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 observation, document review and interview, it was determined that for 1 of 1 inpatient behavioral unit (6 East), the Hospital failed to ensure patients' behaviors associated with safety precautions were monitored, as required. This potentially affected 18 patients on the census during the survey.

Findings include:

1. On 11/7/18 between 10:30 AM and 12:00 PM, an observational tour of 6 East (inpatient behavioral unit) was conducted. 6 East was a 28 bed unit with a census of 18 patients. All 18 patients had a physician's order for higher level Safety Precautions. At approximately 10:35 AM, the patients' safety rounds sheets for 11/7/18 were reviewed. The safety round sheets did not indicate that patients' behaviors were monitored every 15 minutes for behaviors associated with the safety precautions ordered specific for each patient. During the tour, an interview was also conducted with E #4 (Registered Nurse/staff assigned performing the safety rounds). E #4 stated that she (E #4) only records the patients' location (for example bathroom, day room, or hallway) on the safety rounds sheet every 15 minutes.

2. On 11/7/18 at approximately 12:30 PM, the Hospital's policy titled, "Monitoring of Psychiatric Patients" (reviewed 7/2017) was reviewed and required, "... A. Frequency of Monitoring: 1. All patients in the psychiatric will be placed on a Q-15 rounds (every fifteen minute rounds)... unless higher level Safety Precautions are ordered by the physician... Higher Level Safety Precautions. I. One or more of the following Safety Precautions may be ordered when clinically indicated. 1. Suicide Precautions and Self Injury... 2. Assault Precautions... 4. Sexually Acting Out Precautions... 6. Withdrawal Precautions... II. All patients on higher level Safety Precautions on the psychiatric unit will be monitored every 15 minutes for behaviors associated with that precaution... III. Monitoring... A. Patients on the Psychiatric Unit with orders for Precautions will be observed as follows: A. Suicide Precautions... verbalizing they are depressed, despaired... feel gloomy... Assault Precautions... tense, nervous or agitated... Sexually Acting Out (SAO)... Preoccupation with sexual thoughts... exposing self... disrobing... Withdrawal Precautions...shakes, tremors, cravings..."

3. On 11/7/18 at approximately 3:00 PM, an interview was conducted with E #1 (Registered Nurse). E #1 stated that the patient's location is only recorded on the safety rounds sheet every 15 minutes. E #1 could not state how the patient's behaviors associated with the safety precautions order for each patient were documented every 15 minutes.

4. On 11/7/18 at approximately 3:35 PM, findings were discussed with E #5 (Nurse Manager/Covering for Director of Behavioral Health). E #5 agreed that patients' behaviors associated with the safety precautions should be monitored every 15 minutes. However, E #5 could not show documentation to verify that patients' behavior associated with safety precaution orders were monitored every 15 minutes. E #5 said, "The safety precautions are documented every shift (every 8 hours)."