HospitalInspections.org

Based on policy review, medical record review and interview, the facility failed to ensure patient safety, by omission of patient observations for 2 of 6 (Patients #4 and #5) sampled patients.

The findings included:

1. Review of the facility's "OBSERVATIONS, PATIENT" policy (revised 4/2020) revealed, " ...The physician will order one of three levels of observation at time of admission and as the patient's condition warrants a change ...Documentation of the observation is to be completed once the patient has been observed. It is not permissible to complete in advance or to back fill time frames that were not completed in a timely manner ..."

2. Medical record review for Patient #4 revealed an admission date of 6/4/22 with diagnoses that included Schizoaffective Disorder and Bipolar Disorder.

Review of the Admission Order dated 6/4/22 revealed the level of observation ordered for Patient #4 was every 15 minute checks (Q 15 minutes). Review of Patient Observation flowsheets beginning 6/4/22 through 6/16/22 revealed the following:

6/5/22- no documentation of Q15 minute checks from 7:00 PM through 7:45 PM.
6/7/22- no documentation of Q15 minute checks from 4:15 PM through 4:45 PM.
6/15/22- no documentation of Q15 minute checks from 11:15 PM through 11:45 PM.

3. Medical record review for Patient #5 revealed an admission date of 7/20/22 with diagnoses that included Major Depression with psychotic features.

Review of the Admission Order dated 7/20/22 revealed the level of observation ordered for Patient #5 was every 5 minutes (Q5 minutes). Review of Patient Observation flowsheets beginning 7/20/22 through 7/25/22 revealed the following:

7/21/22- no documentation of Q5 minute checks from 11:05 PM through 11:55 PM.
7/22/22- no documentation of Q5 minute checks from 3:00 PM through 7:00 PM.

In an interview on 7/25/22 at 1:00 PM the Risk Manager verified observation checks should be documented as ordered, or documentation as to why the patient was not observed, such as being off unit/out of the facility.

Based on policy review, medical record review and interview, the facility failed to ensure nursing services followed physician orders for Accuchecks for 1 of 1 (Patient #1) sampled patients with ordered Accuchecks and failed to follow-up with ongoing assessments for possible injuries for 1 of 6 (Patient #1) sampled patients.

The findings included:

1. Review of the facility's "DOCUMENTATION PROTOCOL" policy (revised 4/2018) revealed, " ...Facility records, reports, charts and documents are to be accurate, truthful and complete. Staff is to document accurately our services provided ..."

2. Medical record review for Patient #1 revealed an admission date of 7/10/22 with diagnoses that included Schizophrenia, Bipolar Disorder and Diabetes Mellitus.

Review of physician orders and Medication Administration Record (MAR) beginning on 7/12/22 revealed Accuchecks to be performed before 3 meals and at bedtime (QID). Review of Patient #1's MAR beginning on 7/12/22 through 7/23/22 revealed the following:

7/12/22 there was no documentation of Accucheck results at bedtime (9 PM)
7/13/22 there was no documentation of Accucheck results before breakfast (6:30 AM) and at bedtime (9 PM).
7/14/22 there was no documentation of Accucheck results at bedtime (9 PM).
7/15/22 there was no documentation of Accucheck results at bedtime (9 PM).

In an interview on 7/25/22 at 1:00 PM, the facility's Risk Manager verified the Accuchecks were not documented as ordered.

Further medical record review for Patient #1 revealed a nursing progress note documented on 7/19/22 that documented a "late entry" for 7/13/22. The documentation revealed Patient #1 came to the nursing desk on 7/13/22 and asked to use the phone. The nurse observed blood on the patient's mouth and in the mouth. The nurse attempted to exam the patient's mouth, and offered an ice pack, but the patient refused. There was no additional documentation in Patient #1's medical record regarding any follow-up assessment related to the blood noted on the patient's mouth on 7/13/22.

In an interview on 7/25/22 at 1:00 PM the Risk Manager verified there was no follow-up documentation related to Patient #1's bloody mouth, after it was observed on 7/13/22.