HospitalInspections.org

Based on document review and interview, nursing services failed to complete and document every 15 minute observation checks per facility policy for 5 of 10 MRs reviewed. (P1, P4, P5, P8 and P10)

Findings include:

1. Facility policy titled Observation Level, no policy number, last revised 1/2024, indicated under Definitions: a. 15-Minute Observation 1. Minimum observation level for all patients from admission until discharge. 2. Patients will be visually monitored every fifteen (15) minutes, 24 hours a day. 3. All patients' location and behavior/activity are documented every fifteen (15) minutes on the Close Observation Form (CS470A).


2. Review of P1 MR indicated:
a. Patient admitted to facility 9/11/24 through 9/17/24 for diagnosis Other Persistent Mood Disorder and ADHD (Attention Deficit Hyperactivity Disorder).
b. Lack of documentation of every fifteen-minute patient observations completed and documented on 9/16/24 from 0930 hours through 1530 hours.


3. Review of P4 MR indicated:
a. Patient admitted to facility 9/13/24 through 9/18/24 for diagnosis of ADD (Attention Deficit Disorder), Developmental Delay and Other Persistent Mood Disorder.
b. Lack of documentation of every fifteen-minute patient observations completed and documented on 9/18/24 from 0000 hours through 0901 hours.

4. Review of P5 MR indicated:
a. Patient admitted to facility 9/13/24 through 9/16/24 with diagnosis of Other Mood Disorder and Autism.
b. Lack of documentation of every fifteen-minute patient observations and documented on 9/16/24 from 0000 hours through 2245 hours.

5. Review of P8 MR indicated:
a. Patient admitted to facility 9/15/24 through 9/19/24 with diagnosis of Other Persistent Mood, Autistic, ADHD and Conduct Disorder.
b. Lack of documentation of every fifteen-minute patient observations and documented on 9/16/24 from 0000 hours through 2245 hours.

6. Review of P10 MR indicated:
a. Patient admitted to facility 09/17/24 and is a current inpatient with diagnosis of Aggression, Other Mood Disorder and ADHD.
b. Lack of documentation of every fifteen-minute patient observation and documentation on 9/20/24 from 1800 hours through 1915 hours, 9/21/24 from 2000 hours through 2245 hours and on 9/22/24 from 1440 hours through 1530 hours.

6. In interview on 9/24/24 at approximately 1253 hours with A1 (Chief Administrative Officer), A3 (Chief Operating Officer) and A4 (Chief Nursing Officer), they confirmed the lack of documentation on Close Observation Form in P1 MR of every fifteen-minute observation checks on 9/16/24 from 0930 hours through 1530 hours, P4 on 9/16/24 from 0000 hours through 2245 hours, P5 on 9/16/24 at 0000 hours to 2245 hours, P8 on 9/16/24 from 0000 hours through 2245 hours and P10 on 09/20/24 from 1800 hours through 1915 hours, 9/21/24 from 2000 hours through 2245 hours and 9/22/24 from 1440 hours through 1530 hours. A4 also confirmed it is facility policy for every patient in facility to be checked every fifteen minutes.