HospitalInspections.org

Based on observation, interview, and record review, the facility failed to ensure a safe environment for 6 of 10 sampled patients on the 2nd floor adolescent unit [Patient ID # 8, 11, 12, 14, 15, 16].

The facility failed to adhere to its policy requiring staff to conduct visual rounds and accurately document patient whereabouts every 15 minutes.

Review of six (6) of the observation sheets showed multiple blanks spaces (5 lacked documented visual observation for over one hour and 15 minutes). Two (2) of the patients with the blank observations were not located in the activity room (Patient IDs # 11, 12).

Findings include:

TX 00360165

Record review of the facility policy titled "Q (every) -15-20 Minute Rounds,"revised date 02/20, showed that to "assure a safe environment and the safety of each patient":

* Each patient shall have a round sheet;
* Round sheets shall be documented and performed by hospital staff;
* Unit staff shall conduct visual rounds every 15-20 minutes, 24 hours a day;
* Round sheets shall accompany the patient at all times;
* Staff shall document patient whereabouts by direct observation and use the codes found in the observation record.

Observation on 09/29/2020 at 9:45 A.M. (second floor; short hall) showed a staff member leading recreation therapy (music) in an activity room. There were seven (7) adolescent male patients in attendance. Staff L , mental health tech, was observed writing on some papers. Staff L acknowledged he was documenting the "every 15 minute observations." Surveyor asked Staff H, RN, to please copy the observation records.

Record review of the 10 (ten) forms titled "Observation Record Q 15 Minutes," dated 09/29/2020 showed the following:

* five (5) of 6 patient observation records lacked documentation of visual observation for one hour and 15 minutes (Patient ID # 11, 12, 14, 15, 16].

* two (2) of the patients (Patient 11, 12) that lacked documented visual checks for one hour and 15 minutes were observed elsewhere in the unit by this surveyor, accompanied by RN , Staff H.

Observation on 09/29/2020 between 9: 45 and 9:55 A.M. showed :

*Patient # 12 laying in a bed in room # 253.

*Patient # 11 walking down the hall carrying personal care items, told RN he just took a shower.


At the time of observation, RN Staff H said the observation records should be kept current.