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STONY BROOK UNIVERSITY HOSPITAL
MEDICAL STAFF - BYLAWS AND RULES
Tag No.: A0048
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Based on document review and interview it was determined that the facility did not have a documented Environmental Rounds Policy and Procedure on the Behavioral Health Unit (BHU).
The failure to develop a Policy and Procedure places patients on the Behavioral Health Unit at risk for an unsafe environment.
Finding:
During an investigation on the Behavioral Health Unit the facility provided the following documents for review: "Urgent Reminder Re: Environmental Checks and Every 15 Minute Observations" dated 11/04/15, "Revised 10 North Environmental Rounds Assignment" dated 11/11/15 and "10 North Daily Environmental Rounds Assignment" dated 11/11/15. There was no Policy and Procedure describing the Environmental Rounds and the use of the Checklist.
During an interview with Staff A (Chief Quality Officer / Director of Regulatory Affairs / Chief Nursing Officer) and Staff B (Associate Director of Nursing for Neuroscience) on 11/09/15 at 1:50PM, Staff B stated "There is no Policy and Procedure for Environmental Rounds. We are in the process of looking for the best practice."