Clinical Compliance Telemetry (24-Hour Inpatient Unit)
Academic Medical Center
Compliance Score
81.2%
On-Time Rounds
78 / 96
Delayed Checks
12
Missed / Breaches
6
Max Observed Gap
34 min
24-Hour Observation Rounding Timeline & Shift Lapses
Standard: 15-Minute Randomized Visual
On-time (≤15m)
Delayed (16-20m)
Critical Breach (>20m / Missed)
Nursing Handover Window
Observation Interval Inspector
CRITICAL GAP DETECTED
Time Window
02:15 → 02:49
Interval Duration
34 minutes (+19m late)
Assigned Staff ID
RN-Night-B (Handover)
Observed Location
Room 204B (Blind Angle)
Patient Risk Level
High (Suicide Precautions)
Regulatory Violation
CMS §482.13(c)(2) Violation
Complete 24-Hour Observation Log (96 Scheduled Checks)
| # | Scheduled | Actual | Gap | Staff | Location / Patient State | Status |
|---|
Regulatory Standard Findings
CMS CoP §482.13(c)(2) — Patient Rights:
Failure to maintain continuous line of sight or unbroken 15-minute staggered rounds constitutes Condition-level non-compliance and Immediate Jeopardy triggers.
The Joint Commission NPSG.15.01.01:
Requires direct visual verification during shift handoffs. Batch-signing or logging rounded times retroactively is an immediate survey deficiency.
Corrective Action Plan (CAP) Matrix
Add Custom Corrective Measure