HospitalInspections.org

Based on observation, record review and interviews the facility failed to ensure the effective implementation of policies and procedures that promoted care in a safe setting for 1 of 12 patients (Patient B). Specifically, the facility failed to ensure that Staff #5 and Staff #6 (both Mental Health Technicians-MHT's) were able to locate all 12 patients they had been entrusted to conduct rounds on. This resulted in inaccurate documentation for three 15-minute rounds on Patient B. Staff #5 also failed to document an additional 15-minute round on Patient B.

The findings include:

POLICY: "Q15-20 Minute Patient Rounds" Revised 02/20
Each patient shall have a rounds sheet.
Rounds shall be documented and performed by hospital staff.

PURPOSE:
To assure a safe patient environment as well as the safety of each patient in his/her milieu.

PROCEDURE:
1. Units staff shall conduct visual rounds every 15 to 20 minutes, and 24 hours a day on inpatient units.
2. Nursing staff shall document patient the whereabouts by direct observation.
3. Rounds sheets will accompany the patient at all times, round sheets will be given to the staff member responsible for observing the patient.

During an initial tour 10/28/21 at 1050 the second-floor children's dayroom was entered by one surveyor and employee (#2), the Compliance Officer. There were eleven young boys present with one unlicensed Technician (Tech #5). The boys were sleeping and lounging in the dayroom.

Tech #5 was asked for the every 15-minute rounds sheets to review. There were twelve rounds sheets but only eleven patients in the room. Employee #2 was asked to count patients and round sheet and confirmed there were eleven patients and twelve round sheets.

When interviewed at 11/28/21 at 1110 Tech #5 was asked who was missing. Tech #5 counted the patients and the sheets three times before identifying patient #B as not present. She was asked where patient #B was and responded he had walked out into the hallway 10-15 minutes ago. Patient #B's rounds sheet had been documented by Tech # 6 that he was present in the dayroom at 1000, 1015 and 1030. Tech #5 had documented he went was in the dayroom at 1045 and left the rounds sheet blank for 1100 when it was reviewed at 1110.

When interviewed 11/28/21 at 1111, three nursing staff at the nursing station just across from the door to the dayroom were asked if they had seen patient # 2. One responded "no," two shook their heads to gestor no.
Patient #2 was observed in the empty small dayroom with Psychiatrist # 4.

When interviewed 10/28/21 at 1112 psychiatrist # 4 stated patient #2 had been with him, "He's been in here with me about an hour."

Interview on 10/28/2021 at 1114 with employee #2 Compliance Officer after her review of the 15-minute round sheet confirmed that Patient B was not in the dayroom as documented for times 1015 through 1100 and had been in another room with the Psychiatrist. She stated the patient had been in the room with the psychiatrist.

When interviewed 10/28/21 at 1445 employee #1, DON stated employee #5 "usually works upstairs with the adults. She's not very familiar with the kids." She added the rounds sheet should have been given to the hall monitor to complete while in evaluation with the Psychiatrist.