HospitalInspections.org

Based on document review and staff interview, it was determined for 3 of 10 patients (Pt #1, Pt #3, and Pt #7), admitted to the Behavioral Health Unit, the Hospital failed to ensure patients received care in a safe environment by ensuring 15 minute patient observations were being conducted. This has the potential to affect all patients receiving care in the Behavioral Health Unit (current census of 16).

Findings include:

1. On 10/22/18 at 1:00 PM, the medical record of Pt #1 was reviewed. Pt #1 was admitted to the Behavioral Health Unit on 09/22/23. Pt #1 was placed on fall risk and standard observation. Standard observation required assigned staff to make direct visual contact with patients every 15 minutes and document the patient's location and activity and confirm they were in no danger or distress. Pt #1's "Patient Observation" sheet for 09/23/18 did not have the required staff initials, location code, activity code, and behavior code annotated between the times of 10:00 AM thru 10:38 AM.

2. On 10/23/18 at 10:00 AM, the medical record of Pt #3 was reviewed. Pt #3 was admitted to the Behavioral Health Unit on 09/08/18. Pt #3 was placed on fall risk and standard observation. Pt #3's "Patient Observation" sheet for 09/13/18 did not have the required staff initials, location code, activity code, and behavior code annotated between the times of 7:30 PM thru 8:30 PM.

3. On 10/23/18 at 11:00 AM, the medical record of Pt #7 was reviewed. Pt 7 was admitted to the Behavioral Health Unit on 10/07/18. Pt #7 was placed on fall risk and standard observation. Pt #7's "Patient Observation" sheet for 10/10/18 did not have the required staff initials, location code, activity code, and behavior code annotated between the times of 7:00 PM and 7:30 PM. Pt #7's "Patient Observation" sheet for 10/11/18 did not have the required staff initials, location code, activity code, and behavior code annotated between the times of 5:30 PM and 6:00 PM.

4. On 10/23/18 at 1:30 PM, the Hospital policy "BHS.025 Observation Levels" revised 02/01/2016 was reviewed. Under "J. Standard Observation: 1." it indicated "Assigned staff will make direct visual contact with patients and confirm they are in no danger or distress every 15 minutes and document the patient location and activity.

5. On 10/23/18 at 3:00 PM, an interview with the Director of Behavioral Health (E #1) was conducted. E #1 confirmed the "Patient Observation" sheets for Pt #1, Pt #3, and Pt #7 were not complete and explained there should have been annotations every 15 minutes for all patients admitted to the Behavioral Health Unit.