HospitalInspections.org

Based on record review and interviews the facility failed to ensure the effective implementation of policies and procedures that promoted care in a safe setting for two (2) patients on the adolescent unit (ID#s 1 and 3). The facility failed to ensure staff were accurately documenting patient observations every 15 min.

The findings include:

Record review of facility policy titled "Observation Levels" dated 12/14/20 showed the following information:

Policy:
Observation levels are defined as levels of staff awareness and attention to patient safety/security needs requiring the initiation of specific protocols and supplemental documentation. Reasons for these levels of awareness may include but are not limited to: suicide risk, homicide risk, fall risk, potential for aggressive behavior, potential for sexually acting out behavior and/or elopement risk.

It is the policy of behavioral hospital of Bellaire to provide a safe and secure environment for patients during their hospitalization. Special observation for precaution procedures can be initiated by physician or nursing staff when a patient may be considered to be an increased risk of harm to self, others or property, for those patients who are identified as an elopement risk or for those who need an increased level of observation and precaution for other reasons, such as fall prevention. Clinical staff should assess the patient's risk factors and initiate the following procedures to help protect the patient and others.

Procedure:
6. Medical record entries should consistently reflect behavioral observations and patient mental status indicating the necessity for the level of special observations or precautions ordered.

B. Routine Patient Observation every 15 minute

Guidelines for implementation of this level of observation include, but are not limited to, the following:
(1.) The patient should only be allowed off the secure unit under direct staff supervision.

(3.) patients may not leave the facility unless in an emergency at which time a staff member must be assigned to accompany.

(4.) A patient rounds sheet, which reflects the patient's location and observed behaviors every 15 minutes, is maintained.

(5.) a nurse on the unit is required to conduct oversight of patient observation rounds and provide documentation by signature on the patient observation rounds sheets a minimum of every two hours.


Review of video recording on the unit 1/2/2024 showed patient(s) (ID#s 1 and 3) (along with others) elope from the unit/facility at 6:07 PM, returning to the unit at 6:50 PM.

Record review of medical record for patient (ID# 1) showed rounding sheets for 1/2/2024 that documented the patient "in the hallway, talking" at 6:15PM, when the patient had eloped from the unit/facility. AWOL/Elopement precautions were documented on the rounding sheet.

Record review of medical record for patient (ID# 3) showed rounding sheets for 1/2/2024 that documented the patient "in the hallway, talking" at 6:15PM, when the patient had eloped from the unit/facility.

Interview with facility staff (ID# 51) on 1/11/24 at 11:45 AM confirmed the above findings, stating that the observation rounding sheets should be documented and by staff and accurate.