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COMPASS BEHAVIORAL CENTER OF ALEXANDRIA, INC
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on record review, interviews and observations, the hospital failed to ensure patients received care in a safe setting by failing to ensure observations were documented on 8 (#2, #R1, #R2, #R3, #R4, #R5, #R6, #R7) of 15 current psychiatric patients on census.
Findings:
Review of the policy titled Levels of Patient Observation, Policy Number PC-1013, revised July 31, 2012 revealed in part: A) 1). All patients are Monitored a minimum of once every 15 minutes.
Review of the policy titled 15 Minute Check Sheet, Policy Number PC-1014, dated July 10, 2012 revealed in part: 1) A Q 15 sheet will be initiated by each night shift. 2) An MHT will be assigned the responsibility of observing and documenting patient rounds every 15 minutes.
Observation on 11/17/2020 at 10:15 a.m. revealed approximately 7 patients located in the outside smoking area being observed by S6MHT, and 4 patients sitting in the dayroom area. There were 2 patients sitting in the TV room being observed by S8MHT.
Interview on 11/17/2020 at 10:15 a.m. with S6MHT revealed that he had not completed Q 15 minute documentation for the following patients:
Review of the Patient Observation Record dated 11/17/2020 for patient #2 revealed last documented entry was 6:00 a.m.
Review of the Patient Observation Record dated 11/17/2020 for patient #R2 revealed last documented entry was 6:30 a.m.
Review of the Patient Observation Record dated 11/17/2020 for patient #R3 revealed last documented entry was 8:30 a.m.
Review of the Patient Observation Record dated 11/17/2020 for patient #R4 revealed last documented entry was 8:30 a.m.
Review of the Patient Observation Record dated 11/17/2020 for patient #R5 revealed last documented entry was 6:00 a.m.
Review of the Patient Observation Record dated 11/17/2020 for patient #R6 revealed last documented entry was 6:00 a.m.
Review of the Patient Observation Record dated 11/17/2020 for patient #R7 revealed last documented entry was 6:00 a.m.
Interview on 11/17/2020 at 10:20 a.m. with S8MHT revealed that she had not completed Q 15 minute documentation for the following patients:
Review of the Patient Observation Record dated 11/17/2020 for patient #R1 revealed last documented entry was 9:30 a.m.
Interview on 11/17/2020 at 10:30 a.m. with S2DON confirmed the Patient Observation Record sheets should be documented every 15 minutes to reflect the current time for each patient. She further stated that there were no one to one patients that all patients currently were 15 minute observations.