Cedar Crest Hospital & Rtc

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 30250 Based on a review of documentation and interview, the facility failed to ensure all medical records documented information necessary to monitor the patient’s condition as evidence by failing to monitor patients at the level of monitoring most recently specified in the patient’s medical record. Findings included: Facility based policy entitled, Observations, Patient (PolicyStat #18831397) stated in part, “PROCEDURE 1. The psychiatric practitioner will order one of three levels of observation at time of admission and as the patient’s condition warrants a change: a. 15 minute b. 5 minute c. One-to-one ... 5. The RN may not decrease the level of observation, i.e. change from 1 :1 to 5 minute without an order by the psychiatric practitioner. 6. Documentation of Observations a. Proximity-Based Electronic Technology Staff documents all levels of observation on each patient’s profile on the facility issued device using proximity-based electronic technology. The observation report is then printed and becomes a part of the patient record at discharge ... 8. Q 5 Minute Observations a. Patient is placed on Q 5 minutes if their behavior is unpredicable [sic] and there is potential risk for harm to self and others yet behavior is not at the point requiring constant 1 :1 observation. b. Patient is monitored at minimum once in every 5 minute block of time ... 9. 1:1 Observation a. 1:1 is the highest level of observation and is reserved for patients who are so unpredictable that without a dedicated staff member there is risk of patient harming self or others ... e. Staff who are assigned to monitor the patient on 1 :1 observation will have no other assignments.” Review of medical records revealed that according to documentation, the following 3 of 3 Patients were not being monitor the patient at the level of monitoring most recently specified in the patient’s medical record. Patient #1 This patient was admitted on Q 5-minute checks related to Suicide. Review of Patient Observation sheets for Patient #3 revealed the following: * On 08/09/25 from 0822-2351 Q 15 minutes interval was noted. The patient should have been monitored Q 5 on this date. * On 08/10/25 from 0003-2354: Interval of 15 minutes was noted. The patient should have been monitored Q 5 on this date. * On 08/11/25 from 0005-2359: Interval of 15 minutes noted. The patient should have been monitored Q 5 on this date. * On 08/12/25: Interval of 15 minutes noted. The patient should have been monitored Q 5 on this date. From 08/09/25 at 0822 through 08/12/25 at 1226 most observation checks were over 5 minutes, occasionally more than 15 minutes elapsed between documentation. On 8/11/25 at 1730 physician note indicated that Patient #1 was on Q 15-minute checks, however no order was located to reflect this change. Patient #2 This patient was admitted on Q 5 min observations related to assault, elopement, and suicide. Q 5 was discontinued and changed to Q 15 on 08/07/25. Placed on 1:1 for aggression, poor boundaries, explosive agitation on 08/10/25 at 1000. Q 5 while asleep on 08/10/25 at 1211. On 08/11/25 at 0800 physician order changed observation level from 1:1 to q 5 minutes observation for safety/comfort measures. Review of Patient Observation Sheets for Patient #2 revealed the following: * On 08/06/25 from 1114-1626 observed Q 5 minutes. 1627-2234: Q15 minutes intervals. 2226-2357: Q 5-minute intervals. The patient should have been monitored Q 5 on that date. * 08/10/25 from 00004 to 2357: Q 15-minute intervals. The patient should have been monitored Q 5 minutes while asleep. * 08/11/25 from 0011 to 2348: Q 15-minute intervals. The patient should have been monitored Q 5 starting at 0800 on this date. * 08/12/25 from 0000 to 2356: Q 15-minute intervals. The patient should have been monitored Q 5 on this date. * 08/13/25 from 0000 to 0254: Q 15-minute intervals. 0258-0649: Q 5-minute intervals. 0653-1510: 15-minute intervals. Patient should have been monitored Q 5 on this date. Patient #6 This patient was admitted on Q 5 minutes related to assault, elopement, and suicide. On 08/10/25 discontinued Q 5, Q 15 order. On 08/11/25 change observation level to Q 5 minutes for Aggression and Sexually Acting Out. 08/12/25 at 1500 placed on 1:1 observation for safety. 08/12/25 at 2210 1:1 while awake Q 5 while asleep. Review of Patient Observation Sheets for Patient #6 revealed the following: * On 08/12/25 observed Q 5 from 0000-0711. 0723-2345: Interval of 15 minutes was noted. * On 08/13/25 from 0001-2358: Interval of 15 minutes was noted. Patient #6 was on 1:1 observation per orders from 08/12/25 at 1500 through 08/13/25. On 08/12/25 during the evening shift, the same staff members were documenting observations on both Patient #2 and 6, indicating this patient was not being observed 1:1 as ordered. Review of Physician and Observation Sheets for 5 adolescents inpatients on 12/08/25 revealed 2 of 5 patients did not have observation monitoring documented at the level ordered in the medical record. Patient #10 Had a physician order on 12/04/25 at 0800 for “1. Renew or change level of observation to Q 5 minute monitoring due to active command hallucination to kill self”. There were no other observation level orders present in their medical record. Review of the Patient Observation Sheets for Patient #10 from 12/05/25-12/07/25 revealed this patient was observed: * 12/05/25 at 0002-12/06/25 at 2359 monitored at Q 5 minutes intervals. * 12/06/25 from 2156-2356 monitored at Q 5 minutes intervals. A physician note on 12/06/25 at 1320 indicated Q 15 minute checks, however no physician order was present in the medical record to support this change in observation level. According to physician orders Patient # 11 should have been observed Q 5 minutes from 12/05/25-12/07/25. Patient #11 Had a physician order on 12/03/25 at 1000 for “1. Q 5 order”. There were no other observation level orders present in their medical record. Review of the Patient Observation Sheets for Patient #11 from 12/05/25-12/07/25 revealed this patient was observed: * 12/05/25 at 0002-12/06/25 at 2147 monitored at Q 5 minutes intervals. * 12/06/25 from 2156-2356 monitored at Q 15 minutes intervals. A physician note on 12/06/25 at 1400 indicated Q 15-minute checks, however no physician order was present in the medical record to support this change in observation level. According to physician orders Patient # 11 should have been observed Q 5 minutes from 12/05/25-12/07/25. In interview on 12/09/25, staff members #2 and 3 verfied the above findings.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 31690 Based on review of medical records and staff interview, the facility failed to ensure patients received care in a safe setting for 1 out of 4 patients reviewed, when Patient #1’s “Patient Observation Record (Q5 and Q15)” sheets did not accurately reflect the physician’s current observation order. Findings were: Review of the medical record for Patient #1 was transferred on 12/14/24 to the facility Residential Treatment Center for an attempted suicide. On 12/17/24 the patient was moved to the acute unit due to suicidal gestures. She was initially placed on 1;1 monitoring for Suicidal Ideations. Further review revealed she was placed on Q5minute checks on 12/18/24 at 15:20 pm. Patient #1’s Patient Observation Record sheets for 12/18/24 from 19:15-2015 revealed 5-minute checks reporting the patient was “(A) in the activity room, (5) calm, and (h) sitting/lying” at each check documented by Staff #3. Further review of Patient #1’s nursing notes reflected: “1940 BHA found the patient on the floor of her room with a pair of jeans around her neck. Patient was breathing but unresponsive after sternal rubs ... 2004 EMS arrives on scene and assumes care of patient ... 2008 EMS out of building with staff {sic patient}to McClain’s Hospital ...” During a telephone interview, on 12/23/24 at 1:40 pm, Staff # 2 reported that she was not assigned the patient. She continued that she was with the patients on the hall for showers at the time of the incident. She stated “I talked to the patient after her shower. She was sitting on her bed. I asked her if she needed anything, and she said she was feeling anxious. I asked if she wanted to talk to the nurse and she refused. I went to check on another patient. When I was walking down the hall, I saw the blue jeans hanging on the door. I ran in and found her with the jeans around her neck.” When asked how long she was away from the patient she replied, “about 10 or 15 minutes.” During a telephone interview, on 12/23/24 at 3:15 pm, Staff # 3 reported that she “had been documenting her 5-minute checks on the patient she thought was Patient #1.” She continued that “when I called out Patient #1’s name another patient answered. I documented on her.” When asked the process she reported that the tablets were down, so we were documenting on paper. When we use the tablets there is a picture of the patients for us to look at. Review of the facility policy titled “Observations, Patient, Last revised 7/2021, reflected “ ... 8. Q 5 Minute Rounds ... b. Patient is monitored at minimum once in every 5-minute block of time. c. During times of personal hygiene, toileting and other self-care needs, the staff should be in visual and hearing range of the bathroom door ...” During an interview, on the afternoon of 12/20/24, Staff #6 reported that on the day of the incident the tablets used for patient monitoring were out for an update. Typically, the tablets are linked to the patient wrist monitor. The staff must be in a proximity for the tablet to allow them to document. A picture of each patient is on the screen for patient identification. If the staff miss a scheduled check the tablet alerts the assigned staff as well as the administrative staff of the late or missed check. The above information was verified by Staff #6.”