HospitalInspections.org

Based on observation, review of document and staff interview, it was determined that the facility did not ensure care is provide in a safe environment for patients who are admitted to inpatient psychiatric units. Specifically, the facility does not have a process to provide constant monitoring of all areas of the inpatient psychiatric units.

This lapse in monitoring may have placed patients at risk.


Findings include:

During tours of two (2) inpatient psychiatric units (11B and 12B ) on 10/ 29 /15 at 2:00 PM, it was observed that each unit is divided into male and female beds on each side of the unit. The section of the corridor behind the nurses station, includes six (6) rooms which are toward the south end of each hall and and are completely out of view from the nurses station. There were no mirrors in the halls for observation and there are no hall monitors on either side of the halls. Instead, the staff make rounds of the rooms every hour and to patients with a higher level of observation, requiring every 15 minute rounds.

Review of the staff assignments on 10/29/15 identified that no one was assigned to constant monitoring of the hallway, including the area that is out of the view of the nursing station.

During interview on 10/30/15 at 2 PM, the Assistant Director of Nursing (ADN) for Psychiatric Services stated that usually the majority of patients are on "routine observation' which requires hourly monitoring. It was also stated that there are no hall monitors at fixed points that are out of the view of the nursing station.

Review of hospital policy and procedure titled "Close and Constant Observation" Section Inpatient - 3.08, last revision 3/1/11 states there are 3 (three) observation levels ordered by the psychiatrist. These are "Routine" where the patient is observed on an hourly basis; "Close observation," in which patients are observed on an every 15 minute basis, and "Constant Observation" which a 1 to 1 level of supervision.

During interview with the Assistant Director of Nursing (ADN) for Psychiatry on 10/30/15, it was stated that usually the majority of patients are on " routine observation "which requires " hourly monitoring ".It was also stated that there are no hall monitors at fixed posts.

The facility does not have a process to provide constant monitoring of the hallways throughout the unit to ensure a safe environment.