HospitalInspections.org

Based on interview and record review, the facility failed to ensure care of patients in a safe setting. The facility implemented an inconsistent policy and practice related to patient observation levels.

a. The facility "Precaution Level" policy was not fully developed.

b. The current "Patient Observation Form Q 15 " was not consistent with the precaution policy.

c. Facility staff understanding of patient precaution levels was inconsistent.

Findings included:

a. Precaution level policy not filly developed:

Record review of facility policy titled "Precautions," dated 8/1/2022 , showed the following:

* Voyages Behavioral Health (VBH) utilizes the following safety precautions:

-Danger to Self (DTS)
-Danger to Others (DTO)
-Sexually Acting Out ( SAO )
-Vulnerability ( VP)
-Elopement (EP)
-Fall ( FP)
-Seizure (SP)
-Detoxification ( DETOX)

The policy did not define the meaning of any of the above-listed precautions. The policy did not outline specific criteria or patient history that would trigger these precautions to be ordered / initiated

b. Patient Observation Form and Precaution Policy not consistent:

Review of the current "Patient Observation Form Q 15" utilized by the facility showed the following precautions listed on the top of the page are not listed in the policy:

-Suicide
-Homicide
-Assault
-SAO ( aggressor)
-SAO ( victim)

Record review of the policy "Precaution Levels" showed the following precautions are listed in the policy are not listed on the "Patient Observation Form Q 15 " utilized for patient monitoring:

- Danger to Self (DTS);
- Danger to Others (DTO);-
- Vulnerability ( VP);
- Elopement (EP);-
- Seizure (SP);
- Detoxification ( DETOX)

c. Staff knowledge of precaution levels was inconsistent:

During interviews conducted on 1/9/2024 and 1/10/2024 between 10: 30 AM and 12:15 PM , showed the following:

Staff ID-I, RN: named falls and suicide precautions ; was unaware of any precautions related to sexually acting out

Staff ID-M, mental health tech (MHT) could not describe what "vulnerability" or "homicide "precautions meant.