HospitalInspections.org

Based on interview and record review, the facility failed to protect and promote the patient's right to receive care in a safe environment including every 15 minute safety checks for 11 of 11 patients (#3, 5, 9, 11, 12, 13, 14, 15, 16, 17, and 18 ) requiring 15-minute safety checks 24 hours per day, resulting in all 11 patients on the children's (8-12 years old) unit not being monitored for extended periods. Findings include:

See Tag 144 Patient has the right to receive care in a safe setting.

Based on interview and record review, the facility failed to protect and promote each patients right to receive care in a safe environment including every 15 minute safety checks for 11 of 11 patients (#3, 5, 9, 11, 12, 13, 14, 15, 16, 17, and 18 ) requiring 15-minute safety checks 24 hours per day, resulting in all 11 patients on the children's (8-12 years old) unit not being monitored for extended periods. Findings include:

On 05/14/2019 at 1400 staff A was interviewed while supervising review of videos, Staff A stated "Every child admitted here at Health Source is required to have mandatory 15 minute safety checks, it is not based on individual physician orders."

On 05/14/2019 between 1400 and 1800 and 05/15/2019 between 0800 and 1400 during review of video footage for the children's unit (8 years old up to 12 years old) the following was found:

04/15/2019 safety check at 2145 then again at 2217 -32 minutes, staff I
04/15/2019 safety check at 2217 then again at 2243 -26 minutes, staff I
04/15/2019 safety check at 1043 then at 2300 - 17 minutes, staff I stood in hall signing safety check sheets without stepping into rooms
04/15/2019 safety check at 2300 then at 2330 -30 minutes, staff K
04/15/2019 safety check at 2330 then at 0003- 33 minutes staff I (staff I was sleeping at the 2345 safety check time, the Registered nurse staff K was watching the Internet with ear buds in her ear and did not wake staff I up.
04/16/2019 safety check at 0003 then at 0027- 24 minutes, staff I to break
04/16/2019 safety check at 0027 then at 0045- 18 minutes, staff K
04/16/2019 safety check at 0045 then at 0100-15 minutes, Staff K
04/16/2019 safety check at 0100 then at 0117-17 minutes, staff I stood at doorway and signed the safety sheet
04/16/2019 safety check at 0117 then at 0130-13 minutes, staff I standing at doorway signing safety sheets
04/16/2019 safety check at 0130 then at 0145-15 minutes, staff k
04/16/2019 safety check at 0145 then at 0215-30 minutes, staff k, signed safety sheet first, then did rounds
04/16/2019 safety check at 0215 then at 0245-30 minutes, staff k
04/16/2019 safety check at 0245 then at 0300-15 minutes, staff I from doorway, back to desk, lights out and wrapped in blanket asleep by 0301.
04/16/2019 safety check at 0300 then at 0314-14 minutes, staff U arrived to the unit and staff I sent home.

04/18/2019 safety check at 2130 then at 2200-30 minutes staff J
04/18/2019 safety check at 2200 then at 2230-30 minutes staff N
04/18/2019 safety check at 2230 then at 2300-30 minutes staff N
04/18/2019 safety check at 2300 then at 2320-20 minutes staff N
04/18/2019 safety check at 2320 then at 2330-10 minutes, staff L arrived on the unit,
Staff L began a phone conversation at 2345 and continued until 0300 when video review stopped. Staff L was observed setting the receiver down on the desk every 15 minutes for a 30 second walk to each door then return to the desk and proceed with the conversation while watching the computer screen. The RN staff N continued to do paperwork and did not address the ongoing phone call.

On 05/15/2019 at 1700 during the record review for patients # 3, 5, 9, 11, 12, 13, 14, 15, 16, 17, and 18 the safety sheets were reviewed for the above missed times. All safety sheets were filled out as if the every 15 minute rounds were completed every 15 minutes. This documentation contradicted the time stamp noted on the video footage during review. This discrepancy was verified by staff A.

Staff A was interviewed 05/14/2019 at 1400, stated " I have just begun doing video audits the beginning of this month (May) and have found the same problems that you are seeing on this video. We recently began enforcing suspensions without pay for failure to complete 15 minute safety checks. Staff I was one of the first employees to be suspended."

During review of Staff I's employee file the document related to a one day suspension for failure to perform every 15 minute safety checks was reviewed. The suspension was dated May 5th, for a different event.

On 05/15/2019 at 1200 the policy titled "Patient Safety Rounds and Unit Assistance" #6.22 dated effective 09/1983 was reviewed. On page 2 of 3 it states under #7. "Staff members conducting evening/bedtime rounds must enter the room to observe the condition of the patient. Staff shall take care to be able to verify the patient by facial recognition and that they are in no apparent distress (i.e. normal breathing.) Flashlights are to be utilized to assist in conducting evening/bedtime rounds with staff taking care not to flash the light in the patients face."

On 05/15/2019 at 1215 the policy "Communication Devices" #318 dated updated Jan 2019 was reviewed.
On page 2 of 2 it states "Individuals with authorized communication devices are expected to limit incoming and outgoing calls to urgent or emergent situations, so as to limit interruptions of services provided by (facility name) personnel."