HospitalInspections.org

Based on observation, record review and interview, the facility failed to provide a safe environment as evidenced by: failure to make safety rounds every -15 minutes as per policy on the adolescent unit as required.

Findings included:

Record review of Policy & Procedure "Every-15 Minute Patient Rounds" dated 07/2014 revealed: "Unit staff shall conduct visual rounds every 15 minutes 24 hours a day on the inpatient units ... Nursing staff shall document rounds on the individual patient's Observation Record sheet."

Observation of the video dated 4/1/2017 revealed that safety rounds were not being done every 15 minute as indicated by policy:
1039 PM safety rounds on patients made by Employee F
1100 PM safety rounds made by Employee F
1125 PM safety rounds made by Employee S
1145 PM safety rounds made by Employee D

Observation of the video dated 4/4/2017 revealed that safety rounds were not being done every 15 minute as indicated by policy:
1211 AM safety rounds made by Employee D
0126 AM safety rounds made by Employee D

Observation of the video dated 4/5/2017 revealed that safety rounds were not being done every 15 minute as indicated by policy:
1111 PM Employee Q made safety rounds
1138 PM Employee Q made safety rounds
Rounds not made again till 4/6/2017 at 1231 PM

Interview with program manager Employee E on 4/7/2017 at 0945 AM revealed that all units have to make safety rounds every 15 minutes.