HospitalInspections.org

Based on a review of medical records and staff interview, the facility failed to ensure that medical records were completed, as patient monitoring documentation was incomplete.

Findings included:

Review of the medical record of 1 out of 10 patients, Patient #9, revealed that documentation was missing on the DePaul Center Behavioral Health Unit Nursing Monitoring Flow Sheet for two time periods on 4/24/14. The monitoring flow sheet for Patient #9 on 4/24/14 indicated she was on Level I Precautions, requiring monitoring every 30 minutes. The monitoring flow sheet revealed that patient #9 was monitored at 1700, but was not monitored until 1800, which was greater than 30 minutes. Also, at 0630, patient #9 was monitored, but was not monitored again until 0715, which was greater than 30 minutes.

Review of the facility policy entitled, "DePaul Center Administrative Policy, Subject: Precautions", last revised 1/14, stated, in part, "Levels of Precautions are Level I and Level II. Level I Precautions require staff to perform and document safety surveillance checks at least every 30 minutes."

In an interview with Staff #1 the afternoon of 4/29/14 in the facility conference room, she confirmed the above findings, that Patient #9 was not monitored every 30 minutes per order and policy.