HospitalInspections.org

Based on a review of documentation the facility failed to ensure that patient records included other information necessary to monitor the patient's condition, as evidence by failing to document monitoring the patient every 15 minutes per policy.

Findings included:

Review of facility policy entitled Rounds for Patient Observation stated in part,
"A. Staff assignments ...
2. Every patient must be seen by a staff member at a minimum of every fifteen minutes.

C. MHT responsibilities ...
3. Observed each patient, a minimum of every 15 minutes according to observation level and precaution type and indicate these on the patient observation form."

Review of the observation sheets revealed that Patient #1 was not monitored consistently as ordered or per facility policy. Q 15 minute checks were not documented on the following dates and times:
· 09/19/16 at 1930
· 09/26/16 at 1930
· 10/10/16 from 1800-1845
· 10/19/16 from 2130-0645
· 10/28/16 from 0700-0730


The above findings were confirmed on an interview on 10/31/16 with staff staff member #1.