HospitalInspections.org

Based on observation, record review, and interview, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient's rights as evidenced by:
1) Failure of the hospital to provide supervision as ordered by the physician for 10 of 10 current patients on line of sight observation levels with diagnoses including suicidal ideations (Patient #2, 3, R1-R8) and 5 of 8 current patients on routine observation levels (Patients #R11-R15);
2) Failure of the hospital to provide documentation of line of sight observations and every 15 minute observations for 15 of 18 total psychiatric patients who had these observation levels ordered by the physician
3) Failure to ensure that all staff were trained on observation levels
4) Failure to ensure that 1 discharged patient was observed per line of sight observation level and as a result, this patient eloped from the hospital (Patient #1).
Findings:

This resulted in an Immediate Jeopardy Situation. S1Administrator was notified on 08/20/2025 at 3:45 PM.
The hospital provided the following plan of removal for the Immediate Jeopardy situation:
All nurses and mental health technicians present on the day shift and night shift of 08/20/2025 were retrained on observation levels, staff responsibilities, documentation requirements and review of the observation policy. The observation levels will now be added to the white board in the nurses station in addition to the mental health technician's sheet to ensure that all staff are aware of teach patient's observation level. Updating the white board will be the responsibility of the nurse taking the order.

Retraining will be conducted for all remaining nurses and mental health technicians on observation levels, staff responsibilities, documentation requirements and review of the observation policy. This training will be mandatory before being allowed to work on the floor. This training will be completed by 08/31/2025. It will be documented and filed in each employee's file.

To ensure continued compliance, observation levels will be reviewed by the DON or Program Director each morning for accuracy. During their rounds, nurse practitioners will meet with all Level 1 and Level 2 patients first to determine any changes needed in observation levels. RN staff will supervise the mental health technicians to ensure that observation is completed per the policy and review observation sheets to ensure accurate and timely completion.


On 08/21/2025 at 3:00 PM, the Immediate Jeopardy Situation was lifted but there was not enough evidence to determine sustainability of compliance for the Condition of Patient Rights to be cleared therefore the deficiency remains at a Condition level (See findings in A0144);

Based on observation, record review, and interview, the hospital failed to ensure patients receive care in a safe setting as evidenced by:
1) Failure of the hospital to provide supervision as ordered by the physician for 10 of 10 current patients on line of sight observation levels with diagnoses including suicidal ideations (Patient #2, 3, R1-R8) and 5 of 8 current patients on routine observation levels (Patients #R11-R15);
2) Failure of the hospital to provide documentation of line of sight observations and every 15 minute observations for 15 of 18 total psychiatric patients who had these observation levels ordered by the physician;
3) Failure to ensure that all staff were trained on observation levels and
4) Failure to ensure that 1 discharged patient was observed per line of sight observation level and as a result, this patient eloped from the hospital (Patient #1).
Findings:

1. On 08/20/2025 at 12:50 PM, observations in the day room revealed no staff were in the room or to be seen. Further observations at this time revealed that Patients #2, R1 and R2 were in the day room unsupervised. These patients had orders for line of sight observation levels.

On 08/20/2025 at 1:00 PM, the surveyor asked S5BHT to review her (electronic) observation sheets. At that time, S5BHT stated that she had not documented on any of her 6 assigned patients for the day, including 3 line of sight patients (Patient #2, R6, R8). The surveyor then requested to reviewed the observation sheets of S6BHT. Review of S6BHT's observation sheets revealed the last documented observation for her 6 assigned patients was at 7:15 AM that morning, which included 4 line of sight patients (R1, R3, R4, R5). The techs stated they would document later in the shift. When asked how they remember what the patients were doing for the past several hours, they stated that they remembered it all in their heads.

On 08/20/2025 at 1:30 PM, observation revealed Patient #3 was asleep in bed unsupervised. There was no staff on the hall. The patient was ordered line of sight observations at all times.

On 08/20/2025 at 1:35 PM, all three techs assigned for that shift (S5BHT, S6BHT, S7BHT) were sitting at a table in the day room. The surveyor reviewed their assignment sheets with them and noted that they had several Level 2 (line of sight) patients that were not in the day room. They stated the patients were in their bedrooms. When asked how often they check on the line of sight patients who were in their bedrooms, they stated about every 15 minutes. When asked the difference in observations of the Level 2 and Level 3 patients, they all shrugged their shoulders.

On 08/20/2025 at 1:45 PM, S1Program Director went with the surveyor to make observations on the halls. At this time, observations revealed Patients R1, R2, R3, R4, R5 and R7 were in their bedrooms unsupervised. There was no staff on the halls. S1Program Director confirmed that all three techs were currently sitting at the table in the day room. S1Program Director further confirmed that these above patients were on line of sight observation levels and were not being properly observed per physician orders. She stated that line of sight observations meant the staff should be within 20 feet of the patient and in eyesight at all times. S1Program Director further stated that the techs should be documenting the location and behavior of each patient every 15 minutes on the close observation forms and these should be current and up to date. At that time, S1Program Director acknowledged the hospital had issues with the staff properly observing the patients per ordered observation level.

2. On 08/20/2025 at 1:00 PM, the surveyor asked S5BHT to review her (electronic) observation sheets. At that time, S5BHT stated that she had not documented on any of her 6 assigned patients for the day, including 3 line of sight patients (Patient #2, R6, R8). The surveyor then requested to reviewed the observation sheets of S6BHT. Review of S6BHT's observation sheets revealed the last documented observation for her 6 assigned patients was at 7:15 AM that morning, which included 4 line of sight patients (R1, R3, R4, R5). The techs stated they would document later in the shift. When asked how they remember what the patients were doing for the past several hours, they stated that they remembered it all in their heads.

3. On 08/20/2025 at 12:10 PM, the current census and observation levels were reviewed with S3RN. When asked what the difference in Level 2 and Level 3 observation levels were as noted on the census sheet, S3RN revealed that she was unsure and she proceeded to ask S4LPN. S4LPN stated that Level 2 observations indicated line of sight and Level 3 observations were routine every 15 minute observations.

On 08/20/2025 at 1:25 PM, S5BHT was asked what Level 2 and Level 3 observation levels meant, as noted next to each patients name on the tech's assignment sheets. S5BHT stated that she did not know and told the surveyor to ask S7BHT. At that time, S7BHT was asked what Level 2 and Level 3 observation levels meant. S7BHT stated that Level 2 was routine every 15 minute observations and Level 3 was line of sight observations (which was the opposite of what the levels actually meant).

On 08/20/2025 at 1:35 PM, all three techs assigned for that shift (S5BHT, S6BHT, S7BHT) were sitting at a table in the day room. The surveyor reviewed their assignment sheets with them and noted that they had several Level 2 (line of sight) patients that were not in the day room. They stated the patients were in their bedrooms. When asked how often they check on the line of sight patients who were in their bedrooms, they stated about every 15 minutes. When asked the difference in observations of the Level 2 and Level 3 patients, they all shrugged their shoulders.

4. Review of the medical record revealed Patient #1 was admitted to the psychiatric hospital on 07/22/2025 with diagnoses including auditory hallucinations and schizoaffective disorder. The patient was PEC'd and had admission orders for line of sight observation level at all times.

Review of an LDH abuse/neglect self-report dated 07/27/2025 at 6:55 AM revealed in part that the patient moved his bed and furniture and barricaded his bedroom door, preventing staff from entering. The patient then broke the window in his room with the nightstand drawer and eloped from the hospital.

Review of the close observation form revealed documentation that the patient was in his bedroom asleep from 07/26/2025 at 7:30 PM until 07/27/2025 at 6:45 AM.
Review of the close observation form dated 07/27/2025 at 7:00 AM revealed the patient of off the unit. The patient returned at 11:00 AM that day after being located.
Review of the close observation form dated 07/28/2025 at 11:15 PM revealed the form was blank until 07/29/2025 at 6:45 AM.
Further review of the close observation forms revealed no documented evidence that the patient was on a line of sight observation level. There was no mention of the observation level on the forms.

On 08/21/2025 at 1:20 PM, interview with S1Program Director confirmed that the patient had physician orders for line of sight observation level at the time of the above incident. S1Program Director confirmed the patient was not being properly observed per physician order. When asked if there had been any education conducted to any of the hospital staff after this incident, she stated no. When asked if there were any new processes put into place after this incident with Patient #1 eloping while being on line of sight observations, she stated no.

Based on record review and interview, the hospital failed to recognize opportunities for improvement and initiate changes to ensure compliance. This deficient practice was evidenced by failure of the hospital to implement a performance improvement plan after one patient who was on line of sight observations eloped from the hospital (Patient #1).
Findings:

Review of the medical record revealed the patient was admitted to the psychiatric hospital on 07/22/2025 with diagnoses including auditory hallucinations and schizoaffective disorder. The patient was PEC'd and had admission orders for line of sight observation level at all times.

Review of an LDH abuse/neglect self-report dated 07/27/2025 at 6:55 AM revealed in part that the patient moved his bed and furniture and barricaded his bedroom door, preventing staff from entering. The patient then broke the window in his room with the nightstand drawer and eloped from the hospital.

Review of the close observation form revealed documentation that the patient was in his bedroom asleep from 07/26/2025 at 7:30 PM until 07/27/2025 at 6:45 AM.
Review of the close observation form dated 07/27/2025 at 7:00 AM revealed the patient of off the unit. The patient returned at 11:00 AM that day.
Further review of the close observation forms revealed no documented evidence that the patient was on line of sight observation level. There was no mention of the observation level on the forms.

On 08/21/2025 at 1:20 PM, interview with S1Program Director confirmed that the patient was on line of sight observation level at the time of the above incident. S1Program Director confirmed the patient was not being properly observed per physician order. When asked if there had been any education conducted to any of the hospital staff after this incident, she stated no. When asked if there were any new processes put into place after this incident with Patient #1 eloping while being on line of sight observations, she stated no.

Observations at various times during the survey on 08/20/2025 and 08/21/2025 revealed the staff failed to provide constant supervision for 10 of 10 current patients who were on line of sight observation levels.

On 08/20/2025 at 1:45 PM, S1Program Director acknowledged that the hospital had current issues with the staff properly observing the patients per ordered observation level.

Based on record review and interview, the registered nurses failed to supervise and evaluate the nursing care for each client as evidenced by failing to ensure that patients received supervision as ordered by the physician for 10 of 10 current patients on line of sight observation levels with diagnoses including suicidal ideations (Patient #2, 3, R1-R8) and 5 of 8 current patients on routine observation levels (Patients #R11-R15).
Findings:

On 08/20/2025 at 12:10 PM, the current census and observation levels were reviewed with S3RN. When asked what the difference in Level 2 and Level 3 observation levels were as noted on the census sheet, S3RN revealed that she was unsure and she proceeded to ask S4LPN. S4LPN stated that Level 2 observations indicated line of sight and Level 3 observations were routine every 15 minute observations.

On 08/20/2025 at 12:50 PM, observations in the day room revealed no staff were in the room or to be seen. Further observations at this time revealed that Patients #2, R1 and R2 were in the day room unsupervised. These patients had orders for line of sight observation levels.

On 08/20/2025 at 1:00 PM, the surveyor asked S5BHT to review her (electronic) observation sheets. At that time, S5BHT stated that she had not documented on any of her 6 assigned patients for the day, including 3 line of sight patients (Patient #2, R6, R8). The surveyor then requested to reviewed the observation sheets of S6BHT. Review of S6BHT's observation sheets revealed the last documented observation for her 6 assigned patients was at 7:15 AM that morning, which included 4 line of sight patients (R1, R3, R4, R5). The techs stated they would document later in the shift. When asked how they remember what the patients were doing for the past several hours, they stated that they remembered it all in their heads.

On 08/20/2025 at 1:30 PM, observation revealed Patient #3 was asleep in bed unsupervised. There was no staff on the hall. The patient was ordered line of sight observations at all times.

On 08/20/2025 at 1:35 PM, all three techs assigned for that shift (S5BHT, S6BHT, S7BHT) were sitting at a table in the day room. The surveyor reviewed their assignment sheets with them and noted that they had several Level 2 (line of sight) patients that were not in the day room. They stated the patients were in their bedrooms. When asked how often they check on the line of sight patients who were in their bedrooms, they stated about every 15 minutes. When asked the difference in observations of the Level 2 and Level 3 patients, they all shrugged their shoulders.

On 08/20/2025 at 1:45 PM, S1Program Director went with the surveyor to make observations on the halls. At this time, observations revealed Patients R1, R2, R3, R4, R5 and R7 were in their bedrooms unsupervised. There was no staff on the halls. S1Program Director confirmed that all three techs were currently sitting at the table in the day room. S1Program Director further confirmed that these above patients were on line of sight observation levels and were not being properly observed per physician orders. She stated that line of sight observations meant the staff should be within 20 feet of the patient and in eyesight at all times. S1Program Director further stated that the techs should be documenting the location and behavior of each patient every 15 minutes on the close observation forms and these should be current and up to date. At that time, S1Program Director acknowledged the hospital had issues with the staff properly observing the patients per ordered observation level.

On 08/21/2025 at 2:20 PM, interview with S2CEO revealed that the nurses are supposed to make sure that the techs are observing the patients at the correct observation level as ordered by the physician and that they are documenting timely on the close observation forms. When asked if this was occurring, S2CEO stated "It does not look like it." S2CEO further confirmed that no new processess were put in place with the nurses after the incident with Patient #1, who was on line of sight observation level but eloped from the hospital on 07/27/2025.