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Based on document review and interview, it was determined the Hospital failed to promote and protect each patient's rights by failing to ensure assessments and safety checks were conducted, potentially affecting all patients and staff. Therefore, the Condition of Participation, 42 CFR 482.13, Patient Rights was not met.

Findings include:

1. The Hospital failed to ensure the Clinical Institute Withdrawal Assessment (CIWA) Alcohol Scale assessments were conducted as ordered. See A-144 A.

2. The Hospital Failed to ensure safety checks were completed per policy. See A-144 B.

A. Based on document review and interview, it was determined for 1 of 2 (Pt #9) patient records reviewed who had a Clinical Institute Withdrawal Assessment (CIWA) Alcohol Scale ordered, the Hospital failed to ensure the assessment was conducted per order. This has the potential to affect all patients who receive care by the Hospital with a current census of 82 patients.

Findings include:

1. Pt #9 Date of Service (DOS): 3/7/22
Diagnosis: Alcohol Intoxication. The record was reviewed on 4/8/22 at approximately 9:30 AM. A Physician's order dated 3/7/22 at 2:34 PM noted CIWA Alcohol Withdrawal assessments to be conducted every 4 hours. The record lacked documentation the CIWA assessments were conducted every four hours as ordered.

2. During an interview on 4/8/22 at approximately 2:00 PM, the Director of Quality (E#5) reviewed Pt #9's record and verbally agreed the CIWA assessments were not conducted as ordered and should have been.

B. Based on document review and interview, it was determined for 3 of 3 (Pt #3, Pt #8, Pt #10) patients records reviewed who required safety checks, the Hospital failed to ensure the safety checks were completed per policy. This has the potential to affect all patients who receive care by the Hospital with a current census of 82 patients.

Findings include:

1. The Emergency Department/Inpatient Environmental Safety Checklist was reviewed during the record reviews on 4/7/22 through 4/8/22. The Checklist noted "Safety Monitoring Type: Suicide... Behavioral Monitoring Type: Alcohol/Drug Detox (detoxify)... Complete Safety Check on Patient Arrival and at Each Hand Off."

2. Pt #3 DOS: 3/18/22
Diagnosis: Fever. The record was reviewed throughout the survey on 4/7/22 and 4/9/22. The record noted Pt #3 had a Heroin addiction and had used Heroin during the hospitalization on 3/19/22. The record lacked a completed Environmental Safety Checklist.

3. Pt #8 DOS: 3/1/22
Diagnosis: Polysubstance Abuse. The record was reviewed on 4/8/22 at approximately 10:00 AM. The record noted "Possible delirium, agitation and acute psychosis 2/2 polysubstance use... continues to be agitated... now has a fall... placed in restraints... pursue psychiatric evaluation..." The record lacked a completed Environmental Safety Checklist.

4. Pt #10 DOS: 4/3/22
Diagnosis: Alcohol Intoxication. the record was reviewed on 4/8/22 at approximately 10:30 AM. The record noted Pt #10 was in Suicide Precautions on 4/6/22, although the record lacked a completed Environmental Safety Checklist.

5. During an interview on 4/8/22 at approximately 2:00 PM, there Director of Quality (E#5) reviewed Pt#3, Pt#8 and Pt#10's records and verbally agreed the Environmental Safety Checklist had not been completed and should have been.