HospitalInspections.org

Based on document review and staff interview, it was determined that for 3 of 6 (Pts #8, 9, and 10) cliinical records reviewed for monitoring precautions, the Hospital failed to ensure that patient safety rounds were completed per policy.

Findings include:

1. The Hospital's policy entitled "Escape Precautions" (revised 6/13) required, "...Observe activity of patient every 15 minutes..."

2. The Hospital's policy entitled "Assault Precautions" (revised 6/13) required, "...Complete "Assault Precautions" monitoring sheet every 15 minutes..."

3.The Hospital's policy entitled "Suicide Precautions" (revised 6/13) required, "...observe patient's activity around the clock at approximately 15-minute intervals...initial for every 15 minute time slot..."

4. The clinical record for Pt #8 was reviewed on 7/24/13 at approximately 2:30 pm. Pt #8 was a 32 year old female admitted on 7/13/13 with diagnoses of bipolar and anxiety and placed on and elopement precautions. The monitoring sheet dated 7/23/13 lacked safety checks for 11:30 am and 11:45 am.

5. The clinical record for Pt #9 was reviewed on 7/24/13 at approximately 2:35 pm. Pt #9 was a 25 year old female admitted on 7/16/13 with a diagnosis of schizoaffective disorder and placed on assault precautions. The monitoring sheet dated 7/23/13 lacked safety checks for 11:30 am and 11:45 am.

6. The clinical record for Pt #10 was reviewed on 7/24/13 at approximately 2:40 pm. Pt #10 was a 47 year old female admitted on 7/20/13 with diagsoses of bipolar depression and placed on suicide and elopement precautions. The monitoring sheet dated 7/22/13 lacked the safety check for 13:30 pm.

7. The above findings were confirmed with the Director of the Behavioral Health Unit on 7/24/13 at approximately 2:45 pm.