HospitalInspections.org

Based on document review, observational tour, and staff interview, it was determined for 3 of 13 patients (Pt. #4, 5, & 6) on the 4 West male psychiatric unit, the Hospital failed to ensure psychiatric patients were monitored for safety every 15 minutes, as required by physician's order.

Findings include:

1. On 9/4/13 at 7:20 AM, Hospital policy number 1308.75, titled, "Patient Rounds", revised May 2013, was reviewed. The policy required, "Monitor all patients for: 1. Alterations in physical or cognitive functioning that may lead to unsafe behavior. 2. Unsafe behaviors that may require a higher level of precaution. Warning signs... Poor impulse control. Verbal or physical abuse. Early warning signs of: a. Escalation, b. Elopement attempt, c. Suicidal preoccupation or gestures...
The caregiver assigned to rounds: a. Locates each patient, observes his/her activity and physiology and respiratory effort when in bed and documents location and behavior on the rounds every 15 minutes..."

2. On 9/4/13 at 6:25 AM, an observational tour was conducted on the 4 West male psychiatric unit. A Mental Health Counselor (E #1) was completing fifteen minute precautions observation records for 13 of 13 patients while sitting at a table and not locating and observing each patient.

3. At 6:30 AM, the Surveyor asked E #1 permission to examine the fifteen minute precautions observation records he was completing. E #1 had just completed 10 records, 1 record (Pt. #6) partially complete (up to 5:45 AM), and 2 records (Pt. #4 & 5) had no 15 minute safety precaution entries since 3:30 AM, 3 hours earlier.

- The clinical record of Pt. #4 was reviewed on 9/2/13 at 11:20 AM. Pt. #4 was a 28 year old male, admitted on 9/2/13, with a diagnosis of bipolar disorder. Pt. #4's physician's orders dated 9/2/13 at 5:15 PM for suicide, assault, and close observation precautions, required patient monitoring every 15 minutes.

- The clinical record of Pt. #5 was reviewed on 9/2/13 at 11:25 AM. Pt. #5 was a 42 year old male, admitted on 8/14/13, with diagnoses of HIV and Schizophrenia. Pt. #5's physician's orders dated 8/14/13 at 2:00 PM for assault precautions, required patient monitoring every 15 minutes.

- The clinical record of Pt. #6 was reviewed on 9/2/13 at 11:30 AM. Pt. #6 was a 41 year old male, admitted on 8/26/13, with a diagnosis of bipolar disorder. Pt. #6's physician's orders dated 8/26/13 at 8:45 PM, for suicide precautions required patient monitoring every 15 minutes.

4. An interview was conducted with E #1 on 9/4/13 at 6:30 AM. E #1 stated he had completed the hourly rounds, not the 15 minute rounds and did not explain why the 15 rounds were not completed.

5. On 9/4/13 at 6:30 AM, the Psychiatric Unit Nurse Manager / Director of Risk Management (E #2) accompanied the Surveyor on the observational tour of 4 West and observed the deficient practice. On 9/4/13 at 1:50 PM, E #2 stated, during an interview, fifteen minutes precaution observation rounds were to be completed every 15 minutes.