HospitalInspections.org

Based on record review and interviews, the hospital failed to ensure nursing staff followed the policies and procedures of the hospital. This deficiency was made evident by the:
1) failure to document the date and staff signature on paper observation records for 1 (#1) of 4 (#1 - #4) patients reviewed for observations;
2) failure to accurately document wound skin assessments in the daily nursing assessment for 1 (#1) of 4 (#1 - #4) patients reviewed for daily nursing assessments; and
3) failure to document an elopement for Patient #4.

Review of the hospital policy #AS-00-016 titled "Observations, Patient" last revised 11/2024, revealed in part:
"Policy: In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN.
Procedure: 6. Documentation of Observations b. Paper Documentation including Downtime of an EMR i. Staff documents all levels of observation on each patient's observation form which becomes a part of the patient record. Each entry is to include the following: Level of Observation; Precaution; Location; Behavior; Activity; Time; and Staff Initial and Signature."

Review of the hospital policy #TX-11-059 titled "Elopement Precautions and Response" last revised 04/2020, revealed in part:
"Policy: Staff shall provide appropriate assessment and observation of inpatients who have either verbally or non-verbally expressed a desire to elope from the hospital. Patients who leave the hospital without a discharge order are considered to have "eloped." This includes patients who are requesting AMA discharge but have not completed the discharge process. Staff shall make every effort to locate the patient and make notifications to designated persons regarding the elopement.
Procedure: In order to provide protection to patients who are at high risk for elopement the following shall occur: 9. h. Documenting the sequence of events in the Progress Notes, including: i. Date, time and circumstances under which the patient was noted missing; ii. Action taken to locate patient; iii. Information related to notifications - time, names, relationships to the patient, specific information disclosed; iv. If patient is located but not returned, the disposition of the patient; and v. Incident Report shall be completed and submitted to the Director of Risk Management."

1) Failure to document the date and staff signature on paper observation records for 1 (#1) of 4 (#1 - #4) patients reviewed for observations.

Review of Patient #1's medical record revealed she was admitted to the hospital on 07/03/2025 from an outside hospital emergency room with a diagnosis of Disruptive Mood Dysregulation Disorder and ADHD Combined Type.

Review of Patient #1's Physician Orders dated 07/03/2025 to present revealed alternating orders of Q15 and Q5 minute staff observation.

Review of Patient #1's paper chart revealed paper copies of the "Patient Observation Record (Q5 and Q15)" for three separate dates. All three paper copies revealed missing documentation of the date of the observation, level of observation and precaution(s) for Patient #1. Two of the paper copies were missing the observing staff's signature.

On 08/11/2025 at 1:30 PM, an interview was conducted with S5DRM during Patient #1's record review. S5DRM reviewed the three paper copies of the "Patient Observation Record (Q5 and Q15)" in Patient #1's paper chart. S5DRM confirmed all three copies were missing documentation of the date of observation, level of observation and precaution(s) and two of the copies were also missing the observing staff's signature.

2) Failure to accurately document wound skin assessments in the daily nursing assessment for 1 (#1) of 4 (#1 - #4) patients reviewed for daily nursing assessments.

Review of Patient #1's Physician Orders dated 07/03/2025 to present revealed the following in part:
On 07/04/2025 - Amoxicillin/Potassium Clav 500-125mg PO TID x 7 days for skin and skin structure infection Discontinued on 07/08/2025; and Neomycin/Bacitracin/Polymyxinb (Triple Antibiotic Ointment) Topically BID to right arm x 7days for minor bacterial infection
On 07/08/2025 - Wound Care BID Right side upper extremity, rinse wound with normal size, pat dry with 4x4 gauze, cover wound with 4x4 gauze Discontinued on 07/09/2025; Clindamycin HCl 150mg Take 300mg PO TID x 7 days for skin and skin structure infection; and Medical Provider Consult Patient complains of referred/radiating pain from existing wound of the right forearm
On 07/09/2025 - Wound Care BID Right side upper extremity, rinse with normal saline, pat dry with 4x4 gauze, cover wound with wet-to-dry dressing, clean wound with normal saline, pack with wet to dry dressing, cover with Mepilex Discontinued on 07/16/2025
On 07/14/2025 - Anaerobic and Aerobic Culture to Right Forearm wound infection for deep disruption or dehiscence of operation wound
On 07/15/2025 - Wound Care Daily Right Upper Extremity Rinse wound with normal saline, pat dry with cloth, apply to peri-wound, cover wound with dry dressing. Cleanse the wound with wound cleanser. Perform peri-wound care using skin prep. Apply a secondary dressing with adhesive foam. Pack the wound with iodoform gauze, then secure with tape and Tubigrip.
On 07/29/2025 - Transfer Patient to Hospital - outpatient wound clinic sent her to hospital

Review of Patient #1's daily nursing assessments revealed the following in part:
On 07/17/2025 at 8:45 PM - Nursing Note - Day Shift: Skin Assessment- Normal; Narrative Daily Progress Note - Not making progress as evidenced by still removing dressing from wound on arm and not following directions. Not making progress toward treatment as evidenced by still removing dressing and sticking screws in wound to arm. Signed by S6RN
On 07/18/2025 at 6:05PM- Nursing Note - Day Shift: Skin Assessment- Normal. Signed by S7RN
On 07/29/2025 at 4:31 AM - Nursing Note - Night Shift: Skin Assessment- Normal. Signed by S8RN

On 08/11/2025 at 1:30 PM, an interview was conducted with S5DRM during Patient #1's record review. S5DRM confirmed the above daily nursing assessments were incorrect as Patient #1 was actively being treated for a wound to her right forearm.

3) Failure to document an elopement for Patient #4.

Review of Patient #4's medical record revealed he was admitted to the facility on 08/05/2025 from his home for a 90-day subacute treatment for Conduct Disorder; Oppositional Defiant Disorder; ADHD; Reaction to Severe Stress and Disruptive Mood Disorder.

Review of Patient #4's Physician's Orders dated 08/05/2025 revealed elopement precautions due to a history of elopements from his home.

Review of Patient #4's Nursing Progress Notes on 08/07/2025 revealed no documentation of his successful elopement from the facility.

On 08/12/2025 at 5:45 PM, an interview was conducted with S5DRM during his record review. S5DRM confirmed there was no nursing documentation in a progress note or daily assessment note of Patient #4's elopement from the hospital.