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.

PERIMETER BEHAVIORAL HOSPITAL OF SPRINGFIELD 2828 N NATIONAL SPRINGFIELD, MO 65803 May 21, 2020
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interview, record review, and policy review, he hospital failed to ensure that:
- Body piercings/jewelry were recognized as a type of contraband (items that are illegal, forbidden, or that can be used to harm self or others) for one current patient (#6) of one current patient reviewed, who was admitted to the inpatient unit with two nose rings that she later used to pierce her navel.
- Patient observation forms were consistent with the physician orders for the level of observation for three current patients (#1, #3, and #5) of eight current patients reviewed, and three discharged patients (#7, #8 and #9) of four discharged patients reviewed.
- Staff nurses consistently completed patient rounding every two hours on the patient observation forms for five current patients (#1, #2, #3, #5, and #6) of eight current patients reviewed, and three discharged patients (#7, #8 and #9) of four discharged patients reviewed.
These failures had the potential to place all patients at risk for their health and safety. (A-0395)

These deficient practices resulted in the hospital's non-compliance with specific requirements found under 42 CFR 482.23 Condition of Participation: Nursing Services. The hospital census was eight.

The severity and cumulative effect of these practices had the likelihood to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 05/21/20 the hospital was informed of the IJ and they immediately put interventions in place to ensure the safety of all current patients and any future patient admissions.

As of 05/21/20, the hospital had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- All inpatients had a complete skin assessment for any evidence of jewelry, body piercing's or other contraband. No patient had any evidence of these articles.
- Body piercing education was provided to all Assessment and Referral staff, and inpatient nursing staff. All nursing staff were to have this education prior to their next shift with all nursing staff trained by 05/29/20.
- The Contraband and Restricted Articles policy were revised to include body piercings and jewelry.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review, and policy review the hospital failed to ensure that:
- Body piercings/jewelry were recognized as a type of contraband (items that are illegal, forbidden, or that can be used to harm self or others) for one current patient (#6) of one current patient reviewed that was admitted to the inpatient unit with two nose rings.
- Patient observation forms were consistent with the physician orders for the level of observation for three current patients (#1, #3, and #5) of eight current patients reviewed and three discharged patients (#7, #8, and #9) of four discharged patients reviewed.
- Staff nurses consistently completed patient rounding every two hours on the patient observation forms for five current patients (#1, #2, #3, #5, and #6) of eight current patients reviewed, and three discharged patients (#7, #8 and #9) of four discharged patients reviewed.
These failures had the potential to place all patients at risk for their health and safety.

Findings included:

1. Review of the hospital policy titled, "Contraband and Restricted Articles," revised 01/31/19, showed the purpose was to ensure a safe environment and to provide a monitoring system for patients who were utilizing sharps, or items designated as contraband, and that items which are considered a danger or potential danger to patients and others will be locked in the contraband closet. The policy did not list body piercings or jewelry as items that were restricted.

Review of an undated hospital document titled, "Patient Rules," showed jewelry listed as an item not allowed on the unit. Body piercings was not listed.

Review of Patient #6's Initial Psychiatric Evaluation, dated 02/28/20 at 10:29 AM showed that:
- The patient was a [AGE] year old female with a past psychiatric history of Depressive Mood Disorder(involves persistent feelings of sadness, or periods of feeling overly happy, or fluctuations from extreme happiness to extreme sadness), Oppositional Defiant Disorder (ODD, a disorder marked by defiant and disobedient behavior to authority figures), and Attention Deficit/Hyperactive Disorder (ADHD, characterized by problems with keeping attention to one thing and impulsive behaviors).
- The patient presented with aggression and suicidal ideation (SI, thoughts of causing one's own death).
- She was adopted at age three due to history of physical and sexual abuse.
- She had a history of 14 psychiatric hospitalization s for SI with one attempt two years ago when she drank bleach.

Record review of Patient #6's medical record showed:
- Her picture, dated 02/27/20 at 11:32 PM, with two nose rings, one on the side of her right nostril and one underneath her nose.
- She was admitted on [DATE] with a chief complaint of aggression and depression.
- Admission precautions were listed as assaultive, elopement and self-harm/suicide precautions with the precaution level of routine every 15 minute rounding.
- Initial medical screening showed her skin assessment was normal, with two piercings noted on her nose and a scar on her navel.

Review of Patient #6's nursing notes showed that:
- Frequent verbalizations from the patient that she felt suicidal, wanted to self-harm or was threatening to others.
- On 03/30/20, the patient charged at the exit door, pushed and hit staff, and verbally threatened to kick a pregnant nurse's stomach.
- On 04/15/20, the patient informed Staff P, Registered Nurse (RN), that she had removed her nose rings and pierced her navel.
- On 04/17/20, the patient's navel piercing looked red and infected.

During an interview on 05/18/20 at 3:43 PM Patient #6 stated that she "got mad" sometimes and did things she shouldn't and that the staff didn't watch the patients closely.

During an interview on 05/20/20 at 3:25 PM, Staff P, RN, stated that:
- The patient had informed him that she removed her nose rings and pierced her navel.
- He was unaware of when it actually occurred, and that if a patient presented to the hospital for admission with body piercings, whomever admitted them decided if they could keep them in place or not.
- There was another recent patient who was allowed to keep a nose ring, "small earring type" body piercing after admission to the unit.
- He was not aware of the term, "Contract for Safety," used in the hospital policy, but that staff had negotiated with patients previously; if they did not self-harm, their level of observation decreased.

Review of Patient #6's physician orders showed admission orders dated 02/28/20, that did not include an order for the patient to keep her body piercing. A physician order dated 04/16/20, directed staff to clean piercing site with antibacterial soap and water twice a day for two weeks and administer Keflex (oral antibiotic medication) 500 milligrams (mg, a measure of dosage strength) per mouth four times a day for five days.

During an interview on 05/21/20, Staff R, Behavioral Health Technician (BHT, interchangeable with Mental Health Technician [MHT]) stated that:
- Patients were allowed to remain on 15 minute observations if a body piercing was left in.
- If the patient was a self-harmer, and a piercing was allowed to stay in, the observation level would have changed to line of sight (LOS) or one to one (1:1, continuous visual contact with close phsyical proximity).
- Anything that pierced the skin was considered contraband and if a piercing was found at the time of a body search, she would have reported it to the nurse; a physician's order was required for a piercing to have been kept by a patient.
- Self-harmers were usually placed on LOS or 1:1 unless the patient went several days without self-harming.
- Patient #6 was very aggressive and had made threats and attacked many staff members since she was admitted .
- She recalled Patient #6 had threatened to kick a pregnant nurse in her stomach.
- She thought Patient #6 was dangerous and had unpredictable behavior.
- The earring could have been used to self-harm or used to injure staff or another patient.
- Patient #6 had stolen staff members' badges on several occasions and tried to elope through the unit's locked doors.
- Many BHT's reported issues to the nurses, but they were usually so busy that it was not addressed.

During an interview on 05/20/20 at 4:30 PM, Staff G, Chief Executive Officer (CEO), stated that:
- He was unaware that a patient had removed her body piercing and used it to pierce her navel.
- If on admission a patient stated that they were unable to remove body piercings then they were allowed to keep them.
- He expected if an incident occurred, that the incident was noted, the physician notified, and any new orders received were noted in the chart.

During an interview on 05/21/20 at 8:40 AM, Staff B, Assessment and Referral (A&R) Director, stated that upon admission, staff would attempt to have patients remove their body piercings but did not force them to remove them. She stated that the admission staff would communicate with the unit and then the nurse would get an order for the body piercings to remain in.

During an interview on 05/27/20 at 10:50 AM, Staff V, Medical Director stated that his expectations were that patients should have not been allowed to have nose rings. He felt that staff became complacent and overlooked the obvious.

It was unknown when Patient #6 removed her nose rings and used them to pierce her navel, as staff was unaware that this had occurred until the patient verbalized to Staff P what she had done on 04/16/20. The patient frequently verbalized thoughts of self-harm and threatened to hurt others. There was no communication from the A&R staff to the unit nursing staff of the need to obtain a physician order for the patient to keep her body piercings.

2. Review of the hospital's policy titled, "Rounds for Patient Observation," dated 01/19/20, showed that:
- An accurate record of the whereabouts and behavior of all patients were to be maintained during each shift.
- 15 minute patient observation rounds were to occur every 15 minutes, 24 hours a day and seven days a week for all patients.
- Nursing was to oversee the patient observation rounding sheets and authenticate every two hours.
- BHT's were to observe each patient every 15 minutes according to the patient's precaution level and document on the patient observation form.
- BHT's were to document patient location and behavior when the observation occurred.
- BHT's were to monitor hallways and patient care areas to ensure patients were not entering rooms not assigned to them.
- BHT's were to visually observe patients when behind closed doors by knocking, announcing their entrance and opening doors to visually observe the safety of the patient.
- Three levels of observation were assigned to patients according to their risk level; Level one observation (One on one [1:1, continuous visual contact with close physical proximity]), Level two observation (Line of site, [LOS, to continuously visualize contact with the patient]), and Level three observation (every 15-minute observation).

Review of the incident event description dated 03/10/20 at 6:33 PM showed:
- Patient #8 was in the dayroom and requested to go to the bathroom in her room #106.
- Patient #1 was in the dayroom and complained of feeling sick at 6:18 PM and asked to go to his room #105 to lay down.
- At 6:33 PM Staff L, BHT, went to find the patients and they could not be located.
- Staff L then asked for assistance from Staff K, BHT, in locating patients.
- At 6:37 PM, the BHT's entered Patient #8's room and found Patient #8 and Patient #1 in Patient #8's bathroom in room #106, engaged in sexual intercourse.

During the time of the incident, there was a code called on the 200 Unit at 5:20 PM and multiple staff were pulled to that unit. This left the two BHT's on the 100 Unit to care for 10 patients with Patient #8 on a 1:1 level of observation and Patient #1 on LOS observation. The hospital failed to adhere to the observation levels appropriately for these patients.

Review of a video dated 03/10/20 of the hallway in front of Rooms #105 and #106 showed:
- At 5:32 PM three males that included Patient #1 and two females that included Patient #8, were interacting in the hallway unsupervised.
- At 5:54 PM the same five patients were in the hallway, then one male came out of the female's room and threw a football hitting another patient.
- At 5:56 PM Patient #1 and Patient #8 were interacting off to the side by themselves.
- At 6:20 PM Patient #1 and Patient #8 went into Patient #1's room and shut the door.
- At 6:25 PM Patients #1 and #8 exited the room.
- At 6:26 PM Patient #8 entered her room into the bathroom and Patient #1 paced outside the room for a few seconds, then went into her room and shut the door.

Review of Patient #1's history and physical, (H&P) dated 03/08/20 at 4:42 PM, showed that:
- The patient was a [AGE] year old male.
- The patient has had multiple admissions due to SI.
- The patient had a history of physical aggression.

Review of Patient #1's psychiatric evaluation on 03/08/20 at 2:00 PM, showed that the patient was Bipolar (a disorder that causes unusual shifts in mood, energy, activity levels and the ability to carry out day-to-day tasks), Generalized Anxiety Disorder (GAD, ongoing anxiety that interferes with daily activities), ADHD and ODD.

Review of Patient #1's 15 minute observation form dated 03/10/20, showed that the patient's level of observation was LOS and between 4:45 PM and 6:15 PM, no 15 minute rounds were completed. There was a line marked diagonally with the words "high acuity" written in the space. During this hour and a half, there were no observations documented.

Review of Patient #8's H&P dated 03/04/20 showed:
- The patient was a [AGE] year old female.
- The patient had a history of depression, anxiety, Bipolar and Post-traumatic Stress Disorder (PTSD, a condition of persistent mental and emotional stress occurring as a result of injury of sever psychological shock).
- The patient presented for self-harm (cutting) with SI.

Review of Patient #8's psychosocial assessment dated [DATE] at 1:00 PM showed that:
- The patient's biological parents used and dealt drugs out of their home.
- The patient used drugs at nine years old, alcohol at [AGE] years old, and tobacco at [AGE] years old.
- The patient was taken away from her biological parents at nine years old and put into the foster care system.
- The patient reported that she had been raped by her foster parent's [AGE] year old son.

Review of Patient #8's 15 minute observation form dated 03/10/20, showed that the patient's level of observation was 1:1 and between 4:45 PM and 6:15 PM, no 15 minute rounds were completed. There was a line marked diagonally with the words "high acuity" written in the space. During this hour and a half, there were no observations documented.

During an interview on 05/18/20 at 4:00 PM, Patient #1 stated that on 03/10/20, the day of the incident, Staff L, BHT let the patients out in the hall unsupervised. He stated he didn't know Patient #8 was only [AGE] years old.

During an interview on 05/19/20 at 2:10 PM, Staff K, BHT, stated that Staff L, BHT was responsible for watching Patient #1 and Patient #8. She felt that Staff L trusted these patients to do the right thing, but they took advantage of her. She also stated that she felt that the new staff and PRN (as needed) staff were not trained appropriately. Staff L was PRN staff and Staff M, RN, Charge Nurse, had been fired prior to the survey for a separate incident.

Three attempts were made to contact Staff L, BHT, for an interview with no response.

Three attempts were made to contact Staff M, RN, Charge Nurse, for an interview, with no response. Staff M was the nurse responsible for rounding on Patient #1 and Patient #8 to ensure they were properly observed. The rounding sheets for both of these patients showed no documentation for her two hour observations.

Review of Patient #3's psychiatric evaluation on 05/14/20 showed that the patient was a [AGE] year old male with a past psychiatric history of PTSD, who presented to the hospital with aggressiveness, angry outbursts, and mood swings. Patient #3 denied any SI or thoughts of self-harm. The patient had a previous psychiatric admission a couple months prior. Admission observation level was LOS.

Review of Patient #3's medical record showed:
- The patient's observation form, dated 05/15/20 through 05/18/20, showed the observation level was every 15 minute checks.
- The physician's order dated 05/19/20, the level of observation was LOS.
- The patient's observation form, dated 05/19/20, showed the observation level was both 15 minute checks and LOS; the patient observation form did not indicate when the observation level had changed or which observation level was to have been followed.

Review of Patient #5's psychiatric evaluation on 05/06/20 at 8:23 AM showed that the patient was a [AGE] year old female with a past psychiatric history of Bipolar disorder, cannabis (marijuana) use, and ODD, who presented to the hospital for SI related to a miscarriage two years previously. Admission observation level was LOS.

Review of Patient #5's medical record showed:
- The patient observation form dated 05/10/20, no observation level was marked.
- The physician's order dated 05/19/20 at 4:22 PM stated for LOS for self-harm.
- The patient observation form dated 05/19/20 had observation level as 15 minute checks.

Review of discharged Patient #7's psychiatric evaluation on 04/29/20 showed that the patient was a [AGE] year old female with a past psychiatric history of bipolar disorder, PTSD, ADHD, and extensive anxiety, who presented with SI. She had attempted to self-harm over the past three days and had a plan to hang herself. Admission observation level was every 15 minute checks.

Review of Patient #7's medical record showed:
- The physician's order dated 05/02/20 at 8:10 AM stated to change patient to LOS;
- The patient's observation form dated 05/02/20 had observation level as 15 minute checks.
- The physician's order dated 05/02/20 at 5:30 PM to continue LOS for 24 hours/day.
- The patient's observation form dated 05/03/20 and 05/04/20 had observation level as LOS while awake.

Review of discharged Patient #9's psychiatric evaluation on 04/18/20, showed that the patient was a [AGE] year old female with a past psychiatric history of PTSD, Depression, GAD, and ODD, who presented to the hospital for threats to self-harm, SI, and homicidal ideations (HI, thoughts or attempts to cause another's death), which was only directed towards her mother. The patient had four psychiatric hospitalization s this year, with three of those admissions at two other psychiatric hospitals. Admission observation level was LOS.

Review of discharged Patient #9's nursing notes showed frequent documentation that the patient had felt suicidal and wanted to self-harm. .

Review of discharged Patient #9's journals, written while hospitalized , showed in graphic detail that she desired to self-harm and kill herself.

Review of discharged Patient #9's medical record showed:
- The physician's order dated 05/02/20 stated to continue LOS observation level 24 hours/day.
- The patient's observation form dated 05/02/20 showed the observation level was 15 minute checks.
- The physician's order dated 05/03/20 stated to continue LOS for 24 hours/day.
- The patient's observation form dated 05/03/20 showed the observation level was both 15 minute checks and 1:1; the patient observation form did not indicate a time the observation level had changed and did not indicate which observation level was to have been followed.
- The physician's order dated 05/04/20 at 9:03 AM stated to continue LOS 24 hours/day.
- The physician's order dated 05/04/20 at 10:36 AM stated to change patient from LOS 24 hours/day to 1:1 at all times.
- The patient's observation form dated 05/04/20 showed the observation level was both LOS while awake and 1:1; the patient observation form did not indicate a time the observation level had changed and did not indicate which observation level was to have been followed.
- The physician's order dated 05/05/20 and 05/06/20 stated to continue 1:1 at all times.
- The patient's observation form dated 05/05/20 and 05/06/20 showed the observation level was both 15 minute checks and 1:1; the patient observation form did not indicate when the observation level had changed or which observation level was to have been followed.

The failure to consistency follow the physician's orders for the correct observation level, placed all patients at risk for their safety and allowed the opportunity to self-harm or participate in inappropriate behavior while not being appropriately monitored.

3. Review of Patient #2's psychiatric evaluation on 05/14/20 showed that the patient was an eight year old male with a past psychiatric history of ADHD, ODD, Depression, and Disruptive Mood Dysregulation Disorder (DMDD, a condition in which a child is chronically irritable and has frequent, severe temper outbursts out of proportion to the situation), who presented to the hospital after destroying the house, attacking siblings, threatened suicide by ingestion of bleach, and refused to take his medications at home. The patient had denied any SI. Patient #2 was evaluated for suicide risk and was scored as a low risk. Admission observation level was every 15 minute checks.

Review of Patient #2's patient observation forms showed:
- On 05/16/20 observation level was every 15 minute checks. There was no nurse authentication from 10:45 AM to 1:30 PM and 2:00 PM to 4:45 PM.
- On 05/17/20 observation level was every 15 minute checks. There was no nurse authentication from 1:00 PM to 3:45 PM and 4:00 PM to 6:45 PM.
- On 05/18/20 observation level was every 15 minute checks. There was no nurse authentication from 5:45 AM to 7:15 PM.
- On 05/19/20 observation level was every 15 minute checks. There was no nurse authentication from 5:45 AM to 7:30 PM.
- On 05/20/20 observation level was every 15 minute checks. There was no nurse authentication from 5:45 AM to 11:15 AM, the time of discharge.

Review of Patient #3's patient observation forms showed:
- On 05/15/20 observation level was every 15 minute checks. There was no nurse authentication from 7:00 AM to 11:15 AM, 2:45 PM to 5:15 PM, and 5:15 PM to 7:30 PM.
- On 05/16/20 observation level was every 15 minute checks. There was no nurse authentication from 6:15 AM to 9 AM, 10:45 AM to 1:30 PM, and 2:00 PM to 4:45 PM.
- On 05/17/20 observation level was every 15 minute checks. There was no nurse authentication from 1:00 PM to 3:35 PM, 4:00 PM to 6:45 PM, and 7:00 PM to 9:30 PM.
- On 05/18/20 observation level was every 15 minute checks. There was no nurse authentication from 5:45 AM to 7:15 PM.
- On 05/19/20 observation level was every 15 minute checks and LOS. There was no authentication from 5:45 AM to 4:45 PM, the time of discharge.

Review of Patient #5's patient observation forms showed:
- On 05/06/20 observation level was LOS. There was no nurse authentication from 8:30 AM to 1:00 PM and 4:00 PM to 7:30 PM.
- On 05/07/10 observation level was every 15 minute checks. There was no nurse authentication from 5.45 AM to 8:30 AM and 8:45 AM to 12:30 PM.
- On 05/12/20 observation level was every 15 minute checks. There was no nurse authentication from
6:15 PM to 6:45 AM on 05/13/20.
- On 05/13/20 observation level was every 15 minute checks. There was no nurse authentication from 7:00 AM to 8:30 PM.
- On 05/14/20 observation level was every 15 minute checks. There was no nurse authentication from
7:45 AM to 7:00 PM.

Review of Patient #6's patient observation forms showed:
- On 03/08/20 observation level was every 15 minute checks. There was no nurse authentication from 10:30 AM to 6:45 PM.
- On 03/09/20 observation level was every 15 minute checks. There was no nurse authentication from 7:00 AM to 7:30 PM.
- On 04/30/20 observation level was every 15 minute checks. There was no nurse authentication from 7:00 AM to 7:00 PM.
- On 05/19/20 observation level was every 15 minute checks. There was no nurse authentication from 7:00 AM to 7:30 PM.

Review of Patient #7's patient observation forms showed:
- On 04/29/20 observation level was every 15 minute checks and LOS. There was no nurse authentication from 5:00 PM (arrival to unit) to 11:30 PM.
- On 04/30/20 observation level was every 15 minute checks. There was no nurse authentication from 7:00 AM to 7:00 PM.
- On 05/01/20 observation level was 15 minute checks and 1:1. There was no nurse authentication from 8:15 AM to 1:45 PM.
- On 05/03/20 observation level was LOS while awake. There was no nurse authentication from 7:45 AM to 8:15 PM.
- On 05/04/20 observation level was LOS while awake. There was no nurse authentication from 1:30 PM to 7:45 PM.
- On 05/06/20 observation level was every 15 minute checks. There was no nurse authentication from 11:57 AM to 6:30 PM.
- On 05/09/20 observation level was every 15 minute checks. There was no nurse authentication from 7:00 AM to 5:15 PM.

Review of discharged Patient #9's patient observation forms showed:
- On 05/02/20 observation level was every 15 minute checks. There was no nurse authentication from 2:00 PM to 4:30 PM and 8:30 PM to 11:30 PM.
- On 05/03/20 observation level was 15 minute checks and 1:1. There was no nurse authentication from 8:00 AM to 8:00 PM.
- On 05/04/20 observation level was 1:1 and LOS. There was no nurse authentication from 10:30 AM to 1:15 PM.
- On 05/05/20 observation level was 15 minute checks and 1:1. There was no nurse authentication from 5:45 AM to 10:30 AM, 12:45 PM to 3:00 PM, and 6:00 PM to 05/06/20 at 11:45 AM.
- On 05/06/20 observation level was 15 minute checks and 1:1. There was no nurse authentication from noon to 6:45 PM.

During an interview on 05/20/20 at 3:25 PM, Staff P, RN stated that:
- Licensed nurses were expected to initial the patient observation forms every two hours to indicate that they have visibly seen the patient.
- He knows staff does not do this because the video monitors were checked by leadership and if they weren't seen making that visual observation of the patient they were reprimanded and written up for false documentation.
- He was unsure if nurses actually checked and verified the correct level of observation was indicated on the rounding sheet when it was signed.
- It was the responsibility of the licensed nurse to have ensured that each patient's observation form indicated the correct level of observation when it was signed.

During an interview on 05/18/20 at 3:15 PM, Staff E, Licensed Practical Nurse (LPN), stated that staff nurses were to have documented patient rounds every shift and the BHT's were to have documented every 15 minutes on the patient observation form; the level of observation was updated by the BHT.

During an interview on 05/18/20 at 4:09 PM, Staff F, BHT, stated that:
- Staff nurses were to have documented every two hours on the patient observation form at the time they rounded on each patient.
- The BHT checked the dry erase board on the back of the nurse's station door at the start of each shift and verified the patient's level of observation.
- The dry erase board was updated prior to the start of each shift with any updated orders for level of observation.

During an interview on 05/19/20 at 3:05 PM, Staff O, BHT, stated that the staff nurses were to have rounded on each patient and signed the patient observation form every two hours.

During an interview on 05/20/20 at 9:54 AM, Staff S, RN, stated that:
- Staff nurses were to have rounded on patients every two hours and signed the patient observation form.
- As long as the patient observation form was signed close to every two hours, it was ok.
- BHT's were to have checked the dry erase board behind the nurse's station door that is updated with the patient's observation level for that shift.
- She did not usually check the top of the patient observation form to ensure the correct level of observation was indicated.

During an interview on 05/21/20 at 9:00 AM, Staff R, BHT, stated that:
- When there was a change in a patient's level of observation, the same patient observation form was used.
- When there was a change in a patient's level of observation, she documented the date, time, and the changed level in the note section of the patient observation form; she was not taught to document in the notes when the level of observation was changed and has not seen any other staff documented changes there.
- The night shift had the responsibility and started each new patient observation form with the current level of observation ordered.
- Staff nurses were to have rounded on patients every two hours, but the nurses were usually too busy; if she wanted the patient observation form signed by a nurse, she would have had to physically find them and have it signed.

During an interview on 05/19/20 at 4:05 PM, Staff D, QA and Risk Management Director, stated that the patient observation forms had been a problem and often times were not signed every two hours by the staff nurses; when there was a concern brought to my attention about if the form had been completed correctly, she would have watched the unit video, confirmed that it was or was not completed, and then that staff member would have been counseled.

During an interview on 05/27/20 at 10:50 AM, Staff V, Medical Director stated that he expected the level of observations for the 15 minute rounding as well as the 1:1 and LOS observations should have been strictly adhered to but he felt that their staffing algorithm (set of rules to be followed for problem-solving) was not accurate for the acuity (the severity of a patient's illness and the level of attention they will need from the staff) level of their patients.

The lack of supervision by the licensed nursing staff for these vulnerable patients, who were known to have self-injurious behavior, placed all patients at risk for their safety and health.


















































`