HospitalInspections.org

Based on observation, document review, and interview, it was determined, that for 1 of 1 patient (Pt #1), the Hospital failed to ensure patients received care in a safe setting by failing to ensure the patient was monitored every 15 minutes, as required for safety.

Findings include:

1. On 10/27/2021, the Hospital's policy titled, "Precaution Rounds" (revised 10/17/2019) was reviewed and required, " ... Precaution Rounds: A structure designed to document the location and safety of each patient hospitalized on an inpatient unit. Documentation occurs every 15 minutes on each patient ... 5. The staff member keeps the rounding binder ... in his/her possession for the entire hour they are rounding ...."

2. On 10/26/2021 between 1:30 PM and 2:30 PM, the Hospital's Video Surveillance footage of the Behavioral Health Unit -3D was reviewed with the Director of Behavioral Health Unit (E#6). The video footage showed the following:
-On 10/19/2021 the video footage located at 3D east hallway (with view of Pt. #1's room) and Nursing Station was reviewed. It is observed that the MHC (E#1) did not conduct the every 15-minute rounds for Pt #1, who was in their room, on 10/19/2021 from 3:30 PM through 4:30 PM, as required. All patients on census for 10/19/2021 were on routine every 15-minute rounds. The Registered Nurse (E#4) was seen doing the hourly rounds at 4:02 PM.

3. On 10/26/2021 at approximately 2:00 PM, an interview was conducted with the Director of Behavioral Health Unit (E#6). E#6 confirmed that the video footage for 3D east hallway indicated that staff did not conduct the every 15-minute rounds as required from 3:30 PM through 4:30 PM. E#6 stated that the 15-minute rounds should be done to ensure that patients are safe.