HospitalInspections.org

Based on review of facility documentation, medical records (MR) and interview with facility staff (EMP), it was determined that the facility failed to provided care in a safe setting by failing to ensure that 15 minute observation checks were completed on a patient who was subsequently found unresponsive in their room, for one of one medical records (MR1).

Findings Include:

Review of "The Meadows Psychiatric Center Policy Stat ID 15518515 Patient Observation Rounds, 61," last revised January 2024, revealed ... I. Purpose: To define guidelines for completion of Observation Rounding. II. Policy: The purpose is to provide a safe and secure environment for patients during their hospitalization while providing a process for observing and documenting patient location and behaviors. III. Implementation: Staff assigned to complete observation rounding will: A. Complete documentation in accordance with the Employee Conduct and Work Rules Policy. B. Review and update patient observation forms. Reflect changes in individual patient precaution levels, room or bed changes, new admissions and/or discharges as they occur. C. Clearly print employee name and initials in the appropriate section(s) of the patient observation form. D. Observe each patient, a minimum of every 15 minutes and/or according to precaution level and document observation on the Patient Observation Rounds form. ... F. Document patient location and behavior when the observation occurs on the patient observation. ... H. Observe patients who appear to be sleeping by: Looking for the rise and fall of the chest. Counting at least three respirations. Notating if the patient has moved for his/her previous sleeping position. Ensure that skin and/or body part is visible/ Ensure the bedroom door remains open. Utilize the flash light to enhance visualization. ... ."

1. Review of MR1 "Patient Observation Record & Milieu Groups" revealed that the patient was on observation checks every 15 minutes. On January 10, 2025 at 19:45, it was documented that the patient was a 13 for their behavior, indicating "sleeping/rise-fall" on their right side located in their bedroom. There was no documentation at 20:00. At 20:15 the patient was noted to be unresponsive. At 20:30 until 21:00, it was noted that CPR was being performed.
2. Interview with (EMP3) on January 28, 2025 at approximately 1:15 PM confirmed the observation sheet findings.