HospitalInspections.org

Based on review of documentation and interview, it was determined that the facility failed to follow its own policies and procedures.

Findings were:

Facility policy entitled " Night Rounds " stated " It is the policy of Padre Behavioral Hospital that patients will be monitored Q 15 minutes or more frequently when indicated i.e. elopement precautions, seizure precautions, suicide precautions throughout the night (11pm - 7 am). Procedure:
? Nursing staff shall make visual rounds of all patients at least every 15 minutes and more frequently as the patient ' s condition warrants and will include observations of respirations, presence or absence of restlessness, position, etc.
? Any significant observations in the patient ' s status shall be reported to the Charge Nurse
? Documentation in the patient ' s record shall be done at least every shift and more frequently as the patient ' s condition warrants
? Documentation shall include, but not be limited to, quality of respirations, position, bathroom use, frequency of observations during the night, interruptions in sleep or any other relevant data
? The Charge Nurse is to make night rounds every hour

Review of the medical record of patient # 1, who was on Q 15 minute checks for aggression X 24 hours, revealed no documentation of Charge Nurse rounding from September 13 through September 23, 2011.

In an interview with the Chief Executive Officer on 9/19/11, the lack of rounding by the Charge Nurse was confirmed.