in the facility's Behavioral Health Unit for 10 of 10 medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, and MR10).

Findings include:

Review on June 16, 2014, of the facility's "Patient Acuity and Level System - Guideline: [number] 60" policy, last revised January 2014, revealed "Laurel Behavioral Health will classify each patient according to his/her level of acuity, in order to ensure that each patient receives nursing services appropriate to his/her needs and to ensure that each patient receives that care from nursing staff, licensed and/or trained to provide the particular level of care needed. Each patient will be rated by the 7 - 3 charge nurse from the classification system which follows. These ratings are conveyed to the Nursing Director. ... Levels are ordered for each patient at the time of admission. These levels are subject to change in response to the patient's psycho-behavioral status. ... The following are the acuity levels beginning the most intensive level of observation used at Laurel Behavioral Health. ... B. Special Observation II 7.5 hours/day nursing care Level II is for the patient needing frequent contact/observation with staff based on his/her psycho-behavioral status and staff judgment. It includes: 1. Observations every fifteen (15) minutes; 2. Supervision of the use of sharps on 1:1 staff basis; 3. Restriction to Unit except for medical diagnostic tests that cannot be delayed in which case accompaniment 1:1 hospital staff is required; 4. Room search at the time patient is assigned to this level to ensure a safe room; 5. Requirements of a psychiatrist's order to come off this level of observation. ..."

Review on June 16, 2014, of the facility's "Patient Check - Guideline: [number] 61" policy, last reviewed January 2014, revealed "Laurel Behavioral Health nursing staff will know the location of all patients in the program. This will be documented at least every hour and can be done more frequently if necessary. Patient checks are done each hour to ensure the location and safety of each patient and to survey the environment. A specific staff member is assigned to do a tour of the Unit on an hourly basis, but not at the same time each hour. Assigned staff will complete the patient checklist indicating that they have knowledge of where the patient was at the time. See attachment. They will acknowledge responsibility for doing the check by initialing the checklist. While doing tour, it is expected that staff will check the environment for safety and security risks such as: checking on locked doors, looking for sharps in the rooms, and assessing unusual patient behavior. Patients who have been identified as high risk by any member of the clinical team may be checked more frequently."

Review on June 16, 2104, of the facility's "Attachment to the Patient Check - Guidelines [number] 61" policy, last reviewed January 2014, revealed "Three equally divided areas containing room numbers 345, 350 A and B, 351 A and B, 352 A and B, 353 A and B, 354 A and B, 355 A and B, 356 A and B, and 357 A and B. Further review revealed a column labeled level and initials. Continued review revealed columns containing numbers correlating to every 15 minutes for a 24-hour period broken down to the 7:00 AM - 3:00 PM shift, the 3:00 PM to 11:00 PM shift and the 11:00 PM to 7:00 AM shift. Continued review of the top of the page revealed the following numbers and letters: 1 noisy activity, 2 quiet activity, 3 dining hall, 4 hallway, 5 bedroom, 6 one to one, 7 social work, 8 Dr. office, 9 ED's office and 10 walk, P pass, A awake, S sleeping, R restless, BR bathroom, G group, SH shower, T tub, PH phone and a star indicating patio."

1) Review on June 17, 2104, of MR1's admission orders dated June 7, 2014, revealed the physician ordered the patient on a Level II for patient safety checks. Further review revealed no documentation of every 15 minute checks, the patient's location every hour, or staff checks of the environment for safety and security risks.

Interview with EMP2 and EMP3 on June 17, 2014, at approximately 10:00 AM confirmed MR1's medical record did not contain documentation of every 15 minute checks, the patient's location every hour, or staff checks of the environment for safety and security risks.

2) Review on June 17, 2104, of MR2's admission orders dated June 2, 2014, revealed
the physician ordered the patient on a Level II for patient safety checks. Further review revealed no documentation of every 15 minute checks, the patient's location every hour, or staff checks of the environment for safety and security risks.

3) Review on June 17, 2104, of MR3 and MR4's admission orders dated June 10, 2014, revealed the physician ordered the patient on a Level II for patient safety checks. Further review revealed no documentation of every 15 minute checks, the patient's location every hour, or staff checks of the environment for safety and security risks.

4) Review on June 17, 2104, of MR5 and MR6's admission orders dated June 15, 2014, revealed the physician ordered the patient on a Level II for patient safety checks. Further review revealed no documentation of every 15 minute checks, the patient's location every hour, or staff checks of the environment for safety and security risks.

5) Review on June 17, 2104, of MR7's admission orders dated June 8, 2014, revealed the physician ordered the patient on a Level II for patient safety checks. Further review revealed no documentation of every 15 minute checks, the patient's location every hour, or staff checks of the environment for safety and security risks.

6) Review on June 17, 2104, of MR8's admission orders dated June 7, 2014, revealed the physician ordered the patient on a Level II for patient safety checks. Further review revealed no documentation of every 15 minute checks, the patient's location every hour, or staff checks of the environment for safety and security risks.

7) Review on June 17, 2104, of MR9's admission orders dated June 11, 2014, revealed the physician ordered the patient on a Level II for patient safety checks. Further review revealed no documentation of every 15 minute checks, the patient's location every hour, or staff checks of the environment for safety and security risks.

8) Review on June 16, 2104, of MR10's admission orders dated June 14, 2014, revealed the physician ordered the patient on a Level II for patient safety checks. Further review revealed no documentation of every 15 minute checks, the patient's location every hour, or staff checks of the environment for safety and security risks.

Interview with EMP2 and EMP3 on June 17, 2014, at approximately 11:00 AM confirmed MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9 and MR10's medical record did not contain documentation of every 15 minute checks, the patient s location every hour, or staff checks of the environment for safety and security risks.