HospitalInspections.org

Based on a review of documentation the facility failed ensure the right to care in a safe setting by failing to monitor and document observations at the level indicated by the facility (a minimum of every 15 minutes).

Findings included:

Facility policy entitled, "Observation levels and Rounding Protocol (PC-055)" stated 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 and admission department. Special observation protocol, as outlined below, may be ordered by the Physician for patients assessed as a higher risk ....

PROCEDURE

A. Conducting Rounds: ...

3. Staff that are assigned to conduct patient observation rounds shall follow the procedures outlined below:
a. Routine Observation (q15 minute):
i. Observe and account for each patient assigned to employee within the required time frame, and
ii. Conduct rounds at staggered intervals, and in varying patterns or sequence to minimize planned acting out opportunities
iii. Carry the Observation Rounds sheets and document concurrently: Identify and document each patient's location and behavior on the patient observation rounds sheet...

DOCUMENTATION
A. Clearly print name in the appropriate section of the Patient Observation sheet, sign your name and initials legibly
B. Review the Patient Observation sheet to ensure the observation level and precautions are accurate
C. Document the patient's location and behavior as the observations occur, every 15 minutes at a minimum
D. Complete all sections of the Patient Observation form on new admissions
E. Document hand-offs or patient absences ..."

Review of the "Observation Record Inpatient" forms for patients from 04/28/22 to 05/04/22 revealed missing observations on the following dates and times:
* Patient #8 was missing documentation from 1130-1145 on 04/30/22.
* Patient #14 was missing documentation at 1145 on 05/01/22.
* Patient #16 was missing documentation at 2345 on 05/02/22.

Review of the Observation Record Inpatient Form for patients on 05/05/22 revealed that 12 of 12 patients had missing observations documented that morning:
* Patient #2 was missing documentation from 0545 to 0615.
* Patient #3 was missing documentation from 0545 to 0615.
* Patient #4 was missing documentation from 0545 to 0615.
* Patient #5 was missing documentation from 0545 to 0615.
* Patient #6 was missing documentation from 0545 to 0615.
* Patient #7 was missing documentation from 0545 to 0615.
* Patient #8 was missing documentation at 0615.
* Patient #9 was missing documentation from 0545 to 0615.
* Patient #10 was missing documentation from 0545 to 0615.
* Patient #11 was missing documentation from 0545 to 0615.
* Patient #12 was missing documentation from 0545 to 0615.
* Patient #13 was missing documentation from 0545 to 0615.

Several of the patients listed above had notes from the Mental Health Technicians (staff members #10 and 11) that the patients were not observed due to "safety issues on the unit".

In an interview with staff member #2 on 05/05/22 at 2:50 PM they indicated, "Apparently the tech did not do her rounds...The tech declined to do her rounds due to safety issues (apparently a previously aggressive patient was standing at the hall entry point)." This alleged safety issue was not reported to nursing staff, only documented in notes.

On 05/05/22 the Chief Executive Officer indicated that the 2 staff members that failed to monitor patients in the morning of 05/05/22 would immediately be suspended.

Based on the above findings, the facility failed to ensure routine observations were completed and documented appropriately by staff every 15 minutes, as indicated by facility policy. These findings were verified on 05/05/22 with staff members #1 and 9.