HospitalInspections.org

19843


Based on document review and interview, it was determined, for 4 of 10 patients (Pts. #1 - 4) on the first floor adolescent psychiatric unit, the Hospital failed to ensure that psychiatric patients with physician's orders for close observation safety precautions were monitored every 15 minutes.

Findings include:

1. On 4/7/16 at 10:30 AM, Hospital policy titled, "Routine Rounds", approved 8/2014, was reviewed. The policy required, "Procedure: 1. The physician will order one of four levels of observation at the time of admission and as the patient's condition warrens a change. a. Every 15 minutes... 6. Every 15 minute observations: a. Minimum level of observation for all patients. b. Staff will observe and document on the Precaution Flow Sheet every 15 minutes..."

2. On 4/7/16, at 8:57 AM, an observational tour was conducted on the first floor adolescent psychiatric unit, in the company of the Director of Quality (E #1) and the Interim Patient Care Services Manager (E #2). At 8:57 AM, the Patient Observation Records (15 minute safety rounding sheets) were requested. Rounding sheets were not completed for 4 of 10 patients (Pts. #1 - 4) at 8:30 AM and 8:45 AM. These 4 patients included:

- Pt. #1 was an 15 year old male, admitted on 2/4/16, with a diagnosis of psychotic disorder, unspecified, with a physician's order dated 2/8/16, for assault precautions (AP), and sexually acting out (SAO).

- Pt. #2 was a 14 year old male, admitted on 2/23/16, with diagnoses of depressive disorder and opposition defiant, with a physician's order dated 2/23/16 for AP and suicide precautions (SP).

- Pt. #3 was a 16 year old male, admitted on 3/31/16, with diagnoses of depressive disorder unspecified and rule out major depression, with a physician's order dated 3/31/16 for "suicide and aggression".

- Pt. #4 was a 16 year old male, admitted on 4/5/16, with a diagnosis of depressive disorder, with a physician's order dated 4/5/16 for "suicide/aggression".

3. On 4/7/16 at 9:10 AM, an interview was conducted with the Interim Patient Care Services Manager (E #2). E #2 stated the Behavioral Health Technician assigned to 15 minute rounding was doing patient vital signs at the time the 15 minute safety checks were due. E #2 could not explain why someone else did not complete the 15 minute safety checks.