HospitalInspections.org

Based on review of Hospital policy, security video, clinical records, and staff interview, it was determined, that for 4 of 4 (Pt. #s 1-4) clinical records reviewed of patients requiring safety checks every 15 minutes on the Adult Psychiatric Unit, the Hospital failed to ensure safety checks were completed every 15 minutes.

Findings include:

1. Hospital policy No. 18.13 reviewed 12/6/10, titled, "Observation Policy - Behavioral Health Units" required, "Intermittent Observation: Visually observing the patient at Fifteen (15) minute intervals."

2. The security video of the hallway outside of Pt. #1's room was reviewed on 5/31/12 for the timeframe of 5/15/12 at 11:00 PM - 5/16/12 at 2:00 AM and showed the following events: E#1 was in Pt. #1's room at 11:32 PM for 3 minutes 9 seconds; at 11:37 PM for 3 minutes; at 11:41 PM for 1 minute 40 seconds. Pt. #1 followed E#1 down the hall at 11:52 PM and back to Pt. #1's room. E#1 stood in the doorway for 6 minutes having what appeared to be in a friendly conversation with Pt. #1. From 5/15/12 11:59 PM to 5/16/12 1:15 AM, no staff member was seen going down the hallway to make safety checks every 15 minutes. Five patient rooms were visible on the video screen. E#1 did not enter any other patient room in the hallway during the interactions with Pt. #1.

3. The clinical record of Pt. #1 was reviewed on 5/30/12. Pt. #1 was a 32 year old male admitted on 5/14/12 with the diagnoses of Major Depression and Suicide Attempt. Pt. #1 was placed on Intermittent Observations (every 15 minutes) upon admission. The Behavioral Health Special Precautions Checklist noted that Pt. #1 was in the room sleeping, while the video of the same time period showed that E#1 was interacting with Pt. #1 on 5/15/12 from 11:30 PM - 12:00 AM on 5/16/12. There was also documentation that safety checks were completed every 15 minutes for Pt. #1 on 5/16/12 from 12:00 AM - 1:15 AM, and noted that the patient was sleeping, while the video showed that no staff had gone into the room to check the patient during that same time period.

4. The clinical record of Pt. #2 was reviewed on 5/31/12. Pt. #2 was a 35 year old male admitted on 5/12/12 with the diagnosis of Bipolar Disorder. Pt. #2 was placed on Intermittent Observations (every 15 minutes) upon admission. The Behavioral Health Special Precautions Checklist noted that Pt. #2 was in the room, sleeping from 11:30 PM 5/15/12 - 1:30 AM 5/16/12 for the every 15 minute safety checks, while the video showed that no staff had gone into the room to check the patient during that same time period.

5. The clinical record of Pt. #3 was reviewed on 5/31/12. Pt. #3 was a 49 year old female admitted on 5/14/12 with the diagnosis of Depression. Pt. #3 was placed on Intermittent Observations (every 15 minutes) upon admission. The Behavioral Health Special Precautions Checklist noted that Pt. #3 was in the room, sleeping from 11:30 PM 5/15/12 - 1:30 AM 5/16/12 for the every 15 minute safety checks, while the video showed that no staff had gone into the room to check the patient during that same time period.

6. The clinical record of Pt. #4 was reviewed on 5/31/12. Pt. #4 was a 32 year old male admitted with the diagnosis of Depression. Pt. #4 was placed on Intermittent Observations (every 15 minutes) upon admission. The Behavioral Health Special Precautions Checklist noted that Pt. #4 was in the room, sleeping from 11:30 PM 5/15/12 - 1:30 AM 5/16/12 for the every 15 minute safety checks, while the video showed that no staff had gone into the room to check the patient during that same time period.

7. The Director of Human Resources reviewed the tape with this surveyor and stated, "I agree that no staff was seen going down the hall for over 1.5 hours."