HospitalInspections.org

Based on observation, document review, and staff interviews, the hospital's administrative staff
failed to establish and maintain a safe environment by not implementing documentation of the actual times that staff observed patients during patient safety rounds for 15 of 15 patients on the psychiatric unit. Failure to implement a system to document actual times patients were observed for patient safety rounds could potentially result in inappropriate patient behavior, patient death or other life-threatening conditions. The psychiatric
unit staff identified a census of 16 patients at the beginning of the survey.



Findings include:

1. Observation on 7/17/2019 at 1:13 PM to 1:18 PM of psychiatric unit staff performing rounding
safety checks (a process where hospital staff walk the unit and visually observe every patient) on the psychiatric unit revealed a form with the time pre-printed in 15-minute increments. Documentation showed that staff failed to document the actual times they observed patient's activity/location.

2. Review of the forms "Adult Mental Health Daily Care Record," dated 08/2007, revealed the form contained a space for the staff to document the patient's activity/location every 15 minutes, along with columns of pre-printed times starting with the hour and continuing in 15 minute increments.

The form contained pre-printed times and a blank space for the staff to document the patient's location and a blank space for the staff member completing the rounds to document their initials.

3. Observations on 7/17/19 in the adult inpatient behavioral health unit revealed the nursing staff performed patient safety checks from 1:13 PM to 1:18 PM. Review of the Adult Mental Health Daily Care Record revealed the staff documented the patient safety checks as occurring at 1:15 PM. The staff failed to accurately document the time they performed the patient safety check.

4. Review of the policy "Guidelines for Safety (Room and Unit Searches)," reviewed 5/2017, lacked instruction for the staff to document the actual times they observed patient's activity/location.

5. During an interview on 7/17/19 at 1:05 PM, Patient Care Tech A verified they do not document the actual time they observed the patient.

6. During an interview on 7/17/19 at 1:51 PM, Patient Care Tech B verified they do not document the actual time they observed the patient.