HospitalInspections.org

Based on review of a video, documentation and staff interview it was determined Health Service Worker (HSW) #2 falsified documentation of every fifteen (15) minute hallwalks/patient safety checks on twenty-four (24) of twenty-four (24) patients on Unit G-1. This has the potential for all medical records to be inaccurate and the potential for neglect/abuse to occur in all patients on the unit.

Findings include:

1. Review of video of Unit G-1 on 5/31/16 at 11:30 a.m. for the time period of 5:45 p.m. through 6:30 p.m. on 4/23/16 revealed the HSW #2 (assigned to do hallway) was sitting at the nursing station on the computer from 5:45 p.m. through 6:11 p.m. He then started to walk the hallway that started with room one hundred and nine (109), he walked to the glass enclosure by the phone and then turned around and went into room one hundred and nine (109). Patient #1 can be seen leaving the room with HSW #2, no other hallway checks were completed. HSW #2 went to the nursing station and sat back down. HSW #2 can be seen leaving the nursing station at 6:35 p.m. and leaving the unit.

2. Review of the activity sheet titled "patient location/activity sheet" for the time period of 5:45 p.m. through 6:30 p.m. revealed hallway checks were initialed by HSW #2, when the video clearly showed he completed only one (1) room check in the forty-five (45) minutes he was assigned to do hallway/room safety checks.

3. An interview with the Director of Quality Assurance/Performance Improvement on 6/2/16 at 8:00 a.m. revealed when asked the expectation of the accuracy of medical records she stated: "Everyone has to document what actually happens and not sign anything that didn't". She concurred with the above findings.