HospitalInspections.org

Based on document review and interview, it was determined that for 3 of 7 records (Pts. #4, #5, and #7) reviewed for safety precautions, the Hospital failed to ensure that safety precautions were documented on the observational rounding records to ensure that staff were aware of what behaviors to monitor for during rounding.

Findings include:

1. The Hospital's policy titled, "Patient Observations" (revised 8/2020), was reviewed and required, "...The RN [registered nurse] ensures that the patient observation/precaution status is reviewed daily... Documents the patient observation/precaution level on the Patient Observation/Precaution Form... MHA [mental health associate]: ... Review and update patient observation forms. Reflect changes in individual patient precaution levels..."

2. The clinical record of Pt. #4 was reviewed on 4/17/2024. Pt. #4 was admitted on 4/14/2024, with a diagnosis of schizoaffective disorder (mental health disorder). Physician orders for aggression/homicide precautions, elopement risk, sexual victimization risk, and fire starting risk were placed on 4/14/2024 at 7:00 PM. Patient Observation Records from 4/14/2024 and 4/15/2024 lacked any precautions marked for Pt. #4 on these dates.

3. The clinical record of Pt. #5 was reviewed on 4/17/2024. Pt. #5 was admitted on 4/13/2024, with a diagnosis of schizoaffective disorder. Physician orders for aggression/homicide precautions, elopement risk, sexual aggression risk, suicide precaution, and self-harm risk were placed on 4/13/2024 at 7:00 AM. Patient Observation Records from 4/13/2024 to 4/16/2024 did not include homicide/assault precautions and/or self-harm risk.

4. The clinical record of Pt. #7 was reviewed on 4/17/2024. Pt. #7 was admitted on 4/11/2024, with a diagnosis of bipolar disorder (mood disorder). Physician orders for aggression/homicide precautions and suicide precaution were placed on 4/11/2024 at 7:00 PM. Fire starting risk orders were placed on 4/12/2024 at 12:00 PM. Patient Observation Records from 4/11/2024 to 4/14/2024 lacked any precautions marked for Pt. #7 on these dates.

5. An interview was conducted with MHA (E#11) on 4/17/2024, at approximately 12:00 PM. E#11 stated that rounding staff know what precautions a patient is on by looking at what's marked on the observation sheets. E#11 stated that these sheets are reviewed at the beginning of the shift by the nurse and updated throughout the shift if a precaution is added or removed. E#11 stated that it's important to mark the sheets so that staff know what behaviors and risks to monitor for each patient.