HospitalInspections.org

Based on observation, document review and interview, it was determined that 1 (E #18) of 2 staff failed to perform safety monitoring rounds every 15 minutes on patients with close observations (patients that require every 15 minute safety monitoring rounds). This potentially affects 9 of the 16 patients on census assigned to E #18. As a result, the Condition of Participation for Patient Rights, 42 CFR 482.13, was not in compliance.

Findings included:

1. The Hospital failed to ensure the Precaution rounds were completed as required. (A 144)

Based on document review and interview, it was determined for 1 of 2 (Pt. #1) patients' clinical records reviewed for restraint use, the Hospital failed to ensure that the Restriction of Rights form was completed.

Findings include:

1. On 7/5/18 at approximately 10:30 AM, the Hospital's policy titled, "Restraint/Seclusion" (revised 4/2016) was reviewed and required, "To provide guidelines for the safe and effective use of restraints... Documentation... Complete... Restriction of Rights... Give the patient a copy and place a copy in the medical record...

2. On 7/5/18 at approximately 11:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 28 year old female admitted on 6/15/18 with a diagnosis of schizoaffective disorder. The clinical record indicated that Pt. #1 was placed in restraint on 6/23/18. However, the Restriction of Rights form included in Pt. #1's clinical record was left blank.

3. On 7/6/18 at approximately 10:30 AM, findings were discussed with E #15 (Vice President of Patient Care). E #15 said that the staff had been educated to complete the form. E #15 also confirmed that the Restriction of Rights included in Pt. #1's record was left blank.

4. On 7/6/18 at approximately 11:30 AM, findings were discussed with E #13 (Director of Behavioral Health). E #13 stated that the Restriction of Rights form should have been completed.

Based on observation, document review and interview, it was determined that for 1( E #18) of 2 staff assigned to perform precautions (15 minutes safety rounds), the Hospital failed to ensure the precaution rounds were completed as required. This has the potential to affect all 9 patients assigned to E #18.

Findings include:

1. On 7/6/18 from 10:35 AM to 11:20 AM, an observational tour was conducted on 4 South (Behavioral Health Unit). During the tour the "Precaution and Rounding Sheet" binder of the patients assigned to the Nurse technician (E #18) was reviewed. E #18 had 9 (Pt. #9, #11, #12, #13, #14, #15, #16, #17, and #18) patients assigned to conduct precaution rounds for close observations. All 9 patients "Precaution and Rounding Sheet" were signed by the technician for 10:45 AM. However, these rounding sheets did not indicate the status of the patient: Code (location) and the patient's behavior at 10:45 AM, were left blank.

2. On 7/6/18 at approximately 10:55 AM, the "Precaution and Rounding Sheet" form was reviewed and required to be completed every 15 minutes of the following: the "Code" (Location) and the behavior of the patient at that time the observation is being conducted, signature of the staff, and staff's intervention if needed.

3. On 7/6/18, the policy "Precautions" (revised 4/2015) was reviewed and indicated "Purpose: ...The purpose of this policy is to ensure that appropriate precautions are implemented based on the assessment and evaluation of each patient. ...Close Observations: Patients who have been assessed and evaluated who are determined to require more frequent observations than others. ....Precaution Frequency of Monitoring:. Close Observations (CO) every 15 minutes ...3-1 Procedures: ...2. The RN will: ...3. Notify the nurse tech [technician] (observation tech) of the initiation or changes of the precautions and ensure that the precautions are maintained as ordered. 4. Monitor the technician to ensure the precautions are adhered too ..."

4. On 7/6/18 at approximately 10:55 AM, the Nurse Technician E #18 was interviewed. E #18 stated that she was assigned to do the safety rounds for assigned patients on her shift. E #18 stated that she had completed her 10:45 AM rounds and was aware of her patient's location. However, E #18 did not complete the "Precaution and Rounding Sheet" because she had to go to the bathroom. "I sign the sheet (Precaution and Rounding Sheet) before I complete the rounding, that is in case another staff needs to intervene they won't sign where I have to sign and will complete it when the rounding is done." At approximately 11:15 AM, E #18 stated "I have a 5 minute grace period to complete my rounding sheets."

5. On 7/6/18 at approximately 10:57 AM, the Director of the Behavioral Health Unit (E #13) was interviewed. E #13 stated the staff should not sign the "Precaution and Rounding Sheet" if the required sections have not been completed. E #13 stated that she (E #13) is not aware of the 5 minute grace period. The documentation should be completed as the rounds are being conducted.

6. On 7/6/18 at approximately 2:00 PM, the Vice President of Patient Care E #15 was interviewed. E #15 stated the staff is required to complete all sections of the "Precaution and Rounding Sheets" every 15 minutes.

Based on document review and interview, it was determined for 1 of 2 (Pt. #1) clinical records reviewed for restraints usage, the Hospital failed to ensure the patient's care plan was modified to include the use of restraint.

Findings include:


1. On 7/5/18 at approximately 11:00 AM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 28 year old female admitted on 6/15/18 with a diagnosis of schizoaffective disorder. The clinical record indicated that Pt. #1 was placed in restraint on 6/23/18 from 5:15 PM to 7:15 PM. However, Pt. #1's care plan failed to include restraint was used.

2. On 7/6/18 at approximately 1:30 PM, the Hospital's policy titled, "Clinical Care Station Multi-Disciplinary Care Plan" (revised 11/2016) was reviewed and required, "... The nurse caring for the patient is responsible for the completion... and revisions of the care plan... Procedures... B. The... problems requiring obvious nursing intervention or patient/family education are to be included in the patient's care plan.

3. On 7/6/18 at approximately 1:00 PM, findings were discussed with E #15. E #15 stated that staff had been educated to include restraint use in the care plan. E #15 stated that Pt. #1's care plan was not modified to include use of restraint.