HospitalInspections.org

Based on videotape review, record review and staff interview, it has been determined that the hospital failed to meet the Nursing Services Condition of Participation relative providing nursing care in accordance with accepted standards of nursing practice.

1. The hospital failed to properly observe a patient with a physician's order for 1:1 constant observation.(Refer to A- 0395)

2. The hospital failed to follow their own policy for medication administration.(Refer to A-0398)

Based on surveyor observation, medical record review, and staff interview, it has been determined that the hospital failed to provide nursing care in accordance with accepted standards of nursing practice relative to the monitoring of a patient with a physician's order for 1:1 constant observation, for 1 of 3 patient's, Patient ID #1.

Findings are as follows:

The hospital's "Patient Observation Policy," last approved in February 2020, states, in part,

" ...Definitions: Definition of nursing staff equates to Certified Nursing Assistants, Institutional Attendants Psychiatric, Mental Health Worker, and Psychiatric Technicians.

1. Continuous 1:1 Observation: The most intensive standard level of observation. It assigns a staff member to constantly observe the patient. It will be used for patients that inflict self-harm, suicide ideation, and violent behavior thought to be imminent without observation ...
1) An assigned staff member must always be with the patient, including in the bathroom ...
2) The staff member must always be able to visually observe the patient and be able to quickly intercede should it become necessary. The distance between the patient and the staff member should not exceed 8 feet and no more than an arm's [sic] length may be necessary if the patient condition warrants ...

Procedures [for] Continuous 1:1 Observation...
b. Staff must remain with the patient when the patient is showering or using bathroom facilities ..."

Surveyor observation of the videotape for Patient ID #1's constant observation on 12/5/2021 beginning at 1:54 PM revealed the following:

1:54:37 PM: Patient ID #1 removes a grey sweatshirt and black sweatpants from a paper bag while under continuous observation (CO) by Staff D, the Mental Health Worker assigned to the patient. She/he then puts the sweatshirt on and exits the room holding the sweatpants.

1:55:10 PM: Patient ID #1 remains under CO by Staff D as she/he proceeds to and enters the dayroom. While in the dayroom Patient ID #1 picks up a pair of glasses and a drinking cup off the table. She/he motions as to drink from the cup.

1:55:21 PM: Patient ID #1 enters the bathroom with the black sweatpants over his/her shoulder. The door to the bathroom is closed and Staff D was positioned outside of the bathroom.

1:56 PM: Staff D appears to get the attention of the RN, Staff A, through the window of the nurses station.

1:56:12 PM: Staff A and Staff E, another RN, enter the unit bathroom area.

1:56:19 PM: Staff A opens the bathroom door, observes inside the bathroom, and then closes the bathroom door with the patient still inside. Staff A, D and F remain in the hallway outside of the bathroom and appear to be talking amongst themselves. Staff D has the clipboard with the Patient Observation Sheet attached.

1:56:44 PM: Staff A opens the bathroom door to check on Patient ID #1. Staff A closes the door, leaving it slightly ajar. None of the staff are observing the patient when the door is slightly ajar.

1:57:18 PM: Patient ID #1 exits the bathroom and walks down the corridor to the kitchen area and helps his/herself to a cup and drink. Staff A, D and F remain in the day room talking amongst themselves with no CO being performed.

1:57:38 PM: Patient ID #1 removes a cup from the right pocket of the sweatpants she/he is wearing.

1:57:55 PM: Patient ID #1 walks towards Staff A, D and F with 2 cups in his/her hands. Patient ID #1 talks to the staff and shows Staff F his/her mouth along with a cup in his/her right hand and a cup in his/her left hand.

1:58:25 PM: Patient ID #1 puts one of the cups to his/her mouth. Staff A and F run towards the patient and grab his/her hands in attempt to stop Patient ID #1 from ingesting the contents of the cup.

1:58:34 PM: Staff F grabs the patient around his/her waist and appears to perform the Heimlich maneuver. Patient ID #1 takes a gallon of water off the serving kitchen shelf and attempts to drink it.

1:58:46 PM: Patient ID #1 appears to spit white pills and water on the floor.

At 2:37:57 PM, after Patient ID #1 has been evaluated by nursing and assessed by the physician, she/he is taken to an acute care hospital via ambulance for further evaluation and treatment.

Surveyor review of the medical record for Patient ID #1 revealed she/he was admitted to hospital's Forensic unit in August 2021 with a primary diagnosis of Borderline Personality Disorder (a psychiatric illness marked by an ongoing pattern of varying moods, self-image, and behavior which often result in impulsive actions) and a mood disorder.

The most recent provider order for observation from 12/4/2021 at 3:45 PM states, "Continue 1:1 observation on 1st and 2nd shifts [days and evenings] for safety due to [increased] risk of SIB [self-injurious behavior]. [Perform every] 5-minute checks on 3rd shift [during the night] for safety."

Further review of the provider documentation from 12/5/2021 at 2:30 PM revealed that Patient ID #1 ingested a "cupful" of pills that s/he had "evidently concealed over a period of time," resulting in Patient ID #1 being transferred and admitted to an acute care hospital with the diagnosis of "drug overdose."

During an interview with the Risk Manager on 12/7/2021 at approximately 2:00 PM, he stated that Staff D reported to him that he thought he "tagged out" the patient's care to Staff A when she came to the unit to observe the patient in the bathroom; however, he acknowledged that he continued to stay in the area. Additionally, the Risk Manager stated that when he interviewed Staff E, she stated that when she observed the patient holding the 2 cups in the hallway his/her cheeks were full and pills were hanging out of his/her mouth.

During surveyor interview with Staff A on 12/8/2021 at 10:45 AM, she acknowledged that Staff D asked her to check on Patient ID #1 while she/he was in the bathroom. Staff A further acknowledged that she did not visually observe the patient, as per policy, and instead, she checked on his/her verbally.

Staff A recalled that Patient ID #1 left the bathroom and proceeded down the hallway to get a drink; next, she/he stated was when they noticed s/he had a "mouthful of pills." Staff A stated that she observed probably 15-20 pills in Patient ID #1's mouth, and she was able to identify 2 of the pills as Benadryl, based on their color (pink). Staff A stated that there were "a lot of white pills."

Based on surveyor observation, medical record review, and staff interview, it has been determined that the hospital failed to provide nursing care in accordance with accepted standards of nursing practice and hospital policy relative to the administration of medication for 2 of 2 patients, Patient ID #'s 1 and 2.

Findings are as follows:

The hospital's "Medication Management" policy, last updated in August 2021, states, in part,

"Purpose: To insure[sic] the accurate and safe administration of medication by nurses ...

A. Administration: ...

5. Nurses administering oral medications must observe the patient to ensure that the dose has been swallowed. Unless ordered by the physician, medications are never to be left with any patient ...

1. Surveyor review of the medical record for Patient ID #1 revealed she/he was admitted to hospital's Forensic unit in August 2021 with a primary diagnosis of Borderline Personality Disorder (a psychiatric illness marked by an ongoing pattern of varying moods, self-image, and behavior which often result in impulsive actions) and a mood disorder.

Further review of the medical record revealed physician documentation from 12/5/2021 that stated, in part, that Patient ID #1 ingested a "cupful" of pills that she/he had "evidently concealed over a period of time," resulting in Patient ID #1 being transferred and admitted to an acute care hospital with the diagnosis of "drug overdose."

During surveyor interview with the Chief Nursing Officer on 12/7/2021 at 10:54 AM, she acknowledged the Medication Management policy was not followed and resulted in Patient ID #1 collecting and storing several days of medications.

2. Surveyor review of the medical record for Patient ID #2 revealed she/he was admitted to the hospital's Forensic unit in December 2021 with a primary diagnosis of schizoaffective disorder, bipolar type (a psychiatric condition consisting of a loss of contact with reality and involves manic episodes with or without depressive episodes) and cocaine use disorder.

During surveyor observation of Registered Nurse, Staff B, administering oral medication to Patient ID #2, the surveyor did not observe Staff B check the patients mouth for cheeking (concealing a medication in the mouth) to ensure the medication was swallowed, as per policy.

During an interview with Staff B immediately after she administered the medications to Patient ID #2 on 12/8/2021 at 8:17 AM, the surveyor asked Staff B how she verified the medication was swallowed; Staff B stated that she "saw the patient's throat move," verifying the patient swallowed the medication. She further stated that she asked the patient how her day was, and Patient ID #2 responded with saying "fine," which allowed her to see inside Patient ID #2's mouth and evaluate for "cheeking" (when the patient holds his/her medication in his/her cheeks).

During an interview with the Nurse Manager covering the unit on 12/8/2021 at 8:20 AM, she stated that Staff B did not properly check for cheeking as she could not have observed the complete oral cavity with a one-word conversation.

During an interview with the Nursing Staff Instructor (Staff C) and the Clinical Training Specialist on 12/8/2021 at 2:01 PM, Staff C stated that medication administration education consists of both didactic education and clinical competency observation. She further stated that the didactic education includes nursing education for ensuring the patient swallowed their medication by having the patient lift their tongue, feeling the patient's jaw line (for cheeking) and, if necessary, using a tongue depressor to manipulate the tongue. She stated that during the skills competency validation, the nurse must demonstrate having observed and ensured that the patient has swallowed the medication to be considered competent to administer medications.