HospitalInspections.org

Based on review of facility documents, clinical record documentation, and policy review, the facility failed to ensure the patient's right to receive care in a safe setting as patient was not directly observed by staff during the time the male patient entered the female patient's room.

Findings included:

Facility document titled "Investigation Worksheet" states in part," video from 6/01/2017 12:30 pm to 06/02/2017 08:14pm. Patient made a police report on 6/13/17 with assistance of DMR (Director of Risk Management). Incident had opportunity to happen on 06/02/2017 8:06 - 08:14pm. Both patients were in the same room at the same time.
Cameras monitored: 2 PICU: Hall 3 2PICU: Hall 1 2 PICU: Dayroom 1 2 PICU: Dayroom 2
Time of incident: 08:08 pm 06/02/2017
2 PI; Hall 3
08:06 pm Female patient goes to her room
08:08 pm Male patient goes in to room with her
08:14 pm Male patient comes out of female's room"

The facility failed ensure the patient's right to receive care in a safe setting as patient was not directly observed by staff. Facility camera video timeline indicated that female patient #3 was followed into female patient's room by a male patient on 6/2/17 at 8:08 pm. The male patient was seen exiting female patient #3's room at 8:14 pm. No documentation was observed on patient #3 clinical record of the above incident. Patient #3 was discharged from Austin Lakes Hospital on 6/7/17. Patient #3 reported the allegation to staff when she was again admitted to ALH on 6/9/17.
Facility policy titled "Level of Observation Protocols" states, in part:
"Policy: The status and location of all patients shall be directly observed, assessed and documented a minimum of every 15 minutes (routine) in order to ensure maximum safety on the units.

The above finding was acknowledged by the Risk Manager the afternoon of 8/21/17.