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.

GATEWAY REGIONAL MEDICAL CENTER 2100 MADISON AVENUE GRANITE CITY, IL 62040 Oct. 24, 2018
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interview, it was determined for 3 of 10 patients (Pt #1, Pt #3, and Pt #7), admitted to the Behavioral Health Unit, the Hospital failed to ensure patients received care in a safe environment by ensuring 15 minute patient observations were being conducted. This has the potential to affect all patients receiving care in the Behavioral Health Unit (current census of 16).

Findings include:

1. On 10/22/18 at 1:00 PM, the medical record of Pt #1 was reviewed. Pt #1 was admitted on [DATE]. Pt #1 was placed on fall risk and standard observation. Standard observation required assigned staff to make direct visual contact with patients every 15 minutes and document the patient's location and activity and confirm they were in no danger or distress. Pt #1's "Patient Observation" sheet for 09/23/18 did not have the required staff initials, location code, activity code, and behavior code annotated between the times of 10:00 AM thru 10:38 AM.

2. On 10/23/18 at 10:00 AM, the medical record of Pt #3 was reviewed. Pt #3 was admitted on [DATE]. Pt #3 was placed on fall risk and standard observation. Pt #3's "Patient Observation" sheet for 09/13/18 did not have the required staff initials, location code, activity code, and behavior code annotated between the times of 7:30 PM thru 8:30 PM.

3. On 10/23/18 at 11:00 AM, the medical record of Pt #7 was reviewed. Pt 7 was admitted on [DATE]. Pt #7 was placed on fall risk and standard observation. Pt #7's "Patient Observation" sheet for 10/10/18 did not have the required staff initials, location code, activity code, and behavior code annotated between the times of 7:00 PM and 7:30 PM. Pt #7's "Patient Observation" sheet for 10/11/18 did not have the required staff initials, location code, activity code, and behavior code annotated between the times of 5:30 PM and 6:00 PM.

4. On 10/23/18 at 1:30 PM, the Hospital policy "BHS.025 Observation Levels" revised 02/01/2016 was reviewed. Under "J. Standard Observation: 1." it indicated "Assigned staff will make direct visual contact with patients and confirm they are in no danger or distress every 15 minutes and document the patient location and activity.

5. On 10/23/18 at 3:00 PM, an interview with the Director of Behavioral Health (E #1) was conducted. E #1 confirmed the "Patient Observation" sheets for Pt #1, Pt #3, and Pt #7 were not complete and explained there should have been annotations every 15 minutes for all patients admitted to the Behavioral Health Unit.