HospitalInspections.org

Based on document review, observation, and interview, it was determined, for 7 of 17 patients (Pt's #12, 13, 14, 15, 16, 17 and 18) on the behavioral medical mental health unit (4th floor of behavioral health center), the Hospital failed to ensure patient safety rounds were conducted every 15 minutes, as required by policy.

Findings include:

1. On 9/11/14 at approximately 9:30 AM, hospital policy titled, "Assessment And Reassessment Of The Blessing Behavioral Center Patient" (reviewed/revised 1/2011) was reviewed. The policy required "Reassessment 1. Nursing Behavioral/Suicide Flowsheet:are used on patients in the Behavioral Services areas to provide 24 hour (0500 to 0500) documentation of a patient assessment and progress... d. Behavioral/Suicide Flowsheet: All Units, 15 minute checks to be done first 24 hours of admission, and then 15-minute checks from 7 AM-11 PM..."

2. On 9/9/14 at approximately 10:35 AM, an observational tour of the behavioral medical mental health unit (4th floor of behavioral health center) was conducted. Upon entering the unit, the Behavioral/Suicide Flowsheet (15 minute patient rounds monitoring sheet) for 9/9/14 on all patients were reviewed. Seven of 17 patient (Pt's #12, 13, 14, 15, 16, 17 and 18) were lacking the 10:15 AM, checks that included patient location and behaviors (total of 7 missed checks on 7 patients).

Patients include:

- Pt # 12 was admitted on 9/2/14 with diagnoses of depression and suicidal ideation's and was on 15 minute safety checks.

- Pt # 13 was admitted on 9/3/14 with a diagnosis of suicidal ideation's and was on 15 minute safety checks.

- Pt # 14 was admitted on 9/2/14 with diagnoses of depression and suicidal ideation's and was on 15 minute safety checks.

- Pt # 15 was admitted on 9/7/14 with diagnoses of depression and suicidal ideation's and was on 15 minute safety checks.

- Pt # 16 was admitted on 9/5/14 with diagnoses of depression and suicidal ideation's and was on 15 minute safety checks.

- Pt #17 was admitted 9/5/14 with diagnoses of depression and anxiety and was on 15 minute safety checks.

- Pt #18 was admitted 9/6/14 with diagnoses of depression and suicidal ideation's and was on 15 minute checks.


3. During an interview conducted with Director of Psychiatric Services (E #4) conducted on 9/9/14 at approximately 10:45 AM, E #2 stated, the round sheets should have been completed every 15 minutes on all patients.