HospitalInspections.org

Based on record review, the hospital failed to maintain an monitoring program.

Findings include:

Cross Reference

482.23 (b)(3) Supervision of Nursing Care
482.24 (c)(1) Content of Record: Orders Dated and Signed
482.41 (a) Maintenance of Physical Plant

Based on record review, Registered Nurses failed to supervise and evaluate the level of observation needed to assure that a patient at risk to self and others were protected for ten (10) of the ten (10) sampled patients.

Findings include:

Review of ten (10) medical records revealed:

Patient #1, admitted 2/20/2015 with diagnosis of psychosis. Electronic physician orders failed to contain a observation level order.

Patient #2, admitted 3/10/2015 with diagnosis of depression. Electronic physician orders failed to contain a observation level order. Observation flow sheets failed to indicate patient observation level on 3/12/15 and 3/14/15 7:00 PM- 6:45 AM, 3/17/15 7:00 AM- 6:45 PM, and 3/19/15 7:00 PM- 6:45 AM.

Patient #3, admitted 3/11/15 with diagnosis of substance abuse. Electronic physician orders failed to contain a observation level order. The medical record did not contain Observation flow sheets.

Patient #4, admitted 2/12/15 with diagnosis of psychosis. Electronic physician orders failed to contain a observation level order. Observation flow sheets failed to indicate patient observation levels on 7:00 PM- 6:45 AM shift for dates: 2/21/15, 2/22/15, 2/24/15, 2/26/15, 3/3/15, 3/5/15, and 3/8/15. Documentation on 2/23/15 7:00 AM- 6:45 PM, did not include documentation from 6:00 PM-6:45 PM. Observation documentation was performed every fifteen (15) minutes on all flow sheets.

Patient #5, admitted 2/20/15 with diagnosis of schizophrenia. Electronic physician orders failed to contain a observation level order. Observation documentation was marked as level 3, and performed every fifteen (15) minutes on all flow sheets.

Patient #6, admitted 3/15/15 with diagnosis of psychosis. Electronic physician orders failed to contain a observation level order. Observation documentation was performed every fifteen (15) minutes on all flow sheets, but failed to indicate patient observation level on:
3/17/15 7:00 PM- 6:45 AM
3/18/15 7:00 AM- 6:45 PM
3/19/15 7:00 PM- 6:45 AM
3/20/15 7:00 AM- 6:45 PM
3/22/15, 3/24/15, and 3/26/15 7:00 PM- 6:45 AM

Patient #7, admitted 2/11/15 with diagnosis of psychosis. Electronic physician orders failed to contain a observation level order. Observation flow sheets failed to indicate patient observation levels on 7:00 PM- 6:45 AM shift for dates: 2/11/15, 2/13/15, 2/14/15, 2/15/15, 2/16/15, and 2/20/15. Observation documentation was performed every fifteen (15) minutes on all flow sheets

Patient #8, admitted 2/11/15 with diagnosis of schizophrenia. Electronic physician orders failed to contain a observation level order. Observation flow sheet indicated patient was observation level 3, and documentation was performed every fifteen (15) minutes.

Patient #9, admitted 2/19/15 with diagnosis of dementia. Electronic physician orders failed to contain a observation level order. Observation flow sheets failed to indicate patient observation levels on 7:00 PM- 6:45 AM shift for dates: 2/20/15, 2/25/15, 2/27/15, 2/28/15, 3/1/15, 3/2/15, and 3/4/15. Observation documentation was performed every fifteen (15) minutes on all flow sheets.

Patient #10, admitted 2/13/15 with diagnosis of schizophrenia. Electronic physician orders failed to contain a observation level order . Observation flow sheets failed to indicate patient observation levels on 7:00 PM- 6:45 AM shift for dates: 2/13/15, 2/14/15, 2/15/15, and 2/20/15;
On 2/21/15 no staff initials were documented from 7:45 AM-10:45 AM on the flow sheet
No observation level documented on 2/22/15 7:00 AM- 6:45 PM
Observation documentation was performed every fifteen (15) minutes on all flow sheets.

Review of facility policy titled Patient Classification System for Psychiatry, effective 01/2013, revised 12/17/2014, revealed that patients are placed on one of the following levels on admission and the level is adjusted throughout their stay by the treatment team, which included:
· Level One: staff observes patient's whereabouts on the unit every 30 minutes
· Level two: staff observes patient's whereabouts on the unit every 30 minutes
· Level three (close observation including suicide and violent precautions): staff observes patient's whereabouts on the unit every 15 minutes. This is the standard observation level of all new patients.
· Level four (constant observation, including elopement precautions): patient must be maintained within the visual contact of the staff at all times. Staff documents observation every fifteen minutes.
· Level five (1 on 1): one staff member must maintain the patient with the visual contact at all times, including during sleep. Staff documents observation every fifteen minutes.