HospitalInspections.org

Based on record review and interview, the hospital failed to ensure completion of the document titled Hospital Patient Rounds for six (Pt #1, #2, #3, #4, #5 and #13) of 21 patients.

This failed practice placed patients at a risk of incomplete records and the inability for the facility to provide care in a safe setting.

Findings:

A policy titled "Standards of Care" stated, in part, unless otherwise ordered by a physician, all patients are monitored every 15-minutes around the clock.

Patient #1
A review of the medical record for patient #1 showed incomplete documentation on a document titled "Hospital Patient Rounds" dated 01/04/21 at 12:00 PM, 12:15 PM, 12:30 PM, and 12:45 PM and no documentation on 01/05/21 at 11:15 PM.

Patient #2
A review of the medical record for patient #2 showed no documentation on a document titled "Hospital Patient Rounds" dated 01/06//21 at 8:30 AM and 8:45 AM.

Patient #3
A review of the medical record showed no safety rounds documented on the "Hospital Patient Rounds" dated 03/13/21 at 12:15 PM.

Patient #4
A review of the medical record showed no safety rounds documented on the "Hospital Patient Rounds" dated 03/13/21 at 12:15 PM.

Patient #5
A review of the medical record showed "Seizure" precautions not indicated on the "Hospital Patient Rounds" dated 01/07/21, 01/08/21, 01/22/21, 02/03/21, 02/16/21, and 02/17/21 for a patient with a history of seizure activity.

Patient #16
A review of the medical record showed "Seizure" precautions not indicated on the "Hospital Patient Rounds" dated 01/08/21, 01/09/21, 01/10/21, 02/03/21, 01/14/21, and 01/16/21 for a patient with a history of seizure activity.


On 03/16/21 at 12:50 PM, Staff B stated that there was not a policy for seizure precautions but all staff were trained upon hire and annually, regarding seizure precautions.

On 03/16/21 at 1:10 PM, Staff D stated that it is the expectation of the facility that documentation on the "Hospital Patient Rounds" should contain data including patient location, patient behavior, time the round was conducted, and staff initials in 15 minute periods. Staff D stated that they were unsure why these rounds were incomplete.

On 03/17/21 at 1:00 PM, Staff F stated all rounds should be completed and documented and there should be no "blanks" on form. Staff F also stated that the observation record "should be reviewed by the nurse during the shift but not sure if this is a policy."

On 03/17/21 at 1:40 PM, Staff G stated that any patient that has had seizure activity would need to have the "Seizure" precautions checked on the rounds sheets, "according to our policy."