HospitalInspections.org

Based on observation and record review, the facility failed to document every 15-minute safety checks for 2 (P-2, P-11) of 3 patients reviewed resulting in the increased likelihood of negative consequences for the patients. Findings include:

On 5/5/2025 at 1300, P-2's medical record was reviewed with Cheif Nursing Officer (CNO) Staff B. P-2 was admitted on 12/4/2024 and was placed on 15 minute safety checks.

According to P-2's patient observation sheets, there was no documentation for the 15 minute safety checks on the following dates and times:

12/5/2024 at 0215 and 0300
12/6/2024 at 2000 and 2030
12/7/2024 at 0915, 1415, 1515
12/11/2024 at 0800 and 1315
12/14/2024 at 1900 and 2245
12/15/2024 at 0245, 0530, and 1000
12/16/2024 at 0830, 1230, 1245, 1300, and 1700
12/17/2024 at 2200
12/18/2024 at 1045, 1100, 1615, and 2345
12/19/2024 at 0230, 0700, 1100, 1300, and 1345

On 5/6/2025 at 1230, P-11's chart was reviewed with CNO Staff B. P-11 was admitted on 12/10/2024 and was placed on 15 minute safety checks.

The patient observation sheets for P-11 revealed no documentation for the 15 minute safety checks on the following dates and times:

12/11/2024 at 1315 and 2300
12/14/2024 at 1115, 1400 and 1900
12/15/2024 at 0245, 0530, and 1045
12/17/2024 at 1930
12/16/2024 at 1245 and 1300
12/18/2024 at 0015, 1045, 1100, 1545, 1615, and 1645.
12/19/2024 at 0700, 0745, and 2130
12/20/2024 at 1245, 1715, and 1730
12/21/2024 at 0830
12/22/2024 at 2230
12/23/2024 at 0815
12/25/2024 at 1015

According to the facility's policy Observations, Patient, dated 11/2024, "All patients are monitored at minimum once in every 15-minute block of time. During the observations staff are to:

i. Make direct visual contact; look for signs of danger or distress, even if the patient is in the bathroom.
ii. Observe patients close enough to confirm they are breathing and not in any physical distress such as bleeding, lying on the floor, very restless, etc. The policy also revealed that :Documentation of Observations will be completed in real time (as observations are being conducted) and by the person documenting the Observations. Note: there may be times in which actual entries are delayed due to an emergency. Documentation should be made as a late entry as soon a possible with a note indicating the reason for the delay if appropriate.