HospitalInspections.org

Based on document review, observational tour, and interview it was determined for 4 of 10 (Pts. #1-#4) Observation Round form, the Hospital failed the ensure staff monitored patients for safety in accordance with Hospital policy.

Findings include:

1. On 6/18/15 the Hospital Policy titled, "Precautions and Observations" (revised 9/13) was reviewed and required, "Level of observation: rounds documentation will demonstrate patient safety as evidenced by: Every 15 minutes observation - this is the minimum level of observation for all patients. Staff must visually observe every patient and document their location and behavior on the Observation Rounds form ..."

2. The clinical record for Pt. #1 was reviewed on 6/17/15. Pt. #1 was a 9 year old male admitted on 5/5/15 with diagnoses of suicidal ideation, depression and aggression. An admission order dated 5/5/15 included special precautions for suicide and elopement with every 15 minute observation.

* On 5/6/15 at 4:30 PM, the physician ordered increased observation from every 15 minutes to every 10 minutes.
* On 5/08/15 at 3:30 PM, Pt. #1 was placed on 1:1 observation. which was discontinued on 5/15/15. However 1:1 was renewed the next day (5/16/15).
* On 5/18/15 at 12 noon, the physician discontinued the 1:1 observation, and increased observational safety monitoring to every 10 minutes. Staff continued to document 1:1 monitoring until 1:15 PM on 5/18/15. However, documentation on the observation form indicated every 10 minute observations did not begin until 1:35 PM on 5/18/15 (a twenty minute delay in monitoring.).

3. On 6/18/15 at approximately 9:10 AM, an observational tour was conducted on the 1 South Adolescent Boys Unit (ABU). During the tour six (6) medical records and the observational rounds form were reviewed. The observational rounding forms for 3 patients (Pts. #2, #3 and #4) lacked completed documentation of safety monitoring as follows:

-Pt. #2 was a 15 year old male admitted on 6/11/15 with diagnoses of Attention Deficit Hyperactive Disorder (ADHD), and Disruptive Disorder. The rounding log for Pt. #2 dated 6/14/15 at 11:15 PM lacked documentation of Pt. #2's behavior, location, and an appropriate staff signature, a 30 minute gap between observations.

-Pt. #3 was a 13 year old male admitted on 6/10/15 with diagnoses of Suicidal Ideation (SI), Aggression, and Mood Disorder. The rounding log for Pt. #3 dated 6/14/15 at 11:15 PM lacked documentation of Pt. #3's behavior, location, and an appropriate staff signature, a 30 minute gap between observations.

-Pt. 4 was a 13 year old male admitted on 6/12/15 with a diagnosis of Bipolar Disorder. The rounding log for Pt. #4 dated 6/14/15 at 11:15 PM lacked documentation of Pt. #4's behavior, location, and an appropriate staff signature, a 30 minute gap between observations.

4. On 6/18/15 during the observation tour the Director of Performance Improvement (E #7) verified the missing data, and stated "it's odd these [rounding logs] are missing data and none of the other records that were reviewed had missing data."