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Based on observation, interview, video review, record review and policy review the hospital failed to provide one-to-one (1:1, continuous visual contact with close physical proximity) oversight for two current patients (#2 and #4) with a 1:1 order of three current patient medical records reviewed.

These failed practices resulted in a systemic failure and noncompliance with 42
CFR 482.13 Condition of Participation (CoP): Patient's Rights. The hospital census was 20.

Please refer to A-0144.

Based on observation, interview, video review, record review and policy review the hospital failed to provide one-to-one (1:1, continuous visual contact with close physical proximity) oversight for two current patients (#2 and #4) with a 1:1 order of three current medical records reviewed. The hospital census was 20.

Findings Included:

Review of the hospital's policy titled, "Observation Level and Precaution Protocol," revised 06/2025, showed:
- All inpatients will be monitored by staff per physician order every five, 10, 15 minutes, or continuous 1:1. A 1:1 order may be continuous, only when awake or asleep, per physician order specifications.
- During 1:1 supervision and monitoring staff will remain within close proximity of the patient. Close proximity is a distance at which an employee can maintain continuous visualization or intervene for high-risk behaviors.
- Night staff will remain in the doorway of the patient's room, so as to be seen on camera and by other nursing staff, for the safety of the patient and staff.

Review of the hospital's staffing assignment sheets, dated 06/01/25 through 06/08/25, showed:
- Patients #2 and #4 were roomed on the B-Pod. Patient #2 was in room 208-B and Patient #4 was in room 207-B.
- On 06/01/25 through 06/08/25, room 208-A was blocked due to Patient #2's sexually acting out (SAO) behaviors.
- On 06/05/25 through 06/08/25, room 207-A was blocked due to Patient #4's aggressive behavior.

Review of Patient #2's medical record showed:
- On 05/28/25 at 9:10 AM, a provider order was placed to maintain 1:1 observation and to block his room due to his behavior.
- On 06/01/25, from 9:30 PM through 10:00 PM, Staff L, Mental Health Technician (MHT), documented every five-minute checks and that Patient #2 was awake in his room. Staff L was assigned to observe Patient #2 and another patient, simultaneously.
- On 06/03/25, from 2:50 AM through 3:05 AM, Staff R, MHT, documented every five-minute checks and that Patient #2 was awake in his room. Staff R was assigned to observe Patient #2 and two other patients, simultaneously.
- From 6:00 AM through 6:10 AM, Staff S, MHT, documented every five-minute checks and that Patient #2 was awake in his room. Staff S was assigned to observe Patient #2 and two other patients, simultaneously.
- On 06/04/25, at 3:15 AM, Staff L, MHT, documented every five-minute checks and that Patient #2 was awake in his room. Staff L was assigned to observe Patient #2 and two other patients, simultaneously.
- On 06/05/25, from 2:25 AM through 5:05 AM, Staff W, MHT, documented every five-minute checks and that Patient #2 was awake in his room. Staff W was assigned to observe Patient #2 and two other patients, simultaneously.
- On 06/06/05, from 4:10 AM through 4:40 AM, Staff U, MHT, documented every five-minute checks and that Patient #2 was awake in his room. Staff U was assigned to observe Patient #2 and two other patients, simultaneously.
- From 11:00 PM through 11:05 PM, Staff K, MHT, documented every five-minute checks and that Patient #2 was awake in his room. Staff K was assigned to observe Patient #2 and one other patient.
- On 06/07/25, from 4:55 AM through 5:30 AM, Staff K, MHT, documented every five-minute checks and that Patient #2 was awake, cooperative, or standing in his room. Staff K was assigned to observe Patient #2 and one other patient simultaneously.

Review of Patient #4's medical record showed:
- On 05/27/25 at 3:45 PM, a provider order was placed for every five-minute checks.
- On 06/01/25, from 9:30 PM through 10:10 PM, Staff L, MHT, documented every five-minute checks and that Patient #4 was asleep in his room. Staff L was assigned to observe Patient #4 and one other patient, simultaneously.
- On 06/02/25 at 2:20 PM, a provider order was placed for 1:1 observation and every five-minute observation when asleep overnight.
- On 06/03/25, from 2:50 AM through 3:05 AM, Staff R, MHT, documented every five-minute checks and that Patient #4 was asleep in his room. Staff R was assigned to observe Patient #4 and two other patients, simultaneously.
- From 6:00 AM through 6:10 AM, Staff S, MHT, documented every five-minute checks and that Patient #4 was asleep in his room. Staff S was assigned to observe Patient #4 and two other patients, simultaneously.
- On 06/04/25 at the 3:15 AM, Staff L, MHT, documented every five-minute checks and that Patient #4 was asleep in his room. Staff L was assigned to observe Patient #4 and two other patients, simultaneously.
- On 06/04/25 at 2:00 PM, a provider order lifted his 1:1 observation. A tech was to be designated as a "hall monitor" and high acuity staffing on B-Pod was to be maintained.
- At 3:00 PM, a provider order was placed to block his room related to his aggressive behavior.

- On 06/05/25, at 2:25 AM and 5:05 AM, Staff W, MHT, documented every five-minute checks and that Patient #4 was asleep in his room. Staff W was assigned to observe Patient #4 and two other patients, simultaneously.
- On 06/05/25, from 11:00 PM through 11:30 PM, Staff W, MHT, documented every five-minute checks and that Patient #4 was asleep in his room. Staff W was assigned to observe Patient #4 and two other patients, simultaneously.
- On 06/06/25, from 4:10 AM through 4:40 AM, Staff U, MHT, documented every five-minute checks and that Patient #4 was asleep in his room. Staff U was assigned to observe Patient #4 and one other patient, simultaneously.
- On 06/06/25, at 11:00 PM and 11:05 PM, Staff K, MHT, documented every five-minute checks and that Patient #4 was asleep in his room. Staff K was assigned to observe Patient #4 and one other patient, simultaneously.
- On 06/07/25, from 4:55 AM through 5:30 AM, Staff K, MHT, documented every five-minute checks and that Patient #4 was asleep in his room. Staff K was assigned to observe Patient #4 and one other patient, simultaneously.

Review of the hospital's video titled, "B Pod West," dated 06/01/25, showed the following:
- At 9:30 PM, Staff K, MHT, walked down the hall, shone his flashlight in the patient rooms, then walked back up the hall. Staff M, MHT, was sitting on the floor outside Patient #2's room, and Staff L, MHT, was sitting on the floor outside Patient #4's room.
- At 9:40 PM, Staff M stood up, walked down the hallway and exited toward C-Pod.
- At 9:44 PM, Staff L stood up, wrote on a clipboard and sat back down.
- At 9:48 PM, Staff L stood up, wrote on a clipboard and sat back down.
- At 10:10 PM, Staff M, Staff O, RN, and Staff N, MHT, escort Patient #3 from C-Pod to the seclusion room. Staff L stood up and wrote on a clipboard.

Observation on 06/09/25 at 1:55 PM, in the B-Pod unit, showed patient rooms were located across from the medication room, in a continuous row adjacent to each other. Each Pod was separated by locked doors with four rooms in each. The patient rooms on each pod were in a continuous row adjacent to each other.

During a phone interview on 06/11/25 at 11:00 AM, Staff H, MHT, stated that there were times that staffing was so low that she had to watch a 1:1 patient and complete round on the other patients at the same time. This usually happened when there were not enough staff to cover breaks or lunches.

During an interview on 06/11/25 at 3:28 PM, Staff AA, Nurse Practitioner, stated that she would expect staff to be assigned to exclusively monitor a patient who had a 1:1 order. It was not acceptable for the staff member assigned to a 1:1 to perform other duties at the same time. After review of the policy, her understanding and expectation for patient's ordered to have a 1:1 monitoring, was for the assigned staff member to have continuous visualization of the patient. The patient rooms were all located on the same side of the hall adjacent to each other so it would not be possible to see inside more than one room at a time.

During an interview on 06/12/25 at 11:00 AM, Staff Q, CEO, stated that her expectation for safety rounding at night was for staff to point the flashlight at the patient, visualize three breaths from the patient, then document and repeat with the other patients. For patients that were on a 1:1, she expected staff to be within arm's reach of the patient at all times and to have their clipboard. During the night, 1:1 staff were to remain at the hallway at the patient's door to document. For patient's that were on a 1:1 while awake and every five-minute rounds while asleep, if a patient woke up, staff returned to being a 1:1 until the patient was back asleep. During the night, the nurses should have their assessments completed and there were two staff available in the Assessment and Referral (A&R) unit for additional assistance. Staff Q would not expect 1:1 staff to be doing safety rounding on other patients, unless their 1:1 patient was asleep and had orders for being 1:1 only while awake. Sometimes, they had to pull from A&R to cover breaks. Staff were "never left hanging and not getting their breaks."



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