HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the Quality Assurance/Performance Improvement (QAPI) program measured, analyzed and tracked quality indicators to monitor the safety and effectiveness of hospital services and operations. This deficient practice was evidenced by failing to ensure the Registered Nurse entered the risk flags for behavior monitoring on the Observe Smart tablet.
Findings:

Review of current and closed medical records failed to reveal behaviors were monitored in accordance with the patient's Nursing Treatment Plan for 4 of 6 medical record reviewed (Patient #1, #3, #5, #6).

In an interview on 08/06/2024 at 2:10 p.m., S1QA Director stated they monitor incident logs and monitor for updates in the patient's Treatment Plan but they do not currently monitor the Risk Flags on the Patient Observations Sheets to ensure the Registered Nurses are entering the required observation needs into the Observe Smart tablet to reflect the current or updated Treatment Plans.

Based on record reviews and interview, the hospital failed to ensure a Registered Nurse assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs. This deficient practice was evidenced by the Registered Nurse failing to ensure patient's behaviors were monitored in accordance with the patient's Nursing Treatment Plan for 4 of 6 medical record reviewed (Patient #1, #3, #5, #6).
Findings:

Review of the hospital's policy TX.064 titled, "Safety Rounds/Accountability" revealed in part:
Policy: It is the policy of this hospital to provide a safe, secure environment for our patients by ensuring accountability for their well-being.
Safety Rounds Procedure: The charge nurse assigns responsibility for completion of patient observation round at the beginning of each shift ... Every patient not on one to one (1:1) precaution will be monitored at least every 15 minutes. Document via the Observe Smart tablet. During shift handoff the staff relinquishing observation round and the oncoming shift round together to ensure all patients are visualized, high risk precautions are in place and environment is checked. Off going staff discuss any issues experienced through the previous shift and the patient's level of observation.

Review of Patient #1's medical record revealed an Initial Nursing Treatment Plan dated 07/13/2024 and updated 07/23/2024 for Sexual Aggression and Inappropriate Actions and Comments. Review of the Patient Observations Sheets revealed Q15 (every 15) minute monitoring but failed to reveal the risk flags were updated to reflect the current treatment plan.

Review of Patient #3's medical record revealed an Initial Nursing Treatment Plan 07/20/2024 and updated 07/23/2024 for Sexual Aggression and Inappropriate Actions and Comments. Review of the Patient Observations Sheets revealed Q15 minute monitoring but failed to reveal the risk flags were updated to reflect the current treatment plan.

Review of Patient #5's medical record revealed an Initial Nursing Treatment Plan 07/29/2024. The Patient Observations Sheets revealed Q15 minute monitoring but failed to reveal risk flags on the Patient Observation Sheets for 07/29/2024 thru 07/31/2024.

Review of Patient #6's medical record revealed an Initial Nursing Treatment Plan 07/29/2024 and updated 07/30/2024 for Sexual Aggression and Inappropriate Actions and Comments. Review of Patient Observations Sheets revealed Q15 minute monitoring but failed to reveal risk flags on the Patient Observation Sheets for 07/29/2024 thru 08/01/2024.

In an interview following review of the medical records on 08/06/2024 at 2:00 p.m., S1QA Director confirmed the Risk Flags for the Patient Observation Sheets were not updated and/or incomplete for Patients #1, #3, #5, and #6.