HospitalInspections.org

Based on interview and record review, the facility failed to document every 15-minute safety checks for 2 (P-2, P-8) of 13 patients reviewed resulting in the increased likelihood for negative outcomes for the patients. Findings include:

Medical record review with Director of Nursing Staff G on 3/17/2025 at 1245 revealed P-2 was admitted to the facility's Emergency Crisis Center on 2/4/2025 and was placed on constant observation. P-2's frequency observation record checks for 2/5/2025 started at 1530 and were performed as documented through 2345. There were no times documented on 2/5/2025 from 1200 to 1515.

Record review with Staff G of P-8 revealed P-8 was admitted to the facility's on 1/19/2025 and was placed on constant observation for elopement precautions and being uncooperative. P-8's constant observation logs revealed there was no documentation of every 15-minute safety checks performed when P-8 was on the medical surgical unit on 1/28/2025 from 0400 to 0530, on 1/31/2025 from 0930 to 1030, and 2/3/2025 from 1600 - 2300. Staff G confirmed the findings.

According to the facility's policy "Constant Observer for Patients Under Harm Precautions," dated 6/15/22, the policy revealed that "The CCO (Competent Constant Observer) will document patient observations every 15 minutes on the designated flow sheet."

According to the facility's policy "Utilization of Constant Observer for Non-Behavioral Health Patients," dated 8/15/24, the policy revealed that "The Constant Observer will document patient observations every 15 minutes on the designated flow sheet as indicated, and as instructed by the nurse."