HospitalInspections.org

Based on a review of documentation and interviews, the facility failed to ensure patients had the right to receive care in a safe setting, by failing to monitor patients at the level of monitoring most recently specified in the patient's medical record.

Findings included:

Facility based policy entitled, "OBSERVATIONS, PATIENTS" stated in part,
"POLICY

In order to maintain patient health and safety the hospital staff encourage patients to practice daily makes [sic] and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the RN. Level of observation can be increased by the RN any time there is a concern but only a psychiatric practitioner may decrease the level ...

6. Documentation of Observations
a. 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 ...
i. Level of observation
ii. Precaution
iii. Location
iv. Behavior
v. Activity
vi. Time
vii. Staff Initial and Signature ..."

Review of medical records revealed 2 patients (#1 and 16) that did not have monitored documentation at the level most recently specified in their medical records:
* Patient #1 was on Q 15-minute checks on the date of their discharge on 04/16/23. Review of facility Precaution and Levels of Observation sheets for Patient #1 revealed there was no documented monitoring of the patient after 0645 on 04/16/23. Per discharge paperwork signed at 1300 on 04/16/23, the patient should have been monitored until the time of discharge on 04/16/123 at 1300.
* Patient #16 was on Q 15-minute checks on the date of their discharge on 04/20/23. Review of facility Precaution and Levels of Observation sheets for Patient #1 revealed there was no documented monitoring of the patient after 0645 on 04/20/23. Per discharge paperwork signed at 1130 on 04/20/23, the patient should have been monitored until the time of discharge on 04/20/123 at 1130.

The above findings were verified on 06/13/23 with staff member #1 and 4.