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.

EASTPOINTE HOSPITAL 7400 ROPER LANE DAPHNE, AL Dec. 7, 2017
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 policy, medical records, observations and interviews with staff, it was determined the facility failed to ensure patient safety observation rounds were completed according to physician orders. This affected 7 of 7 records reviewed, including Consumer Identifiers (CI) # 1, CI # 2, CI # 3, CI # 4, CI # 5, CI # 6 and CI # 7. This has the potential to negatively affect all patients admitted to this facility.

Findings include:
Facility Policy
Policy # CTS.5.03
Subject: One to One (1:1), Q (every) -15, and Q - 30 Observations
Effective: 1/03
Revised: 10/16

Policy:
When a consumer is unable to function within the structure of the program due to acting out behaviors, being a possible elopement risk and/or verbalizing intention of harming self/others, etc., One to One (1:1), Q-15 minute and Q-30 (Routine) Observations may be ordered as a safety measure.

One to One Observation (1:1):

When a consumer is placed on one to one (1:1) status, it is typically because he/she has verbalized intention of harming himself/herself, or someone else, or as need is determined by psychiatrist/CRNP (Certified Registered Nurse Practitioner) is the only staff member who is capable of initiating and discontinuing one to one observation orders for a consumer.

Procedure:

A. 1:1 Observations

... e. Document on the Precautions Record form every 15 minutes via the IPad...

B. Q-15 Minute Observations

Q-15 minutes observation means a consumer is to be monitored by staff at least every 15 minutes. The location, activity and behaviors of the consumer should be documented every 15 minutes...

Procedure:
1. Employee must locate consumer at least once every 15 minutes and document required information on the Precautions Record form...

5. The employee assigned Q-15 minute observation must find a replacement when he/she takes a break.

6. Please remember that when you are assigned Q-15 minute observations, it is your responsibility to ensure Q-15 minute procedure is being fully observed...

1. CI # 1 was voluntarily admitted to the facility on [DATE] with diagnoses including Major depressive disorder, severe without psychotic features and Persistent complex bereavement with passive death wish.

Review of the Physician order dated 7/12/17 at 12:06 PM revealed observation/precaution orders for Q-15 minute observation due to suicidal.

Review of the Observations documentation dated 7/14/17 revealed the following observations were documented as follows:
7:00 AM, 7:15 AM and 7:30 AM were all documented at 8:27 AM,
7:45 AM was documented at 8:29 AM,
8:00 AM and 8:15 AM were documented at 8:30 AM,
9:00 AM was documented at 10:16 AM,
9:15 AM, 9:30 AM and 9: 45 AM were all documented at 10:17 AM,
10:00 AM and 10:15 AM were documented at 10:22 AM,
11:15 AM, 11:30 AM and 11:45 AM were all documented at 11:53 AM,
12:00 PM and 12:15 PM were documented at 12:20 PM,
12:45 PM, 1:00 PM, 1:15 PM were all documented at 2:30 PM,
1:30 PM, 1:45 PM, 2:00 PM, 2:15 PM and 2:30 PM were all documented at 2:32 PM,
2:45 PM, 3:00 PM, 3:15 PM all documented at 3:34 PM,
3:30 PM was documented at 3:35 PM, (one minute after the above)
3:45 PM and 4:00 PM were documented at 4:02 PM,
5:15 PM was documented at 6:03 PM,
5:30 PM, 5:45 PM and 6:00 PM were all documented at 6:06 PM,
7:15 PM was documented at 8:10 PM
7:30 PM, 7:45 PM and 8:00 PM were all documented at 8:11 PM,
8:15 PM was documented at 8:48 PM,
8:30 PM was documented at 8:49 PM,
8:45 PM, 9:00 PM, 9:15 PM, 9:30 PM, 9:45 PM and 10:00 PM were all documented at 10:05 PM,
10:30 PM was documented at 10:42 PM,
10:45 PM, 11:00 PM and 11:15 PM were all documented at 11:21 PM,
11:30 PM was documented at 11:40 PM.

There was no documentation the above observations were completed every 15 minutes as ordered.

Review of the Observations documentation dated 7/15/17 revealed the following observations were documented as follows:
12:00 AM was documented at 12:13 AM
1:00 AM and 1:15 AM were documented at 1:29 AM,
1:45 AM and 2:00 AM were documented at 2:05 AM,
2:15 AM, 2:30 AM and 2:45 AM were all documented at 2:58 AM,
3:00 AM and 3:15 AM were documented at 3:19 AM,
4:00 AM and 4:15 AM were documented at 7:01 AM,
4:30 AM, 4:45 AM, 5:00 AM, 5:15 AM, 5:30 AM, 5:45 AM, 6:00 AM, 6:15 AM, 6:30 AM 6:45 AM and 7:00 AM were all documented at 7:02 AM.

There was no documentation the above observations were completed every 15 minutes as ordered.

Review of the Nursing Progress Note dated 7/15/17 at 6:15 AM, revealed the nurse documented, "... Cons (consumer) came to nurse station to report (he/she) had fallen in the bathroom... denied pain, alert/oriented self and surroundings, no acute distress noted. Per Doctor instructions cons is to be sent to (hospital name) non-emergent for evaluation and treatment, EMS (Emergency Medical Services) notified... will continue to monitor and assess for changes in mood and behavior..."

Review of the Nursing Progress Note dated 7/15/17 at 7:25 AM, revealed the nurse documented, "... Cons taken to (hospital name) by non-emergent EMS ambulance for eval (evaluation) and treatment for fall in bathroom... No acute distress observed, cons calm, cooperative, alert and oriented to self and surroundings, cons denies pain... will report off to incoming shift..."

Review of the Observations documentation dated 7/15/17 revealed the following observations were documented at 7:30 AM and 7:45 AM, the patient was in the day room and was calm and eating. These two observations were documented at 8:08 AM.

Review of the Observations documentation dated 7/15/17 revealed the following observations were documented at 8:00 AM and 8:15 AM, the patient was in the day room calm and activity was "Movie/Music/TV." These two observations were documented at 8:27 AM.

Review of the Observations documentation dated 7/15/17 revealed the following observations were documented at 8:30 AM and 8:45 AM, the patient was in the bedroom, quite/resting/lying down and activity was sleeping. These two observations were documented at 8:59 AM.

Review of the Observations documentation dated 7/15/17 revealed the following observations were documented at 9:00 AM and 9:15 AM, the patient was at the nurse's station, calm and the activity was "Medication."

Review of the Observations documentation dated 7/15/17 revealed the following observations were documented at 9:30 AM and 9:45 AM, the patient was in the day room and was calm and eating. The observations from 9:00 AM to 9:45 AM were all documented at 9:25 AM.

Review of the Medication Administration Record dated 7/15/17 revealed the patient the patient was to receive Cymbalta 30 milligrams (mg) every morning and was scheduled for 9:00 AM. The nurse documented the administration of Cymbalta 30 mg at 5:09 PM.

Review of the Nursing Progress Note dated 7/15/17 at 4:47 PM revealed the nurse documented, "... Consumer back from hospital, awake and alert, no problems noted, denies any issues..."

There was no documentation Every 15 minute observations were conducted from 9:45 AM on 7/15/17 to 12:00 AM on 7/16/17.

An interview was conducted on 12/7/17 at 10:00 AM with Employee Identifier (EI) # 1, Director of Performance Improvement, who verified the above findings.

2. CI # 2 was voluntarily admitted to the facility on [DATE] with diagnoses including Substance induced mood/psychotic disorder, Cannabis use disorder, sever and Unspecified personality disorder with cluster B traits (borderline and antisocial).

Review of the Physician order dated 8/8/17 at 9:23 PM revealed observation/precaution orders for Q-15 minute observation.

Review of the Observations documentation dated 8/12/17 revealed the following observations were documented as follows:
12:15 AM, 12:30 AM, 12:45 AM were all documented at 12:45 AM
1:00 AM, 1:15 AM and 1:30 AM were all documented at 1:40 AM,
1:45 AM, 2:00 AM and 2:15 AM were all documented at 2:17 AM,
2:45 AM was documented at 3:41 AM,
3:00 AM, 3:15 AM and 3:30 AM were all documented at 3:42 AM,
3:45 AM and 4:00 AM were documented at 4:16 AM,
4:45 AM and 5:00 AM were documented at 5:06 AM,
5:15 AM and 5:30 AM were documented at 5:38 AM,
5:45 AM was documented at 5:58 AM,
6:00 AM and 6:15 AM were documented at 6:23 AM,
6:45 AM and 7:00 AM were documented at 7:03 AM,
7:15 AM and 7:30 AM were documented at 7:46 AM,
8:45 AM was documented at 9:00 AM,
9:30 AM and 9:45 AM were documented at 9:51 AM,
10:00 AM and 10:15 AM were documented at 10:23 AM,
10:45 AM was documented at 11:07 AM,
11:00 AM was documented at 11:11 AM,
11:30 and 11:45 AM were documented at 11:59 AM,
12:15 PM was documented at 12:26 PM,
12:30 PM and 12:45 PM were documented at 12:54 PM,
1:30 PM was documented at 1:45 PM,
2:15 PM was documented at 2:21 PM,
2:45 PM was documented at 2:57 PM,
3:00 PM was documented at 3:14 PM,
3:45 PM and 4:00 PM were documented at 4:03 PM,
4:15 PM, 4:30 PM and 4:45 PM were documented at 4:56 PM,
5:00 PM was documented at 5:19 PM,
5:15 PM and 5:30 PM were documented at 5:32 PM,
5:45 PM was documented at 5:51 PM,
6:00 PM was documented at 6:16 PM,
6:30 PM was documented at 7:12 PM,
6:45 PM was documented at 7:13 PM,
7:15 PM, 7:30 PM were documented at 8:13 PM,
7:45 PM and 8:00 PM were documented at 8:14 PM.

There was no documentation the above observations were completed every 15 minutes as ordered.

Review of the Observations documentation dated 8/12/17 revealed the following observations were documented at 8:30 PM and 8:45 PM, the patient was at the nurse's station, calm and the activity was "Medication."

Review of the Nursing Progress Note dated 8/12/17 at 9:00 PM revealed the nurse documented, "... Cons had tied a length of pant hold - up string around neck... Nurse went to cons room found cons sitting on bed, awake, alert, no acute distress noted, nurse removed string from neck, O2 (oxygen) Sat (saturation) 98%, HR (heart rate) = 91, cons said he was very depressed, cons redirected and given... PRN (as needed), Doctor notified, cons tolerated... Will continue to monitor and assess and monitor for changes in mood and behavior..."

Review of the Observations documentation dated 8/12/17 revealed the following observations were documented at 9:00 PM (documented at 9:08 PM), 9:15 PM (documented at 9:17 PM) and 9:30 PM (documented at 9:32 PM), the patient was in the bedroom, calm and sleeping.

Review of the Medication Administration Record dated 8/12/17 revealed the patient received Depakote 500 mg at 9:26 PM.

An interview was conducted on 12/7/17 at 10:00 AM with EI # 1, who verified the above findings.

3. CI # 3 was voluntarily admitted to the facility on [DATE] with diagnoses including Substance induced depressive disorder, Alcohol use disorder, moderate-severe, persistent depressive disorder.

Review of the Physician order dated 7/12/17 revealed observation/precaution orders for Q-15 minute observation.

Review of the Observations documentation dated 7/14/17 revealed the following observations were documented as follows:
12:00 AM, 12:15 AM, 12:30 AM and 12:45 AM were all documented at 12:51 AM,
1:15 AM was documented at 1:26 AM,
1:30 AM, 1:45 AM, 2:00 AM, 2:15 AM, 2:30 AM, 2:45 AM, 3:00 AM were all documented at 3:12 AM,
3:00 AM was documented at 3:12 AM,
3:30 AM, 3:45 AM, 4:00 AM, 4:15 AM, 4:30 AM were all documented at 4:41 AM,
5:15 AM was documented at 5:26 AM,
5:30 AM, 5:45 AM and 6:00 AM were all documented at 6:14 AM,
6:30 AM was documented at 6:41 AM,
6:45 AM was documented at 6:52 AM,
7:00 AM was documented at 7:54 AM,
7:15 AM, 7:30 AM and 7:45 AM were all documented at 7:55 AM,
8:00 AM, 8:15 AM and 8:30 AM were all documented at 8:43 AM,
9:00 AM, 9:15 AM and 9:30 AM were all documented at 9:45 AM,
10:00 AM and 10:15 AM were documented at 10:29 AM,
10:45 AM was documented at 10:56 AM,
11:15 AM was documented at 11:26 AM,
11:30 AM and 11:45 AM were all documented at 11:47 AM.

There was no documentation the above observations were completed every 15 minutes as ordered.

An interview was conducted on 12/7/17 at 10:00 AM with EI # 1, who verified the above findings.

4. CI # 4 was admitted to the facility on [DATE] with diagnosis including Unspecified depressive disorder.

Review of the Physician order dated 7/11/17 at 4:51 PM revealed observation/precaution orders for Q-15 minute observation due to unpredictable behavior.

Review of the Observations documentation dated 7/12/17 revealed the following observations were documented as follows:
12:00 AM, 12:15 AM, 12:30 AM and 12:45 AM were all documented at 12:52 AM,
1:15 AM was documented at 1:38 AM,
1:45 AM and 2:00 AM were both documented at 2:06 AM,
2:15 AM and 2:30 AM were both documented at 2:34 AM,
2:45 AM, 3:00 AM and 3:15 AM were all documented at 3:27 AM,
3:45 AM, 4:00 AM, 4:15 AM, 4:30 AM, 4:45 AM, 5:00 AM, 5:15 AM, 5:30 AM, 5:45 AM, 6:00 AM and 6:15 AM were all documented at 6:22 AM,
6:45 AM and 7:00 AM were both documented at 7:03 AM,
7:15 AM was documented at 7:57 AM,
7:30 AM and 7:45 AM were both documented at 7:58 AM,
8:00 AM and 8:15 AM were both documented at 8:20 AM,
8:30 AM and 8:45 AM were both documented at 8:49 AM,
9:00 AM was documented at 9:22 AM,
9:15 AM was documented at 9:26 AM,
9:30 AM and 9:45 AM were both documented at 9:53 AM,
10:00 AM and 10:15 AM were documented at 10:19 AM,
10:30 AM, 10:45 AM, 11:00 AM, 11:15 AM, 11:30 AM, 11:45 AM, 12:00 PM were all documented at 12:25 PM,
12:15 PM, 12:30 PM and 12:45 PM were all documented at 12:49 PM,
1:15 PM was documented at 1:25 PM,
2:15 PM, 2:30 PM, 2:45 PM, 3:00 PM, 3:15 PM and 3:30 PM were all documented at 3:46 PM.

There was no documentation of every 15 minute observations documented from 3:45 PM to 5:00 PM.

Further review of the Observations documentation dated 7/12/17 revealed the following observations were documented as follows:
5:00 PM, 5:15 PM, 5:30 PM were all documented at 6:06 PM,
5:45 PM and 6:00 PM were documented at 6:07 PM,
6:15 PM was documented at 6:28 PM,
6:30 PM and 6:45 PM were both documented at 6:53 PM,
7:00 PM, 7:15 PM and 7:30 PM were all documented at 9:42 PM,
7:45 PM was documented at 9:44 PM,
8:00 PM, 8:15 PM, 8:30 PM and 8:45 PM were all documented at 9:42 PM,
9:00 PM, 9:15 PM and 9:30 PM were all documented at 9:43 PM,
9:45 PM, 10:00 PM, 10:15 PM and 10:30 PM were all documented at 10:33 PM,

There was no documentation the above observations were completed every 15 minutes as ordered.

An interview was conducted on 12/7/17 at 10:00 AM with EI # 1, who verified the above findings.

5. CI # 5 was involuntarily admitted to the facility on [DATE] with diagnosis Family relational problems.

Review of the Physician order dated 7/11/17 at 4:51 PM revealed observation/precaution orders for Q-15 minute observation due to unpredictable behavior.

Review of the Physician order dated 7/12/17 at 5:05 PM revealed observation/precaution orders for Q-15 minute observation.

Review of the Observations documentation dated 7/16/17 revealed the following observations were documented as follows:
12:45 AM, 1:00 AM and 1:15 AM were all documented at 1:24 AM,
1:30 AM and 1:45 AM were both documented at 1:53 AM,
2:15 AM and 2:30 AM were both documented at 2:33 AM,
2:45 AM was documented at 2:52 AM,
3:00 AM and 3:15 AM were both documented at 3:20 AM,
3:45 AM, 4:00 AM and 4:15 AM were all documented at 4:29 AM,
4:30 AM, 4:45 AM, 5:00 AM, 5:15 AM and 5:30 AM were all documented at 5:45 AM,
6:00 AM, 6:15 AM and 6:30 AM were all documented at 6:34 AM,
7:00 AM, 7:15 AM, 7:30 AM, 7:45 AM and 8:00 AM were all documented at 11:08 AM,
8:15 AM, 8:30 AM and 8:45 AM were all documented at 11:09 AM,
9:00 AM, 9:15 AM, 9:30 AM, 9:45 AM, 10:00 AM and 10:15 AM were all documented at 11:10 AM,
10:30 AM, 10:45 AM and 11:00 AM were all documented at 11:09 AM,
11:15 AM, 11:30 AM, 11:45 AM and 12:00 PM were all documented at 12:07 PM,
12:30 PM, 12:45 PM, 1:00 PM, 1:15 PM, 1:30 PM and 1:45 PM were all documented at 3:15 PM,
2:00 PM, 2:15 PM, 2:30 PM and 2:45 PM were all documented at 3:14 PM,
3:00 PM was documented at 3:12 PM,
3:30 PM, 3:45 PM, 4:00 PM, 4:15 PM, 4:30 PM and 4:45 PM were all documented at 4:52 PM,
5:15 PM was documented at 5:30 PM,
5:45 PM, 6:00 PM and 6:15 PM were all documented at 6:24 PM,
6:30 PM was documented at 6:44 PM,
6:45 PM and 7:00 PM were both documented at 7:03 PM,
8:30 PM, 8:45 PM, 9:00 PM and 9:15 PM were all documented at 9:17 PM,
10:00 PM, 10:15 PM, 10:30 PM and 10:45 PM were all documented at 10:49 PM,
11:00 PM was documented at 11:12 PM,
11:15 PM was documented at 11:21 PM,
11:30 PM was documented at 11:44 PM.

There was no documentation the above observations were completed every 15 minutes as ordered.

An interview was conducted on 12/7/17 at 10:00 AM with EI # 1, who verified the above findings.

6. CI # 6 was involuntarily admitted to the facility on [DATE] with diagnoses including Unspecified psychotic disorder, Cannabis use disorder and unspecified depressive disorder.

Review of the Physician order dated 7/5/17 at 4:07 PM revealed observation/precaution orders for Q-15 minute observation.

Review of the Observations documentation dated 7/9/17 revealed the following observations were documented as follows:
12:15 AM was documented at 12:38 AM,
12:30 AM was documented at 12:40 AM
12:45 AM, 1:00 AM, 1:15 AM, 1:30 AM and 1:45 AM were all documented at 1:47 AM,
2:00 AM, 2:15 AM, 2:30 AM and 2:45 AM were all documented at 2:51 AM,
3:00 AM was documented at 3:14 AM,
3:15 AM, 3:30 AM, 3:45 AM, 4:00 AM, 4:15 AM, 4:30 AM, 4:45 AM, 5:00 AM, 5:15 AM, 5:30 AM and 5:45 AM were all documented at 7:19 AM,
6:00 AM, 6:15 AM, 6:30 AM and 6:45 AM were all documented at 7:20 AM,
7:00 AM and 7:15 AM were both documented at 7:17 AM,
7:30 AM was documented at 1:18 PM,
7:45 AM was documented at 7:52 AM,
8:00 AM, 8:15 AM, 8:30 AM, 8:45 AM, 9:00 AM and 9:15 AM were all documented at 9:31 AM,
9:45 AM, 10:00 AM, 10:15 AM and 10:30 AM were all documented at 10:44 AM,
10:45 AM was documented at 10:54 AM,
11:00 AM, 11:15 AM, 11:30 AM, 11:45 AM and 12:00 PM were all documented at 12:12 PM,
12:45 PM was documented at 1:19 PM,
1:00 PM was documented at 1:23 PM.

There was no documentation the above observations were completed every 15 minutes as ordered.

Review of the Observations documentation dated 7/9/17 revealed the following observations were documented at 1:00 PM (documented at 1:23 PM) revealed the patient was outside, activity was recreation group, behavior was "Elopement- checking for unlocked doors."

Review of the Observations documentation dated 7/9/17 revealed the following observations were documented at 1:15 PM (documented at 1:33 PM) revealed the patient's location was outside, activity and behavior were documented as "other."

Review of the Nursing Progress Note dated 7/9/17 at 1:30 PM revealed the nurse documented, "... Consumer escaped during outside recreation... slid through the gate and ran off through the woods. (Physician's Name) was notified... police department was notified as well are... police department as the consumer lives in Silverhill (town name).

Review of the Observations documentation dated 7/9/17 revealed the following observations were documented at 1:30 PM (documented at 1:41 PM) and 1:45 PM (documented at 1:48 PM) revealed the patient's location was outside, activity and behavior were documented as "other."

There was no further documentation of Q 15 minute observations for this patient from 7/9/17 at 1:45 PM until 7/10/17 at 11:45 AM.

Review of the Nursing Progress Note dated 7/11/17 at 10:53 AM the nurse documented, "...Consumer was in (his/her) room, staff made it aware that (patient's) window frame was broke and a piece of the metal was missing from the frame. Security was called and a room search was ordered. During the room search a piece of 4 inch metal was found under consumer # 5. Both consumers denied knowing anything about the window until the metal was found... On 7-10-2017 this consumer was overheard talking that (he/she) wads (was) going to try and elope again on 7-11-2017, that it is very easy to do. (Physician's name) called, orders were given for room search, twice daily, consumer was made 1:1, All outside privileges were revoked as well as visit until notice. Consumer continued to deny saying anything about trying to elope... states that everything that happened was because this nurse was mean and it was not (his/her) fault. Dr. explained the reasons for all orders. Will continue to watch for changes..."

Review of the Physician order dated 7/11/17 at 11:11 AM revealed observation/precaution orders for 1:1 Routine observation due to elopement.

Review of the Observations documentation dated 7/11/17 revealed the following observations were documented as follows:
12:00 PM was documented at 12:11 PM,
12:45 PM was documented at 12:54 PM,
1:15 PM was documented at 1:27 PM,
1:30 PM and 1:45 PM were documented at 1:47 PM,
2:45 PM, 3:00 PM, 3:15 PM and 3:30 PM were all documented at 3:35 PM,
5:00 PM was documented at 5:13 PM
5:15 PM was documented at 5:22 PM,
5:30 PM and 5:45 PM were documented at 6:01 PM,
6:15 PM was documented at 6:25 PM,
6:30 PM and 6:45 PM were documented at 6:50 PM,
7:00 PM and 7:15 PM were both documented at 8:13 PM,
7:30 PM, 7:45 PM and 8:00 PM were all documented at 8:14 PM,
8:15 PM and 8:30 PM were both documented at 8:33 PM,
11:15 PM and 11:30 PM were both documented at 11:34 PM.

There was no documentation the above observations completed as 1:1 observations as ordered or at least every 15 minutes.

An interview was conducted on 12/7/17 at 10:00 AM with EI # 1, who verified the above findings.

On 12/7/17 at 9:11 AM, EI # 1 and the surveyor toured the 400 hall of the facility to investigate if there were problems with the Ipads the Behavioral Health Aides (BHA) were using to document patient observations. During this tour, EI # 1 and the surveyor observed the following: CI # 8 was standing with the BHA in the hall near the medication area. At that time, it was found that CI # 8 was 1:1 observation. The patient and the BHA were standing in the hall at the medication area for approximately 20 minutes. The BHA's IPad was located on the floor next to a chair, which was located just outside of CI # 8's room (Room 401).

The tour continued to the 300 hall of the facility. Most of the patients were in the dining area of the 300 hall. Three BHAs were seated on a bench in the hallway just outside of the dining area. EI # 1 and the surveyor reviewed the IPad entries of the patients who were Q 15 minute observations. At that time, none of the observations of the patients had been documented since 8:00 AM.

The tour concluded in the 200 hall of the facility. During this time, EI # 1 and the surveyor observed a Certified Nurse Aide (CNA) sitting at the doorway of room 206 and the patient was seated in the wheelchair just inside the door of the patient's room. The CNA stated that the patient was 1:1 observation and she was relieving the BHA for break. Located in the room on the table was an IPad. When questioned, the CNA stated that CNAs do not chart on the patient's unless they have to.

Once the tour was completed, the surveyor asked for a list of all patients in the 300 hall and it was provided. The surveyor randomly selected, CI # 7 from the list and requested the observation orders and the observation documentation for 12/7/17.

7. Review of CI # 7's Physician order for observation dated 12/6/17 at 2:19 PM revealed the patient was Q-15 minute observation.

Review of the Observations documentation dated 12/7/17 revealed the following observations were documented as follows:
8:00 AM and 8:15 AM were both documented at 9:33 AM
8:30 AM was documented at 9:42 AM,
9:00 AM was documented at 9:43 AM,
9:15 AM was documented at 9:27 AM
9:45 AM was documented at 9:54 AM.

There was no documentation the above observations were completed every 15 minutes as ordered.

An interview was conducted on 12/7/17 at 10:30 AM with EI # 1, who verified the above findings.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical record, facility policy and interview, it was determined the registered nurse (RN) failed to complete a suicide risk assessment for 1 of 1 patient with increased risk for suicide. This affected Consumer Identifier (CI) # 2 and had the potential to negatively affect all patients admitted to this facility.

Findings include:
Facility Policy:
Policy #: PE 1.4
Subject: Special Assessments/Referrals
Effective: 08/88
Revised 09/17

Policy:

As the assessment process progressed, the need for special assessments and services may become evident. This will ensure that consumers' needs or requirements will be met...

Procedure:
1. Suicide Risk Screen and Assessment
AltaPointe Health Systems has a system for assessing the risk of suicide which can also be used to determine intervention for such risk...

Suicidality ranges on the continuum from low to high based on identifiable risk factors. The following continuum will be used to facilitate consistent communications and guidelines for care within the program.

1. Lower Risk - no intent to die
2. Mild Risk - minimal intent to die.
3. Moderate Risk - moderate intent to die and may indicate need for further assessment.
4. High Risk - Clear intent to die and indicate cause for immediate assessment of risk intervention.

Standard

a. Each consumer will be screened for suicide risk by the medical staff/therapist/RN (Registered Nurse) at admission. The screening results will be documented appropriately in the electronic medical record on the Suicide Risk Screen for. If screening raises a question of suicide risk, the expanded Suicide Risk Screen form should be completed.

b. A suicide risk assessment should be considered when a consumer is believed to be at risk of suicide. Indications of increased suicide risk may include consumers with multiple risk factors, especially when presenting with psychiatric illness, substance abuse and co-morbid conditions. These consumers should be assessed further for suicide risk and necessary precautions. The total number and severity of risk factors should be considered...

d. The Suicide Risk Screen form will be used as a tool for completing the suicide risk assessment. The tool is designed to screen for demographic factors that may help identify consumers who fall into a statistically higher risk for self-harm. The tool is not intended to be a definitive or comprehensive assessment. Consumers with higher scores should be assessed further for referral to the necessary level of care to minimize the risk of self-harm.

e. The results of the suicide risk assessment should be communicated by the clinician completing the assessment to the consumer's treatment team. Any appropriate action should be taken by the treatment team and discussed with the consumer. When suicide risk is present, there should be documentation of options considered and rational for strategies that are chosen...

1. CI # 2 was voluntarily admitted to the facility on [DATE] with diagnoses including Substance induced mood/psychotic disorder, Cannabis use disorder, sever and Unspecified personality disorder with cluster B traits (borderline and antisocial).

Review of the Suicide Risk Screen dated 8/8/17 revealed the RN documented, "... Intent/Ambiance: 4 Clear Intent, Lethality of Attempt (or Plan): 2 Gesture, Prior Attempts: 4: 1 week - 6 months ago, Past suicide attempt in a hospital or secure setting including jail: 2: Gesture, Hopelessness: 3: Ambivalent... Support system 3: Conflicted, Current stressor severity: 3: Moderate, Loss and Trauma (past 6 months): 2: Moderate... Age: 15-35... Risk Summary: Lower Risk: 2, Mild Risk: 5, Moderate Risk: 5, High Risk: 2... In-Depth Suicide Risk Assessment: ... 15-35 or > 65 years: Yes..."

Review of the Nursing Admission assessment dated [DATE] revealed, "... Behavior: Agitated, Demanding, Distracted, Hostile, Impulsive, Increased Energy, Intrusive, Negative... Delusions: Present... b. Suicidal ideation: Actual plans, Able to contract for safety..."

A review of the medical record revealed no documentation an In-Depth Suicide Risk Assessment had been completed.

An interview was conducted on 12/7/17 at 10:00 AM with Employee Identifier # 1, Director of Performance Improvement, who verified the above findings.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review on medical record and interview with facility staff, it was determined the facility failed to ensure a medical record was complete and accurate with all events for 1 of 7 medical records. This affected Consumer Identifier (CI) # 6 and had the potential to negatively affect all patient medical records.

Findings include:

1. CI # 6 was involuntarily admitted to the facility on [DATE] with diagnoses including Unspecified psychotic disorder, Cannabis use disorder and unspecified depressive disorder.

Review of the Observations documentation dated 7/9/17 revealed the following observations were documented at 1:00 PM (documented at 1:23 PM) revealed the patient was outside, activity was recreation group, behavior was "Elopement- checking for unlocked doors."

Review of the Observations documentation dated 7/9/17 revealed the following observations were documented at 1:15 PM (documented at 1:33 PM) revealed the patient's location was outside, activity and behavior were documented as "other."

Review of the Nursing Progress Note dated 7/9/17 at 1:30 PM revealed the nurse documented, "... Consumer escaped during outside recreation... slid through the gate and ran off through the woods. (Physician's Name) was notified... police department was notified as well are... police department as the consumer lives in Silverhill (town name).

Review of the Observations documentation dated 7/9/17 revealed the following observations were documented at 1:30 PM (documented at 1:41 PM) and 1:45 PM (documented at 1:48 PM) revealed the patient's location was outside, activity and behavior were documented as "other."

Review of the Nursing Progress Note dated 7/9/17 at 5:05 PM revealed the nurse documented, "... Consumer observed throughout shift. Remains medication compliant. No observed signs of mental or physical distress. Continued to encourage active participation in groups/group activities, make needs known, and alert staff to any feelings of distress..." This documentation was completed after the patient had eloped from the facility.

There was no further documentation of Q 15 minute observations for this patient from 7/9/17 at 1:45 PM until 7/10/17 at 11:45 AM.

Review of the Nursing Progress Note End Shift Note dated 7/10/17 at 6:50 PM revealed the nurse documented, "... Q 15 minute observation in progress. No acute distress at this time..."

A review of the medical record revealed no documentation of when and how the patient was returned to the facility or an assessment of the patient's physical or mental status at the time the patient was returned to the facility.

An interview was conducted on 12/7/17 at 10:00 AM with Employee Identifier # 1, Director of Performance Improvement, who verified the above.