HospitalInspections.org

Based on record review and interview, the facility failed to ensure that patients were protected by monitoring the patient at the level of monitoring most recently specified in the patient's medical record, including assault/homicide precautions. This presents a safety risk for patients and staff members when they are not monitored or observed as ordered.

Findings included:

The Mental Health Tech Daily Note in the medical record for Patient #11 was reviewed the afternoon of 11/12/2020 in the facility conference room. The observation note revealed that Patient #11 was on Assault/Homicide Precautions with a Q15 Level of Observation. Documentation reflected that Patient #11 was observed at 1400, but there were only initials at 1415 and 1430 without a location or activity noted. At 1445, there were no initials, location, or activity noted. There was no means to determine that Patient #11 was monitored for safety during that time.

Facility policy, Level of Observation Protocols, Policy Number PC-154 stated, in part, "The status and location of all patients shall be directly observed, assessed and documented a minimum of every 15 minutes (routine) in order to ensure maximum safety on the units ....
5. Documentation ...
c. Document the patient ' s location and behavior as the observation occur, every 15 minutes."

The above findings were confirmed in an interview the afternoon of 11/12/2020 with Staff #1 in the facility conference room.

Based on a review of documentation and interviews, the facility failed to ensure that a treatment plan was developed based on the findings of the physical examination and medical diagnoses. These findings could result in inadequate care of the patient's physical needs and increased risk of exposure of infectious disease to staff and patients if complete treatment planning is not conducted. 

Findings included:

Facility policy, Interdisciplinary Patient-Centered Care Planning, Policy number PC-1324 stated, in part, "Developing the Treatment Plan
1. The Nurse completing the Nursing Assessment or designee shall develop the initial Treatment Plan within eight (8) hours of admission ...
a. Any medical problems or diagnoses that are not receiving treatment will be listed on the Treatment Plan cover sheet/problem list as deferred with justification provided. If the medical problem requires active treatment, it will either be included in the plan as a "Chronic/Stable" medical problem if only routine care is provided or on a separate problem sheet if more than routine care is indicated."

Review of the medical record for patient #5 the morning of 11/11/2020 in the facility conference room revealed the following diagnoses from the History and Physical exam on 8/30/2020, "COVID-19 Positive." Physician Admission Orders on 8/26/20 at 1315 stated, Precautions: Other: "(+) COVID". Patient #5 was placed on COVID isolation precautions due to testing positive for COVID-19 at admission.

Review of the Master Treatment Plan for Patient #5 revealed that "Medical Problems" was left blank and there was no mention of COVID-19 positive or isolation precautions in the treatment plan for Patient #5 at any point during his stay.

The above findings were confirmed in an interview the afternoon of 11/12/2020 with Staff #1 in the facility conference room.