HospitalInspections.org

Based on review of policy and procedure, record review and interview it was determined the facility failed to provide a safe environment in that two (#1 and #2) of twenty (#1-#20) patients reviewed were not observed per physicians order every 15 minutes. The failed practice did not ensure that patients were provided care in a safe setting free from harm. The failed practice had the likelihood to affect all patients who had a physician order for observation at timed intervals. Findings follow:

A. Review of "Path to Purpose - Onboarding Program for All Employees" on 10-14-24, showed that all employees received education and training regarding "Levels of Observations/ObservSmart" on all levels of observation including "observation - 15 min" during orientation.

B. Record review for Patient #1 and Patient #2 showed the patients had physician orders to be observed every 15 minutes.

C. Review of "Behavioral Health - Patient Observation Sheet" for Patient #1, reviewed on 10-14-24, showed no evidence that observations had been completed per the physician order for the following dates and times:
1) 9-9-24 at 4:45 PM, and 9-10-2024 at 8:30 PM, 8:45 PM, 9:00 PM, 9:15 PM, and 9:45 PM.
2) Review of Progress note dated 9-10-24 at 8:52 PM, showed that another patient entered Patient #1's room, and an altercation occurred in which Patient #1 received minor injuries. No evidence was provided that patient observations had occurred since 8:15 PM prior to incident.

D. Review of "Behavioral Health - Patient Observation Sheet" for Patient #2, reviewed on 10-14-2024, showed no evidence that observations had been completed per the physician order for the following dates and times:
1) 1-23-24 no observations documented from 12:00 AM to 2:15 AM and 5:15 AM.
2) 1-24-24 at 8:00 PM and 10:00 PM.
3) 1-25-24 at 10:30 AM and 4:00 PM.
4) 1-28-24 at 5:45 PM, 6:00 PM, 6:15 PM, 6:45 PM, 7:00 PM, and 7:15 PM.

E. During an interview on 10-15-24 at 10:54 AM with the Director of Nursing, findings in A-D were confirmed.