HospitalInspections.org

Based on a review of documentation and interview, the facility failed to ensure that all patient medical record entries were complete.

Findings included:

Review of medical records for Patients # 1, 3, 4, and 5 revealed a sheet entitled, "Patient Observation/Rounds Form". This form stated the level of observation was every two hours. "To be done by licensed nurse". At the bottom of the form this notation was present, "Must be completed by RN. Rounds are done every 2 hours, write starting time every shift." In the medical records for these 4 patients, this form was noted to be incomplete

Review of the medical record for Patient # 1 (this patient had withdrawal listed as target concern on the sheet) revealed this form was incomplete on the following dates:
· On 09/08/15 there was a gap in documentation from 1800-2200 (the 2000 check was missing).
· On 09/10/15 there was a gap in documentation from 1400-1800 (the 1600 check was missing).
· No observation sheet was present on 09/12/15.

Patient # 3 had an incomplete form (this patient had withdrawal listed as target concern on the sheet) revealed this form was incomplete on the following dates:
· On 09/08/15 there were no documented checks after 1700 (1900, 2000, and 2200 checks were missing).
· On 09/09/15 there was a gap in documentation from 1400-2000 (the 1600 and 1800 checks were missing).

Patient # 4 had an incomplete form (this patient had withdrawal listed as target concern on the sheet) revealed this form was incomplete on the following dates:
· On 09/08/15 there was a gap in documentation from 1800-2200 (the 2000 check was missing).

Patient # 5 had an incomplete form (this patient had suicidal listed as target concern on the sheet) revealed this form was incomplete on the following dates:
· On 09/08/15 there were no documented checks after 2000 (a check at 2200 should have been documented).

In an interview on 12/07/15, staff member #1 verified this form was to be completed every two hours by a nurse.