HospitalInspections.org

Based on review of documents, medical records and staff interview, it was determined the facility failed to ensure a Registered Nurse (RN) supervised the Mental Health Technicians (MHT) in the documentation of every fifteen (15) minute face to face checks of the patient's on the Behavioral Health Unit. This has the potential to create an unsafe environment for all patient's, when patient's are not monitored according to hospital policy.

Findings include:

1. Hospital policy titled "Observation and Precautions " last revised 7/11, states in part: "The Charge RN is responsible for assuring that all patient observations are completed and documented by a member of the nursing staff. A patient check is a visual identification or the patient with his/her location and observable behavior. Patient checks are assigned to specific staff members for specific time periods on each shift. The staff person assigned to these checks is responsible for circulating continuously on the unit for the assigned time period. The assigned staff records the patient's location on the appropriate flow sheet (depending on level of observation ordered) at the time the patient check is done."
"A patient observation Q 15 minute flowsheet is maintained for the duration of 15-minute checks and becomes a permanent part of the patient's medical record placed on the flowsheet section of the record. The patient's location, behavior/activity will be documented on the flowsheet."

2. During observation on 10/29/13 of the behavioral health unit from 1120 to 1150 a tour of the unit was provided. The current census on the unit was fifteen (15) patient's. At 1140 the SA requested the binder which held the Q 15-Minute Flowsheet's and discovered eight (8) of the fifteen (15) flowsheet's had not been documented on since 1045.

3. These flowsheet's were reviewed with the Nurse Manager of the Behavioral Health Unit at 1150 on 10/29/13 during an interview and she agreed with these findings.