HospitalInspections.org

Based on record review and interview, the facility failed to ensure safety requirements were met in one (patient #20) of two records reviewed for one to one safety precautions, from a total sample of 31 records. This has the potential to place all patients that need one on one supervision for safety at risk for patient harm. Findings include:

On 6/9/2016 at approximately 1000,with Staff A and B, review of film/video records of activity on the patient unit Mod A on 5/17/2016 2300 to 0700 (midnight shift) revealed Staff Z entering room 244-1 (the room assigned to patient #20) at approximately 0230. He was not seen again until 0425 when he came to the doorway of 244-1 and was visible to the camera.

On 6/8/2016 at 1430 the assignment sheets for Mod A were reviewed for 5/16/2016 through 5/18/2016. Staff Z was on the schedule for one on one supervision of patient #20 on 5/17/2016 on the 1500 to 2300 shift and the 2300 to 0700 shift.

On 6/8/2016 at 1630 the assignment sheets for Mod A were reviewed. Staff Z was noted on the schedule for one on one supervision of patient #20 on 5/17/2016 for the 1500 to 2300 shift and for the 2300 to 0700 shift. The "Round Sheets" for documenting 15 minute patient checks for 5/17/2016 were reviewed and revealed a lack of documentation for 15 minute patient checks for patient
#20. Specifically, 15 minute patient checks for patient 20 were not documented from 0230-0345. Review of the electronic medical record revealed a time stamp of 0445 at which time Staff Z documented 15 minute checks for 0345, 0400, 0415, and 0430.

On 6/8/2016 at approximately 2000 document review of general notes for patient #20 revealed Staff Z documented on patient #20 at 2107, 2128, and not again until 0428.

On 6/8/2016 at approximately 2030 review of the policy titled "Continuous One to One Observation." #8.19.05 dated revised 10/2014 revealed on page 1 of 1 under "Nursing Procedure: 4. Documentation of the patients behavior will occur at least hourly...5. Staff sitting on one to one will document 15 min rounds on the one to one patient."

On 6/9/2016 at 1100 Staff B verified that Staff Z was assigned to do one to one patient observation for safety and failed to document every 15 minutes for safety on 5/17/2016 through the midnight shift ending at 0700 on 5/18/2016 and hourly for general behavior as required by facility policy. Staff B also confirmed that Staff Z was also not visible to the security camera from 0230 until 0425.

On 6/9/2016 at 1200 Staff Z was interviewed. He stated "to prevent allegations we need to remain in view of the security camera." He also stated "Yes, I know we are supposed to document every 15 minutes when doing 1:1 observations."