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ROCK SPRINGS
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on review of medical records and interview, it was determined that the patients at Rock Springs Hospital did not always receive care in a safe setting.
Findings were:
Patient # 3 had MD orders to be observed and document on every 15 minutes during her stay at Rock Springs Hospital. On 2 occasions, there was a lack of documentation on the Observation Record--indicating that the patient was not checked on every 15 minutes per MD order.
On 12/29/23, the Observation record was not documented on from 18:15 through 19:00 (45 minutes).
On 12/31/23, the Observation record was not documented on from 22:00 through 24:00 (2 hours).
The Director of Nursing confirmed the lack of the above documented observations on 4/29/24 and admitted that not rounding and documenting on the patients was an unsafe practice.