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.

Based on interview, review of the ongoing facility investigation, and facility policy, it was determined the facility failed to provide care in a safe setting by failing to follow facility policy related to providing one to one (1:1) observation for one (1) of ten (10) sampled patients (Patient #1).

On 07/17/16, Patient #1 was placed in a four (4)-point restraint with chest binder and Patient Aide (PA) #1 was assigned to be 1:1 with the Patient. However, PA #1 walked away from the patient and the resident removed his/herself from the restraint. The staff involved failed to report the incident immediately and failed to remove PA #1 from direct care.

The findings include:

Review of the facility Restraint Policy, dated August 2015, revealed patients placed in four (4)- point restraints are put on 1:1 observation.

Review of the 1:1 Supervision policy, dated March , revealed patients placed on 1:1 supervision are to be monitored constantly to ensure patients receive care in a safe setting.

Review of the Incident Investigations Policy, dated March 2016, revealed reporting of incidents is to be done immediately.

Record review revealed the facility admitted Patient #1 on 07/12/16 with diagnoses, which included Erratic Mood, Aggression, and Suicidal Thoughts. Review of a Seclusion-Restraint Documentation form, dated 07/17/16 at 2:15 AM, revealed at approximately 2:30 PM the patient was placed in a four (4) point restraint with a chest binder with a staff assigned to continuously monitor the patient. Review of Seclusion-Restraint Documentation form, dated 07/17/16 at 2:35 AM, revealed the staff assigned to the patient walked away and the resident was able to get out of the restraints.

Interview with Patient Aide (PA) #1 on 07/21/16 at approximately 8:47 AM, revealed she was assigned to sit on 1:1 observation with Patient #1 who was in a 4 point restraint with a chest binder. She stated she broke the 1:1 observation when she stepped to the side and the patient was not in her direct line of sight. She revealed she had been trained on 1:1 observation stating the patient could never be out of eyesight when sitting 1:1. She stated she went back to the 1:1 observation of Patient #1 after Registered Nurse (RN) #1 had told her that during 1:1 her eyes must always be on the patient. She also stated she told RN #1 she knew she had made a mistake.

Interview with Licensed Practical Nurse (LPN) #1, on 07/21/16 at approximately 9:30 AM, revealed she assigned PA #1 to sit on 1:1 with Patient #1 and then she went into the office. LPN #1 stated when she came out of the office at approximately 2:35 AM she found Patient #1 out of his/her room, out of the restraint, and did not see PA #1 who should have been sitting 1:1 with the patient. LPN #1 revealed she was the first to see Patient #1 out of his/her room and the patient was acting in an aggressive manner. LPN #1 stated her and LPN #2 got the patient calmed and back in the restraint and another patient aide was sitting with the patient. She reported she did not know where PA #1 was at this point but when she saw PA #1 she told PA #1 "you left the patient you were assigned to sit 1:1. When sitting 1:1 with a patient you have to keep your eyes on the patient at all times." She stated PA #1 said she was going for the 1:1 paperwork. LPN #1 revealed she reported this to RN #1, and they completed the LPN #1 stated RN #4 did not pull PA #1 from direct patient care.

Interview with RN #1, on 07/21/16 at approximately 10:00 AM, revealed she was in the nurse's office doing the restraint paperwork for Patient #1 when LPN #1 came in and told her Patient #1 got out of the restraint, was found in the hallway, and PA #1 was not sitting 1:1 with the patient. RN #1 reported she called the coordinator's office and was told by RN #4 to come to her office. She stated she talked to PA #1 and PA #1 stated she did step away, approximately 12 feet with her back turned to Patient #1 while she was sitting 1:1 with the patient. RN #1 revealed she told PA #1 you could never take your eyes off a patient when sitting 1:1. She stated she did not pull PA #1 from direct patient care and when she and LPN #1 went to the coordinator's office, the coordinator did not pull PA #1 from direct patient care.

Interview with RN #4, on 07/21/16 at approximately 2:20 PM, revealed she was the coordinator on duty on 07/17/16 at 4:00 AM when RN #1 and LPN #1 came to the coordinator's office and brought her the restraint paperwork. She stated she did not tell RN #1 and LPN #1 to pull PA #1 from direct patient care and did not report the incident to Risk Management.

Interview with RN #2, on 07/21/16 at approximately 1:30 PM, revealed PA #1's shift ended at 7:00 AM on 07/17/16, and she called Risk Management to report the incident and then called PA #1 to let her know she had been pulled from patient care.

Interview with Risk Management Investigator (RMI) #2, on 07/21/16 at approximately 12:30 PM, revealed incidents should be reported to risk management within one (1) hour and their policy defines immediate as without delay.