HospitalInspections.org

Based on record review and interview the facility's Registered Nurses failed to monitor and ensure the Mental Health Tech's accurately completed the documentation of the patient record specifically the activity flowsheet on 1 of 1 patient's whose medical record was reviewed for the time frame of 4/26/2022 through 5/5/2022, 10 days.

This deficient practice had the likelihood to effect all patients of the facility.

Findings included.

On 5/23/2022 at 11:00 AM the medical record (MR) for patient #1 was reviewed.
The record indicated pt. #1 was admitted on 4/26/2022 at 6:30 PM for severe depression and anhedonia (the loss of interest, in living). The MR indicated the psychiatrist noted she was not actively suicidal but simply had no desire to live. When the social worker asked if she would answer questions she slowly silently shook her head no.

Interview with staff #1 and #2 indicated upon arrival pt #1 was placed in a wheelchair for transfer but could take 3-5 steps with hold on support. This was witnessed during the initial transfer from her son's pick-up to the wheelchair.

During the review of pt. #1's MR it was determined pt. #1 was on every 15 minutes observation. This required the Registered Nurse (RN) to sign the flowsheet every 2 hours. By signing every 2 hours the RN was cosigning the MHT entry. The RN was verifying the documentation was complete and accurate to the best of her/his knowledge. A review of the mental health tech (MHT) documentation on the "Observation Check Sheet/Graphic Flowsheet" reflected many opportunities for documentation that were left blank.

Date of admission 4/26/2022 the MHT flowsheet was initiated. Every 2-hour incontinent check for pt. #1 was left blank beginning with the first opportunity after pt. #1 arrived to the unit, at 6:30 PM and no incontinent check was recorded for the completion of the shift at 6:00 AM (6 missed opportunities). The flow sheet indicated pt. #1 had 2 episodes of voiding. The documentation did not record if pt. #1 was independent with her toileting or if she was incontinent of bladder function.

Pt #1 remained in the Psychiatric unit for 10 days for a total of 95 missed opportunities for documentation of position change, incontinent or assisted bathroom privileges out of 108 times pt. #1 was checked.

The facility's RN staff, signed off every 2 hours without noticing the MHT documentation was incomplete.

Interview with staff #1 and #2 confirmed there were many omissions on the MHT flowsheet's, for pt. #1.