HospitalInspections.org

Based on the review of medical records, it was determined that in one of two medical records of individuals who received inpatient services in the Behavioral Health Unit (BHU)-Johnson Unit, medical record # 1, the hospital failed to ensure the patient's right to receive care in a safe setting. Findings:

Documentation in medical record # 1 reflects that 15-minute checks were not always provided according to the physician's order and hospital policy. This failed to ensure the patient's right to receive care in a safe setting at all times.

The following policy was reviewed: Behavioral Health Services, Johnson Unit policy entitled Observation of patients and use of the Behavioral Health Security Flow Sheet (also called "15-minute checks") and the Behavioral Health Security Flow and Sleep Record, Document Number: 412. The policy/procedure directed the following: All patients identified by the Behavioral Health Suicide Risk Assessment either as at-risk for self-harm or harm to others will be placed on 15-minute checks. The 15-minute checks will be maintained until the physician discontinues it by a written order. Patients not on 15-minute checks will be checked hourly.

Medical record # 1 was reviewed. Documentation reflects Patient # 1 was a 27 year old individual who was admitted voluntarily to the BHU at 0159 hours on 05/13/2010 with a diagnosis of depression. Patient # 1 had expressed suicidal ideation. The untimed physician's Admission Orders dated 05/12/2010 reflect an order for "15 min. checks x ____hrs". The number of hours was left blank.

The Admission Assessment by the Registered Nurse (RN) dated 05/13/2010 timed 0338 hours reflects Patient # 1 expressed suicidal ideation and a plan. The Behavioral Health Services Nursing Suicide Assessment Flow Sheet dated 05/13/2010 timed 0250 hours reflects an Immediate Safety Plan that identified "Every 15 min checks". The Behavioral Health Services Nursing Suicide Assessment Flow Sheet dated 05/13/2010 timed 1100 hours identified an intervention of "Every 15 minute Safety Flow Sheet".

The Behavioral Health Security Flow Sheet and Sleep Record reflects documentation of 15-minute checks between 0200 hours and 0730 hours on 05/13/2010.

However, the Behavioral Health Security Flow Sheet reflects documentation of hourly checks between 0800 hours and 1530 hours on 05/13/2010 instead of the 15-minute checks directed by the physician's order and the Behavioral Health Services Nursing Suicide Assessment.

Documentation on the Behavioral Health Services Progress & Orders form reflects the physician did not order "1 hr [checks]" until 1044 hours on 05/14/2010.



-These findings also reflect noncompliance with the following Oregon Administrative Rule for Hospitals:
333-505-0033 Patient Rights, A hospital shall comply with the requirements for patients rights set out in 42 CFR 482.13 (71 FR 71426, December 8, 2006).