Failure to Complete Physician-Ordered 15-Minute Safety Checks
Penalty
Summary
The facility failed to ensure that physician-ordered 15-minute safety checks were completed for a resident with a diagnosis of anxiety and a history of behavioral issues, including inappropriate interactions with female residents. According to facility policy, staff are required to visually observe residents on 15-minute checks and document their status using an observation tool. The resident in question had a physician's order and nursing documentation indicating the need for 15-minute safety checks due to ongoing behavioral concerns. On the day of observation, the resident was seen resting in his room for a period of 44 minutes without any staff conducting the required safety checks. An agency nurse aide, who entered the room during this time, was unaware of the safety check requirement and reported that this information was not provided during shift report. The aide also noted she was unable to access the computer system to review orders. The Director of Nursing confirmed that staff should have been conducting and documenting the 15-minute checks as per policy and physician orders.