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FORBES HOSPITAL 2570 HAYMAKER ROAD MONROEVILLE, PA 15146 July 17, 2019
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on a review of Facility Documentation and Medical Records (MR) and staff interview9s0, it was determined the facility failed to consistently document observation of 1:1 observation patient as ordered by physician for one medical record reviewed. (MR1).
Findings Include.
Review of facility policy " Sitter Policy, 5340) last approved July 2018 revealed " ...Policy Guidelines ...The sitter will use the appropriate 1:1 Observation Flow Sheet indicated on the sitter Request Form: 1:1 Observation Flow Sheet, Observation Level 1 ... "
Review of MR1 physician order dated June 4, 2019 revealed " Sitter at bedside. "
Review of Facility Documentation Observation Flow Sheet Level 1 for MR1 dated June 9, 2019 at 1600 through June 10, 2019, until 0600 revealed no sitter signature or behavior ' s documented.
During interview on July 16, 2019 at approximately 11:00 AM confirmed the above findings and revealed " ...as you can see the documentation was not completed .... "
Cross Reference with: 482.22(c) Standard: Medical Staff Bylaws
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
Based on a review of facility documentation, record review and interview, it was determined that the facility failed to ensure the medical staff rules and regulations were enforced for one of one medical record reviewed (MR1).

Findings included:

Review of facility documentation, "MEDICAL STAFF RULES AND REGULATIONS," revision date July 19, 2017, revealed "2. MEDICAL ORDERS...2.2 Legibility...Orders must be entered clearly, legibly, and completely."

Review of facility policy "Sitter Policy," last revised April 2017, revealed "POLICY PURPOSE Establish appropriate levels of patient observation to minimize the risk of self-harm. Provide guidelines regarding sitter (a specially-trained staf member) responsibilities providing continuous observation of a patient." "POLICY DEFINITIONS" described "Observation Level 1" duties versus "Observation Level 2" duties.

Review of MR1 on July 17, 2019, revealed a physician order dated June 4, 2019, for "Sitter at bedside." The order failed to specify the level of observation required for this patient.

During an interview on July 17, 2019, at 1:40 PM, EMP #4 confirmed that the order for MR1 for sitter at bedside was incomplete, and the level of observation required was not specified in the order.

Cross Reference with: 482.24(b) Standard: Form and Retention of Record
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on review of facility policy, medical records (MR), and interview with staff (EMP), it was determined the facility failed to follow their policy for documenting intake and output for one of one medical records reviewed (MR1).
Findings include:
Review of facility policy, Nursing Documentation Policy, last revised October 2018, revealed, " ... II. Expectations for charting using the computer system: ... G. Intake and Output (I&O). 1. I&O data is entered a minimum of every shift if ordered by physician. Intake and output should be recorded at the time of the observation (meal tray evaluated to output container emptied) whenever possible. ... "
Review of MR1 revealed a physician's order dated June 4, 2019, for Intake and Output every shift.
Review of MR1 revealed June 4, 2019 output documentation at 0700, no intake. June 5, 2019 no intake or output documentation. June 6, 2019, output documentation at 0700 and intake at 0700. June 7, 2019 and June 8, 2019, no intake or output documentation. June 9, 2019, and June 10, 2019, intake and output documentation at 0700. June 11, 2019, no intake or output documentation.
Interview with EMP4 on July 17, 2019, at 1:50 PM confirmed the above findings.