HospitalInspections.org

Based on record review and interview, it was determined that the facility failed to follow policies and procedures related to observation of patients for safety.

Findings were:

Review of Patient #1's medical record on 7/15/14 revealed the following:
- A nurse's note and assessment on 7/6/14 at 8:00 am stated that there was no reported patient fall from the night shift, however the patient had a dressing on his head and his "right eye was(sic) swollen shut, with eye purple in color"; the nurse's note further stated that at 8:40 am a medical evaluation consult was placed for the facial swelling and cellulitis.
- The MHT/C.N.A. Flowsheet for 7/6/14 revealed that the patient was on a monitoring level of "II - Constant Visual."
- A medical consult after the fall on 7/6/14, stated the following under Recommendations section "concern for skull injury with battle sign."
- There was no documentation present in the medical record to indicate when and how the facial swelling occurred.

Facility policy titled "Patient Monitoring and Precautions Policy #: 605.1" stated the following in part, "1. In order to provide protection to patients, three levels of staff monitoring are provided...B. Level II: close observation, constant monitoring within 20 feet distance....G. The patient's behavior is documented on the Close Observation Sheet."

The above findings were confirmed in an interview with the facility's CEO and CNO on 7/16/14.