HospitalInspections.org

Based on review of available records and staff interviews, the hospital failed to ensure that Patient #1 received care in a safe setting as he was not monitored according to physician order.

Findings were:

Patient #1 was not monitored every 15 minutes as ordered between 2:50 pm and 3:20 pm on 9/4/2011. The patient was found with a sheet around his neck in his bedroom wardrobe at approximately 3:20 pm. The patient sustained no harm. This was confirmed in interview on 12/6/11 with Staff #2, Staff #3, and Staff #4.

Based on review of the patient record and staff interviews, the hospital failed to ensure that a registered nurse supervised and evaluated the care for each patient as a patient was not monitored according to orders and documentation was not complete.

Findings were:

Review of the medical record for Patient #1 revealed that Staff #6, an MHT who was responsible for monitoring Patient #1 every 15 minutes documented that she observed the patient on 9/4/11 at 3:00 pm, but per review of video monitoring of the unit, facility reports, the personnel record for Staff #6, and staff interviews, Staff #6 did not observe the patient for the 3:00 pm monitoring.

Review of hospital policy 15 Fifteen Minute Rounds revealed " The charge nurse will be responsible for assigning, ensuring the rounds are performed and documented by the assigned staff ...the staff member will converse with each patient during each round while awake ...the staff member will ensure the patient is not experiencing any difficulties or performing self injurious behavior. "

Review of the medical record for Patient #1 revealed that there was no nursing assessment or progress note for 9/6/2011 between 7 am and 7 pm. Patient #1 had a physician ' s order for 1:1 monitoring on 9/6/2011 between the hours of 7 am and 7 pm and there was no nursing documentation to reflect 1:1 monitoring between those hours. Staff #1 and Staff #3 stated in an interview on 12/6/11 that a nursing assessment/nursing progress note is required for each patient every 12 hour shift. In an interview on 12/6/11, Staff #1, Staff #2 and Staff #3 confirmed that there was no nursing assessment or progress note for Patient #1 on 9/6/2011 during the day shift between 7 am and 7 pm.

The above was confirmed in interview with Staff #1, Staff #2, and Staff #3 on 12/6/2011.

Based on review of the patient record and staff interviews, the hospital failed to ensure that the medical record for Patient #1 was complete.

Findings were:

Review of the medical record for Patient #1 revealed that there was no nursing assessment or progress note for 9/6/2011 between 7 am and 7 pm. Patient #1 had a physician ' s order for 1:1 monitoring on 9/6/2011 between the hours of 7 am and 7 pm and there was no nursing documentation to reflect 1:1 monitoring between those hours. Staff #1 and Staff #3 stated in an interview on 12/6/11 that a nursing assessment/nursing progress note is required for each patient every 12 hour shift. In an interview on 12/6/11, Staff #1, Staff #2 and Staff #3 confirmed that there was no nursing assessment or progress note for Patient #1 on 9/6/2011 during the day shift between 7 am and 7 pm.