HospitalInspections.org

Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights. This deficient practice was evidenced by:
1) Failure to complete 15 minute observation checks on 9 (#1 - #5, #11, #12, #18, #19) of 21 (#1 - #21) Patients with physician orders for 15 minute observation checks during a 3.5 hour interval;
2) Failure to complete 5 minute observation checks on 12 (#6 - #10, #13 - #17, #20, #21) of 21 (#1 - #21) Patients with physician orders for 5 minute observation checks during a 3.5 hour interval; and
3) Failure to perform observations checks as ordered on 1(#4) of 6 (#1-#6) patient medical records reviewed.
(See findings under Tag A0144)

Based on record review and interview, the hospital failed to provide care in a safe setting. The deficient practice is evidenced by:
1) Failure to complete 15 minute observation checks on 9 (#1 - #5, #11, #12, #18, #19) of 21 (#1 - #21) patients with physician orders for 15 minute observation checks during a 3.5 hour interval;
2) Failure to complete 5 minute observation checks on 12 (#6 - #10, #13 - #17, #20, #21) of 21 (#1 - #21) patients with physician orders for 5 minute observation checks during a 3.5 hour interval; and
3) Failure to perform observations checks as ordered on 3(#3, #4, #6) of 6 (#1-#6) patient medical records reviewed.
Findings:

A review of facility policy NO: AS-00-016, "Electronic Patient Observation" being originally approved on 06/2000 and revised on 10/2023 revealed in part, #5. Documentation of Observations, Item b. Ordered precautions should be entered into the patient profile and are visible to the staff on rounding of the patient. Item c. Documentation of the observation is to be completed once the patient has been observed. #6. Q 15 Minute Rounds, Item a. All patients are monitored at minimum once every 15 minute block of time. #7. Q 5 Minute Rounds, Item a. Patient is placed on Q 5 minutes if behavior is unpredictable and there is potential risk for harm to self and others. Item b. Patient is monitored at minimum once in every 5 minute block of time.

1) Failure to complete 15 minute observation checks on 9 (#1 - #5, #11, #12, #18, #19) of 21 (#1 - #21) patients with physician orders for 15 minute observation checks during a 3.5 hour interval

A record review of Unit A's Electronic Patient Observation Sheets for 12/17/2023 from 12:01 a.m. to 11:59 p.m. revealed undocumented observation checks from 6:00 p.m. to 9:30 p.m. on 9 (#1 - #5, #11, #12, #18, #19) of 21 (#1 - #21) Electronic Patient Observation Sheets reviewed with physician orders for 15 minute observation checks. Further, the Electronic Patient Observation Sheets revealed a trend in undocumented observations during the approximate time frames of 7:20 pm to 7:55 p.m., 7:55 p.m. to 8:45 p.m. and 8:45 p.m. to 9:20 p.m. The undocumented observations placed Patients #1-21 at risk for harm during the before mentioned approximate time frames. The Electronic Patient Observation Sheet for each of the 9 (#1 - #5, #11, #12, #18, #19) Patients revealed:
Patient #1:
Level of observation: every 15 minutes; Risk Status: assault precautions, suicide risk-low.
Electronic Patient Observation Sheet revealed observation being performed at 7:13 p.m., 7:51 p.m., 8:26 p.m. and 8:44 p.m. This revealed undocumented observations for 38 minutes, 35 minutes and 18 minutes respectively.
Patient #2:
Level of observation: every 15 minutes; Risk Status: assault precautions, elopement precautions, suicide risk-high.
Electronic Patient Observation Sheet revealed observation being performed at 7:02 p.m., 7:52 p.m., 8:26 p.m. and 8:45 p.m. This revealed undocumented observations for 50 minutes, 34 minutes and 19 minutes respectively.
Patient #3:
Level of observation: every 15 minutes; Risk Status: elopement precautions, fall precautions, seizure precautions, suicide risk-low.
Electronic Patient Observation Sheet revealed observation being performed at 6:31 p.m., 7:04 p.m., 7:14 p.m. and 8:20 p.m. This revealed undocumented observations for 35 minutes and 66 minutes respectively.
Patient #4:
Level of observation: every 15 minutes; Risk Status: none assigned.
Electronic Patient Observation Sheet revealed observation being performed at 7:11 p.m., 7:55 p.m. and 8:32 p.m. This revealed undocumented observations for 44 minutes and 37 minutes respectively.
Patient #5:
Level of observation: every 15 minutes; Risk Status: suicide precautions, suicide risk-low.
Electronic Patient Observation Sheet revealed observation being performed at 7:12 p.m., 8:43 p.m. and 9:20 p.m. This revealed undocumented observations for 91 minutes and 37 minutes respectively.
Patient #11:
Level of observation: every 15 minutes; Risk Status: none assigned.
Electronic Patient Observation Sheet revealed observation being performed at 6:30 p.m., 7:10 p.m., 8:49 p.m. and 9:21 p.m. This revealed undocumented observations for 40 minutes, 99 minutes and 32 minutes respectively.
Patient #12:
Level of observation: every 15 minutes; Risk Status: assault precautions, elopement precautions, suicide risk-low.
Electronic Patient Observation Sheet revealed observation being performed at 7:14 p.m., 7:52 p.m. and 8:31 p.m. This revealed undocumented observations for 48 minutes and 39 minutes respectively.
Patient #18:
Level of observation: every 15 minutes; Risk Status: assault precautions, elopement precautions, restrict to unit, suicide risk-low.
Electronic Patient Observation Sheet revealed observation being performed at 7:23 p.m., 7:57 p.m., 8:39 p.m. and 9:19 p.m. This revealed undocumented observations for 34 minutes, 42 minutes and 40 minutes respectively.
Patient #19:
Level of observation: every 15 minutes; Risk Status: assault precautions, suicide risk-low.
Electronic Patient Observation Sheet revealed observation being performed at 7:14 p.m., 7:51 p.m., and 8:26 p.m. This revealed undocumented observations for 37 minutes and 35 minutes respectively.

In an interview on 12/28/2023 at 12:15 p.m. S2DON and S3PI confirmed the undocumented observations on the Electronic Patient Observation Sheets. S2DON and S3PI also confirmed the Electronic Patient Observation Sheets indicated an observation was made late if the sheet revealed > 15 min in the interval column when a patient was on every 15 minute rounds.

2) Failure to complete 5 minute observation checks on 12 (#6 - #10, #13 - #17, #20, #21) of 21 (#1 - #21) Patients with physician orders for 5 minute observation checks during a 3.5 hour interval

A record review of Unit A's Electronic Patient Observation Sheets for 12/17/2023 from 12:01 a.m. to 11:59 p.m. revealed undocumented observation checks from 6:00 p.m. to 9:30 p.m. on 12 (#6 - #10, #13 - #17, #20, #21) of 21 (#1 - #21) Patient's Electronic Patient Observation Sheet reviewed with physician orders for 5 minute observation checks. Further, the Electronic Patient Observation Sheets revealed a trend in undocumented observations during the approximate time frames of 7:20 pm to 7:55 p.m., 7:55 p.m. to 8:45 p.m. and 8:45 p.m. to 9:20 p.m. The undocumented observations placed Patients #1-21 at risk for harm during the before mentioned approximate time frames. The Electronic Patient Observation Sheet for each of the 12 (#6 - #10, #13 - #17, #20, #21) patients revealed:

Patient #6:
Level of observation: every 5 minutes; Risk Status: suicide risk-high.
Electronic Patient Observation Sheet revealed observation being performed at 7:24 p.m., 7:52 p.m. and 8:20 p.m. This revealed undocumented observations for 28 minutes and 28 minutes respectively.
Patient #7:
Level of observation: every 5 minutes; Risk Status: assault precautions, elopement precautions, suicide precautions, suicide risk-low.
Electronic Patient Observation Sheet revealed observation being performed at 6:09 p.m., 7:57 p.m., 8:42 p.m. and 9:19 p.m. This revealed undocumented observations for 108 minutes, 45 minutes and 37 minutes respectively.
Patient #8:
Level of observation: every 5 minutes; Risk Status: fall precautions, suicide risk-low.
Electronic Patient Observation Sheet revealed observation being performed at 7:14 p.m., 7:55 p.m., 8:43 p.m. and 9:19 p.m. This revealed undocumented observations for 41 minutes, 48 minutes and 36 minutes respectively.
Patient #9:
Level of observation: every 5 minutes; Risk Status: none assigned.
Electronic Patient Observation Sheet revealed observation being performed at 7:16 p.m., 7:55 p.m., 8:43 p.m. and 9:22 p.m. This revealed undocumented observations for 39 minutes, 48 minutes and 41 minutes respectively.
Patient #10:
Level of observation: every 5 minutes; Risk Status: suicide risk-high.
Electronic Patient Observation Sheet revealed observation being performed at 7:11 p.m., 7:26 p.m., 7:56 p.m., 8:40 p.m., 8:49 p.m., 9:01 pm and 9:21 p.m. This revealed undocumented observations for 15 minutes, 30 minutes, 44 minutes, 12 minutes and 20 minutes respectively.
Patient #13:
Level of observation: every 5 minutes; Risk Status: assault precautions, suicide precautions, suicide risk-high.
Electronic Patient Observation Sheet revealed observation being performed at 7:16 p.m., 7:56 p.m., 8:43 p.m. and 9:19 p.m. This revealed undocumented observations for 40 minutes, 47 minutes and 36 minutes respectively.
Patient #14:Level of observation: every 5 minutes; Risk Status: suicide precautions, suicide risk-high.
Electronic Patient Observation Sheet revealed observation being performed at 6:55 p.m., 7:14 p.m., 8:43 p.m. and 9:20 p.m. This revealed undocumented observations for 19 minutes, 89 minutes and 37 minutes respectively.
Patient #15:
Level of observation: every 5 minutes; Risk Status: suicide precautions, suicide risk-high.
Electronic Patient Observation Sheet revealed observation being performed at 6:54 p.m., 7:11 p.m., 7:55 p.m., 8:42 p.m. and 9:20 p.m. This revealed undocumented observations for 17 minutes, 44 minutes, 47 minutes and 38 minutes respectively.
Patient #16:
Level of observation: every 5 minutes; Risk Status: elopement precautions, suicide risk-high.
Electronic Patient Observation Sheet revealed observation being performed at 6:54 p.m., 7:11 p.m., 7:56 p.m., 8:43 p.m. and 9:19 p.m. This revealed undocumented observations for 17 minutes, 45 minutes, 47 minutes and 36 minutes respectively.
Patient #17:
Level of observation: every 5 minutes; Risk Status: suicide risk-high.
Electronic Patient Observation Sheet revealed observation being performed at 6:34 p.m., 7:03 p.m., 7:12 p.m., 7:15 p.m., and 8:38 p.m. This revealed undocumented observations for 29 minutes, 9 minutes, 3 minutes and 83 minutes respectively.
Patient #20:
Level of observation: every 5 minutes; Risk Status: suicide precautions, suicide risk-low.
Electronic Patient Observation Sheet revealed observation being performed at 6:53 p.m., 7:14 p.m., 7:25 p.m., 7:55 p.m., 8:43 p.m. and 9:19 p.m. This revealed undocumented observations for 21 minutes, 11 minutes, 30 minutes, 48 minutes and 36 minutes respectively.
Patient #21:
Level of observation: every 5 minutes; Risk Status: suicide risk-high.
Electronic Patient Observation Sheet revealed observation being performed at 6:55 p.m., 7:05 p.m., 7:11 p.m., 7:23 p.m., 7:55 p.m., 8:43 p.m. and 9:19 p.m. This revealed undocumented observations for 10 minutes, 6 minutes, 12 minutes, 37 minutes, 47 minutes and 36 minutes respectively.

In an interview on 12/28/2023 at 12:15 p.m. S2DON and S3PI confirmed the undocumented observations on the Electronic Patient Observation Sheets. S2DON and S3PI also confirmed the Electronic Patient Observation Sheets indicated an observation was made late if the sheet revealed > 5 min in the interval column when a patient was on every 5 minute rounds.

3) Failure to perform observations checks as ordered on 1(#3, #4, #6) of 6 (#1-#6) patient medical records reviewed

A medical record review of revealed observation levels not being performed as ordered on 3 (#3, #4, #6) of 6 (#1 - #6) patient medical records reviewed. This deficient practice placed Patients #1 - #6 at risk for harm. The medical records revealed:

Patient #3
A medical record review of revealed an admission on 11/21/2023 with the diagnosis of Major Depressive disorder. Patient #3 was placed on an observation level of every 5 minutes from 11/21/2023 till 12/14/2023 at 5:41 p.m. On 12/14/2023, Patient #3 observation level was changed to every 15 minutes. A review of Patient #3's Patient Observation Sheets from 12/10/2023 through 12/20/2023 revealed Patient #4 observation level being performed every 15 minutes. Patient #3's observation level was not being performed as ordered from 12/10/2023 till 12/14/2023 at 5:41 p.m.

In an interview on 12/28/2023 at 2:00 p.m. S2DON and S3PI confirmed the observation levels ordered and the patient was not being observed per order from 12/10/2023 till 12/14/2023.
Patient #4
A medical record review revealed an admission on 12/17/2023 with the diagnosis of Major Depressive disorder. She was placed on an observation level of every 5 minutes and a precaution level of Suicide Risk. A review of Patient #4's Patient Observation Sheets from 12/17/2023 through 12/20/2023 revealed Patient #4 observation level being performed every 15 minutes.

In an interview on 12/28/2023 at 2:00 p.m. S2DON and S3PI confirmed the observation level ordered and the patient was not being observed per order.
Patient #6
A medical record review revealed an admission from 12/12/2023 to 12/20/2023 with a diagnosis of Major Depressive Disorder with Suicidal Ideations. Admission orders revealed an observation level of every 5 minutes. This order was in place during Patient #6's entire admissions. A review of the Patient Observation Sheets revealed a level of observation being performed every 15 minutes from 12/12/2023 to 12/13/2023.

In an interview on 12/28/2023 at 9:45 a.m. S2DON and S3PI confirmed the observation level ordered and the patient was not being observed per order.

Based on record review and interview, the hospital failed to maintain a patient medical record entry for a complete physician order entry. This deficient practice is evident by an incomplete seclusion and restraint order on 1 (Patient #1) of 6 (Patient #1 - #6) sampled patient medical records reviewed.
Findings:

A medical record review of Patient #1 revealed a physician order on 12/17/2023 for Seclusion and Restraint. The order included an option to choose the type of seclusion and restraint. In part, the order was written as follows: Mark an X for the Type: [ ] Seclusion, [ ] Physical Restraint, [ ] Chemical Restraint, [ ] Mechanical Restraint 2 Point, [ ] Mechanical Restraint 4 Point. The order did not have an item marked for the type to be used.

In an interview on 12/28/2023 at 12:15 p.m. S2DON and S3PI confirmed the above mentioned physician order was not complete.