HospitalInspections.org

Based on review of documentation and interview, it was determined that the facility failed to adequately document appropriate discharge criteria on all of its patients.
Findings were:
Facility policy entitled " Level of Observation Protocols " stated in part: " The physician shall order one of three levels of observation at time of admission, and may change the level of observation if the patient ' s condition warrants a change:
? Q 15 minute (may order a precaution level if indicated)
? Line of sight (requires a precaution level)
? One-to-one (requires a precaution level)
Q 15 Minute Observations:
? Minimum level of observation for all patients.
? Staff will observe patient and document on the Patient Observation Record q 15 minutes.
? Assigned staff will make direct visual contact with patients and confirm they are in no danger or distress.
? Whenever possible, staff should make informal, verbal contact with assigned patients to ascertain safety and well-being.
? Staff will be vigilant for potential risk factors identified for specific patients (levels of precautions).
? Sleeping patients will be observed at close enough proximity to confirm they are in no physical distress. Staff must observe the rise and fall of the chest, listen for snoring or other sounds from the patient, and/or watch for other movements when checking patients who are in bed. A flashlight may be used to aid with observation."

6 of 6 patients admitted on suicide precautions remained on suicide precautions until the moment of discharge. It is questionable that a patient on suicide precautions would be deemed appropriate for discharge.

In an interview with the Chief Nursing Officer on 4/7/15, it was admitted that through an oversight by medical staff, the above patients remained on suicide precautions until discharge.