HospitalInspections.org

Based on observations, record reviews, and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by:

1) Failing to ensure the RN received a physician's order to change a patient's level of observation as required by hospital policy for 2 (#F5, #FR10) of 6 (#F5, #F6, #FR9, #FR10, #FR11, #FR12) current patients' records reviewed on Esplanade I Unit (acute adult unit) for physician orders to change the observation status from a total of 16 current patients on Esplanade I Unit and
2) Failing to ensure the MHTs (Mental Health Technicians) observed patients according to Physician's Orders and hospital policy for:
-3 (#F5, #FR9, #FR10) of 3 current patients on Suicide Precautions, 1 (#FR11) of 7 current patients on Close Staff Sight, and 1 (#FR12) of 9 current patients on Routine Observation from a total of 16 current patients on Esplanade I Unit (acute adult unit).
-2 (Patient #F3 and Patient #F15) out of 2 current patients on visual contact (V.C.) on Esplanade II Unit;
-1 (#F10) of 4 ( #FR7, #FR8, #F10, #F12) current patients on Visual Contact Precautions on out of a total of 6 active patients on the Live Oak Unit (Adolescent Unit).
Findings:
1) Failing to ensure the RN received a physician's order to change a patient's level of observation as required by hospital policy:

Review of the hospital policy titled "Level of Observation and Precaution", policy number TX7-1001, revised 03/20/14, and presented as the current policy by SF1Director of Clinical Services, revealed that the types of observations were Routine Observation (every 15 minutes direct observation of the location and activity of the patient is documented), Close Staff Sight (CSS) (every 10 minutes direct observation of the location and activity of the patient is documented), Visual Contact (VC) (maintain visual contact of the patient at all times), and One-to-one (1:1) (one staff member assigned within 3 to 6 feet of visual contact of the patient at all times during waking hours; during sleeping hours the staff member assigned will monitor the client from the bedroom doorway). Further review revealed the types of precautions include Suicide Precautions, Elopement Precautions, Fall Precautions, Seizure Precautions, and Withdrawal Precautions. At admission all patients will be placed on Routine Observation, and the level of observation can be adjusted when a patient poses a risk of harm to self, others, or property at the time of admission or in response to the Initial Nursing Assessment results. An order must be written to change a level of observation/precaution outside the initial placement of Routine Observation upon admission. The order must be written by a physician. If an order is written to discontinue a level of observation/precaution, the patient will revert back to Routine Observation, unless otherwise indicated in the physician's order.

Patient #F5

Review of Patient #F5's medical record revealed his admission orders were signed on 05/28/14 at 6:15 p.m. by SF16Medical Director. Review of his "RN Assessment of Risk/Initial Care Needs" revealed he arrived on Esplanade I Unit on 05/29/14 with no documented evidence of the time of arrival. Review of his "RN Assessment" revealed SF15RN completed her admit assessment on 05/29/14 at 1:30 a.m. Further review of Patient #F5's medical record revealed he was PEC'd (Physician's Emergency Certificate) on 05/28/14 at 2:00 p.m. after being found by police standing in the middle of the road telling passing drivers that he wanted to kill himself. Further review revealed he was PEC'd as being suicidal, dangerous to himself, and gravely disabled.

Review of Patient #F5's "Initial Care Orders" signed by SF16Medical Director on 05/28/14 at 6:15 p.m. revealed he was ordered to be on VC with no documented evidence of the type of precautions that were to be followed. His preliminary psychiatric diagnosis was Mood Disorder with a history of Asthma. Review of Patient #F5's "Doctor's Order Sheet" revealed an order written on 05/29/14 at 1:20 a.m. by SF15RN to change his precautions from VS (should be VC) to Routine Observation with Suicide Precautions. There was no documented evidence that the order was received from verbally or by telephone with read-back verification from a physician as required by hospital policy.

Review of Patient #F5's "Suicide Risk Assessment" included in his "RN Assessment of Risk/Initial Care Needs" and completed by SF15RN revealed Patient #F5's suicide risk was scored as a "4" by SF15RN (the factors checked totaled 5 rather than 4) with a score of 1 next to gender, Depression,use of alcohol within 72 hours, diagnosed or perceived chronic medical condition, and support system lacking. A note above the assessment on the form stated "if starred factors or three or more factors circled, then consider visual contact or 1:1." There was no documented evidence that SF15RN had reviewed her assessment with a physician as evidenced by the section for the time reviewed and the name of the physician being blank.

In an interview on 05/29/14 at 2:45 p.m., SF19DON indicated that she had done one-to-one education with the nurses about needing a physician's order to change a patient's observation level, but she had not gotten to SF15RN yet.

In a telephone interview on 05/30/14 at 8:30 a.m., SF15RN indicated "I'm new at the company and just do what the other nurses told me to do... can use our discretion" when asked if she had a physician's order to decrease the level of observation for Patient #F5. She confirmed that she did not get a physician's order to change Patient #F5's observation from VC to Routine Observation. SF15RN indicated that they do not have enough staff for everyone to be on VC, but if it's necessary, "I'd keep them on VC." She indicated that after she assessed Patient #F5, he told her that he was upset because his girlfriend had cheated on him. She further indicated that he was anxious to get to sleep and was placed on the side of the unit where a MHT was seated near his room most of the night. When asked if she was aware that he had been found in traffic telling drivers passing by that he wanted to kill himself, SF15RN answered, "he said he was trying to get to his daughter's house and never wanted to commit suicide." SF15RN indicated that she read Patient #F5's PEC. When the surveyor read what was written as stated above (about being found in traffic), she answered, "I read the PEC but sometimes I can't read the writing... I can't actually remember reading what you read to me." When asked if it was common practice for the nurses to change the patient's level of observation without obtaining a physician's order, SF15RN answered, "I'm not clear on it, but I'm going on what I'm trained on and wouldn't do what I haven't been trained on." She indicated that in the middle of the night "I don't have access to SF16Medical Director."

In an interview on 05/30/14 at 10:05 a.m., SF1Director of Clinical Services indicated that Patient #F5 remained on Routine Observation with Suicide Precautions. She confirmed that after administration was notified on 05/29/14 that there was no documented evidence that the order written by SF15RN to change Patient #F5's level of observation had been given by a physician, there had been no assessment made and a new order other than VC written by a physician as required by hospital policy.

Patient #FR10

Review of Patient #FR10's medical record revealed he was admitted on 05/28/14 at 12:00 p.m. with a diagnosis of Mood Disorder and arrived on the unit at 6:20 p.m. He was PEC'd on 05/27/14 at 6:15 p.m. due to being suicidal and dangerous to self. He was CEC'd on 05/28/14 at 12:00 p.m. as being suicidal and dangerous to self.

Review of Patient #FR10's admission orders signed by SF16Medical Director revealed an order for VC with no documented evidence of special precautions. Review of his "Doctor's Order Sheet" revealed a telephone order was received from SF17NP (Nurse Practitioner) to change from VC to CSS with Suicide Precautions. Further review revealed an order was writte