HospitalInspections.org

Based on documentation and interview, nursing services failed to document 15-minute observation checks in 1 of 10 (Patient 3) medical records reviewed.

Findings include:

1. Facility policy titled Patient Rounding and Observation, Policy No. NR.23, last reviewed 12/2024, indicated under Policy: Rounds are to be made on the unit on all patients by the assigned nursing staff at a minimum of every 15 minutes or more frequently as ordered for each 24-hour period and under Procedure: Patient Rounds are recorded on the daily rounds sheet or in the electronic medical record by assigned staff member.

2. Review of Patient 3's medical record indicated the following:
a. On 09/05/2025, the patient was admitted for psychiatric care. Medical record indicated patient admission orders included precautions as indicated which include 15-minute observations.
b. On 09/15/2025, the patient was diagnosed with Shingles and placed in contact isolation. Medical record lacked documentation of 22 of 96 15-minute patient observation checks including but not limited to 1:45 p.m. and 11:15 p.m.
d. On 09/16/2025 medical record lacked documentation of 33 of 96 15-minute patient observation checks including but not limited to 7:45 a.m. and 5:15 p.m.
e. On 09/17/2025 medical record lacked documentation of 34 of 96 15-minute patient observation checks including but not limited to 4:45 a.m. and 8:45 p.m.
f. On 09/18/2025 medical record lacked documentation of 34 of 96 15-minute patient observation checks including but not limited to 10:30 a.m. and 7:15 p.m.
g. On 09/19/2025 medical records lacked documentation of 54 of 96 15-minute patient observation checks including but not limited to 8:30 a.m. and 8:45 p.m.
h. On 09/20/2025 medical records lacked documentation of 64 of 96 15-minute patient observation checks including but not limited to 11:15 a.m. and 5:45 p.m.
i. On 09/21/2025 medical records lacked documentation of 17 of 96 15-minute patient observation checks including but not limited to 4:30 p.m. and 8: 15 p.m.
j. On 09/22/2025 medical records lacked documentation of 21 of 96 15-minute patient observation checks including but not limited to 1:15 a.m. and 8:30 p.m.
k. On 09/23/2025 medical records lacked documentation of 10 of 96 15-minute patient observation checks including but not limited to 2:45 a.m. and 2:45 p.m.
l. On 09/24/2055 medical records lacked documentation of 6 of 43 15-minute patient observation checks including but not limited to 1:45 a.m. and 6:30 a.m.

3. Interview with A1 on 11/06/2025 at approximately 4:25 indicated patient 3's medical record lacked documentation of 15-minute observations as mentioned above between 09/15/2025 through 09/24/2025.