HospitalInspections.org

Based on document review and interview, it was determined, for 3 of 4 patients (Pts. #11 - 13) on the third floor intensive treatment psychiatric unit (ITU), the Hospital failed to ensure that psychiatric patients with physician's orders for close observation safety precautions were monitored every 15 minutes.

Findings include:

1. On 4/6/16 at 11:35 AM, Hospital policy number 200.29, titled, "Rounds for Patient Observations", effective 1/10/14, was reviewed. The policy required, "Every patient must be seen by a staff member at a minimum of every fifteen minutes... Hand off assigned patient observation rounds to another staff member before leaving the patient treatment area (meals, breaks, emergencies)."

2. On 4/4/16, at 11:25 AM, an observational tour was conducted on the third floor adults intensive treatment psychiatric unit, in the company of the Director of Clinical Services (E #6). At 11:25 AM, the Patient Observation Records (15 minute safety rounding sheets) were requested. Three of 4 patients (Pts. #11 - 13) did not have rounding sheets completed for 11:00 AM and 11:15 AM.

- Pt. #11 was an 18 year old female, admitted on 3/20/16, with a diagnosis of psychosis, and a physician's order dated 3/21/16, for escape precautions (EP), assault precautions (AP), and self injury precautions (SIP).

- Pt. #12 was a 20 year old female, admitted on 4/1/16, with diagnoses of psychosis and bipolar disorder, and a physician's order dated 4/1/16 for EP, AP, and SIP.

- Pt. #13 was a 19 year old male, admitted on 3/31/16, with a diagnosis of bipolar disorder, and a physician's order dated 3/31/16 for EP, AP, and SIP.

3. On 4/4/16 at 11:30 AM, an interview was conducted with the Mental Health Counselor (E #3) who was assigned to patient observation rounding. E #3 stated he was catching up on the rounding sheets because he had been "busy with a patient".

4. These findings were discussed with the Director of Clinical Services (E #6) during the observational tour on 4/4/16 at 11:30 AM.