HospitalInspections.org

Based on record review and interview it was determined that the facility failed to document observation of patient #1 every 15 minutes on 1 of 12 "Patient Observation Records" reviewed in the patients's medical record.

Findings were:
Review of a policy entitled "Level of Observation Protocols" on 6/15/10 revealed on page 1 "All patients will be routinely observed in compliance with physician orders and prescribed protocols". And on page 2 under the heading "Q (every) 15 Minute Observations" the policy indicated that this was the "minimum level of observation for all patients" and that "staff will observe patient and document on the Patient Observation Record q (every) 15 minutes".

Review of patient #1's medical record on 6/15/10 revealed a document entitled "Admission Orders" dated 3/18/10, which had "Every 15 Minute Checks" and "High Risk for Falls" checked under the heading "Observation/Precautions".

Review of patient #1's medical record on 6/15/10 reveal a document entitled "Patient Observation Record" dated 3/24/10. Under the heading "Indication Type(s) of Precautions" a box labeled "Fall" was checked. The document was blank on every line labeled "code" (a code key at the top of the document identified where and what a patient could be doing) and "MHT Init." (Mental Health Technician Initials) from 4:45pm to 10:00pm.

During an interview with the Director on 6/15/10 she stated that because the document was blank during this time frame the patients location and actions could not be accounted for. She also confirmed that this violated the facilities policy and physician orders.