HospitalInspections.org

Based on a review of documentation and interview the hospital failed to ensure the right to receive care in a safe setting, as evidenced by failing to monitoring the patient at the level most recently specified in the patient's medical record.

Findings included:

Facility based policy entitled, "OBSERVATIONS, PATIENT" stated in part,
"The RN may not decrease the level of observation, i.e. change from 1: 1 to Q5 without an order by the psychiatric practitioner.
Documentation of Observations
o Staff documents all levels of observation on each patient's observation form which becomes a part of the patient record. Each entry is to include the following ...
- Level of observation
- Precaution
- Location
- Behavior
- Activity
- Time
-Staff Initial and Signature

o Documentation of the observation is to be completed once the patient has been observed. It is not permissible to complete in advance and or to back fill time frames that were not completed in a timely manner ...
o Documentation of 1: 1 observation occurs q 15 minutes even though the patient is being observed continuously ...
Q 5 Minute Rounds
o All patients are monitored at minimum once in every 5 minute block of time."

Review of medical records revealed the following issues

Patient #1 medical record review included:
Physician order on 05/08/21 at 1405 "Please place on 1:1" for safety.
Patient Observation Sheets revealed the following:
* On 05/17/21 from 0000-0945 the patient observations sheet indicated elopement, assault, fall, and sexual acting out. The level of observation (check every 15 minutes, check every 5 minutes, 1:1, LOS (Line of Sight) was not marked.
Physician order on 05/17/21 at 0945 "D/C 1:1 Observation, Start Q 5 observation."
Patient Observation Sheets revealed the following:
* 05/21/21 from 0000-2345 check every 5 minutes for elopement, assault, fall, and sexual acting out. Missing documentation of q 5-minute checks from 2350-2355.
* 05/23/21 from 0000-2355 check every 5 minutes for elopement, assault, fall, and sexual acting out.
Missing documentation of q 5-minute checks from 1420-1455.

Patient #2 medical record review included:
Physician's MOT Orders on 05/15/20 at 120 stated in part,
"Precautions: Assaultive, Sexually Acting Out, Suicide
Level of Observation: Q 15 mins, Increase to Q 5 minutes for Moderate or High Suicide Risk level on Safe-t Columbia SSRS. May place on 1:1 suicide risk level as needed."
Due to high risk on the Safe-t Columbia scale he was on q 5 minute checks.

Patient Observation Sheets revealed the following:
* 05/21/21 from 0000-2345 check every 5 minutes for suicide, assault, and sexual acting out. Missing documentation of q 5-minute checks from 2350-2355.

Patients #1 and 2 had alleged sexual contact reported by Patient #1 to staff on 05/22/21 (the date of occurrence was not specified) as occurring 2-3 days prior. Both patients involved had missing monitoring on 05/21/21 from 2350-2355. Patient #1 also has missing documentation on 05/23/21. Both patients were appropriately separated after the sexual contact was reported to staff. Therefore it cannot be established that these 2 patients were observed/monitored at the level most recently specified in the patient's medical record.

At the time of the survey on 05/27/21, 8 of 9 patients were being appropriately monitored at the level most recently specified in the patient's medical record. 1 patient was being monitored more frequently than at the level most recently specified in the patient's medical record on 05/25/21 and 05/26/21.

Patient #9 medical record review included:
Physician order on 05/25/21 at 1500 "Change to Q15 obs".
Patient Observation Sheets revealed the following:
* 05/25/21 from 0000-2355 check every 5 minutes for elopement, suicide, and assault was documented.
* 05/26/21 from 0000-2355 check every 5 minutes for elopement, suicide, and assault was documented.

Based on the above findings, patients were not observed/monitored at the level most recently specified in the patient's medical record. In an interview on 05/27/21, staff member #1 verified the above findings.