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Based on document review and interview, nursing services failed to document 15-minute patient observation checks in 2 of 10 patient medical records reviewed. (Patient 6 and Patient 9)

The cumulative effects of these systemic problems resulted in the facility's inability to provide nursing care in a safe manner.

Based on document review and interview, nursing services failed to document 15-minute patient observation checks in 2 of 10 patient medical records reviewed. (Patients 6 and 9)

1. Facility Policy titled, "Patient Rounding", Policy No.: NU60, last revised 10/2020, indicated under Policy: Rounds are to be made on the unit on all patients by the assigned nursing staff at a minimum of every 15 minutes or more frequently as ordered for each 24-hour period.

2. Review of Patient 6's medical record from 08/13/2024 to 09/03/2024 lacked documentation of 821 of 1996, 15-minute patient observation checks including but not limited to 08/17/2024 at 8:45 p.m., 08/21/2024 at 4:00 p.m., 08/24/2024 at 1:30 p.m., 08/27/2024 at 11:15 a.m., 08/27/2024 at 11:30 a.m., and 09/02/2024 at 10:45 p.m.

3. Review of Patient 9's medical record from 08/27/2024 to 09/04/2024 lacked documentation of 302 of 796, 15-minute patient observation checks including but not limited to 08/28/2024 at 5:15 a.m., 08/29/2024 at 3:30 p.m., 09/01/2024 at 2:30 p.m., 09/03/2024 at 3:00 p.m., and 09/04/2024 at 3:45 a.m.

4. Interview with A1 (Chief Executive Officer), A2 (Quality Manager), and A3 (Director of Nursing) on 09/04/2024 at approximately 5:00 p.m. confirmed that patient 6's and 9's medical record lacked 15-minute patient observation checks as mentioned above.