HospitalInspections.org

Based on review of Hospital policy, observation, clinical record review, and staff interview, it was determined, that for 4 of 17 patients (Pts. 2 - 5) requiring safety checks every 15 minutes on the Geriatric/ Generations (Gero) Unit, the Hospital failed to ensure safety checks were completed and documented every 15 minutes.

Findings include:

1. Hospital policy No. CLIN 078, revised, 4/26/12, titled, "Safety Precautions" required, "H. Close observation ("CO") - Used when a patient requires closer supervision than General Precautions... 1. Observe every 15 minutes...

N. Suicide Precautions ("S") - Used when patient at risk for suicide... Observed every 15 minutes...."

2. An observational tour was conducted on 5/9/12 between 9:07 AM and 11:05 AM on the Geriatric/ Generations (Gero) Unit. At 9:07 AM, a Behavior Health Associate (E #1) at the far end of the Unit was completing the 15 minute safety check sheets for the unit. For 3 of the 17 patient's (Pts. 2 - 4) safety check sheets had not been completed since 8:00 AM, over 1 hour earlier. E #1 stated that he had taken a group of patients to the cafeteria for breakfast at 8:00 AM, had just returned and was completing the documentation. E #1 stated that other team members told him where the other patients were when he was downstairs.

3. Pt. #2's clinical record was reviewed on 5/9/12 at 9:45 AM. Pt. #2 was a 54 year old female, admitted on 5/1/12, with a diagnosis of Suicidal Ideation. A physician's order dated 5/1/12, required suicidal safety precautions.

4. Pt. #3's clinical record was reviewed on 5/9/12 at 10:10 AM. Pt. #3 was a 53 year old male, admitted on 5/7/12, with diagnoses of Suicidal Ideation and Depressive Disorder. A physician's order dated 5/7/12 at 8:25 PM, required suicidal safety precautions.

5. Pt. #4's clinical record was reviewed on 5/9/12 at 10:30 AM. Pt. #4 was a 61 year old female, admitted on 5/5/12, with a diagnosis of Psychosis. A physician's order dated 5/6/12, required suicidal and fall safety precautions.

6. The Director of In-Patient Services confirmed these findings during the tour and staff interview on 5/9/12 at 11:00 AM.

7. Pt. #5's physician's order dated 4/20/12 at 9:00 AM, discontinued S precautions and required "CO" (Close Observation). Pt. #5's 15 minute safety sheet was incomplete on 5/7/12 at 5:00 PM and 5:15 PM.

8. The Director of Specialty Services confirmed the finding related to Pt. #5 during the clinical record review and staff interview on 5/9/12 at 1:30 PM.