HospitalInspections.org

Based on a review of documentation and observation, the facility failed ensure the medical record contained all the information necessary to monitor the patient's condition, including observation documented at the level ordered by a physician per facility policy.

Findings included:

Facility Policy entitled, "Electronic Patient Observations" stated in part,
"5. Documentation of Observations
a. 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. Each entry is to include the following:
i. Location
ii. Behavior/Activity
iii. Time is recorded electronically when the entry is made
iv. Signatures are completed electronically by the assigned staff using their unique login to the system ....

6. Q 15 Minute Rounds
a. All patients are monitored at minimum once in every 15 minute block of time.
b. In order to minimize the chance that patient may anticipate the timing of the rounds, the staff are instructed to vary the order in which patients are observed within each 15 minute period.
c. During the rounds staff are to:
i. Make direct visual contact; look for signs of danger or distress.
ii. Observe sleeping patients close enough to confirm they are breathing and not in any physical distress such as bleeding, lying on the floor, very restless, etc.
iii. Remain vigilant for specific risks for patients on Special Precautions.
iv. Allow reasonable privacy for dressing and bathing."

Review of medical records of 8 of 8 patients that were inpatient on 07/29/23 revealed they also had a missing block of observation with checks recorded at 11:16 AM and 12:20 PM, representing a block of unobserved time for over an hour.
* Patient #1 was placed on Q 15-minute checks on 07/26/23 at 0620. On 07/29/23 this patient's "Behavioral Health- Patient Observation Sheet" had checks recorded at 11:16 AM and 12:20 PM, representing a block of unobserved time for over an hour.
* Patient #3 was placed on Q 15-minute checks on 07/27/23 at 0108. On 07/29/23 this patient's "Behavioral Health- Patient Observation Sheet" had checks recorded at 11:16 AM and 12:20 PM, representing a block of unobserved time for over an hour.
* Patient #4 was placed on Q 15-minute checks on 07/28/23 at 0613. On 07/29/23 this patient's "Behavioral Health- Patient Observation Sheet" had checks recorded at 11:16 AM and 12:20 PM, representing a block of unobserved time for over an hour.
* Patient #5 was placed on Q 15-minute checks on 07/23/23 at 1850. On 07/29/23 this patient's "Behavioral Health- Patient Observation Sheet" had checks recorded at 11:16 AM and 12:20 PM, representing a block of unobserved time for over an hour.
* Patient #6 was placed on Q 15-minute checks on 07/18/23 at 1929. On 07/29/23 this patient's "Behavioral Health- Patient Observation Sheet" had checks recorded at 11:16 AM and 12:20 PM, representing a block of unobserved time for over an hour.
* Patient #7 was placed on Q 15-minute checks on 07/20/23 at 1120. On 07/29/23 this patient's "Behavioral Health- Patient Observation Sheet" had checks recorded at 11:16 AM and 12:20 PM, representing a block of unobserved time for over an hour.
* Patient #8 was placed on Q 15-minute checks on 07/30/23 at 0858. On 07/29/23 this patient's "Behavioral Health- Patient Observation Sheet" had checks recorded at 11:16 AM and 12:20 PM, representing a block of unobserved time for over an hour.
* Patient #9 was placed on Q 15-minute checks on 07/18/23 at 1950. On 07/29/23 this patient's "Behavioral Health- Patient Observation Sheet" had checks recorded at 11:16 AM and 12:20 PM, representing a block of unobserved time for over an hour.

The facility uses the Observe Smart system for monitoring patients via beacons and computer pads. In an interview with staff member #1 on 08/02/23, they stated that the technical department for the Observe Smart indicated that it appeared the system possibly lost signal for that time period, hence why observation rounds were not documented.

Based on the above finding, it could not be established that the above patients were monitored at the level most recently specified in the patient's medical record (in this case every 15 minutes), as evidenced by monitoring not documented every 15 minutes in the record per facility policy. The above findings were verified with staff member #1, 2, and 3 on 08/02/23.