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OCEANS BEHAVIORAL HOSPITAL OF PERMIAN BASIN
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on record review and interview the facility failed to provide a safe environment for 1 of 2 patient records reviewed.
Findings were:
The medical record of patient #1 was reviewed on 5/24/11.
- Documents entitled "BCA Patient Observation" were present in her medical record. These documents indicated that her location and actions were accounted for every 15 minutes by BCA staff from the time she was admitted on 3/14/11 to the time she was discharged on 3/24/11, however there were two 15 minute blocks of time that she was not accounted for at 6:45am and 7:00am on 3/16/11.
- A physician admitting order in her medical record, written at 4:35pm on 3/14/11, stated that she was to have "Close Observation (q15 minute checks)".
A facility policy entitled "Ethics and Compliance", reviewed on 5/24/11, stated "employees perform frequent environmental checks along with checks every 15 minutes to help maintain a safe environment".
During an interview with the Director of Nursing on 5/24/11 she confirmed the above findings and stated that patient #1 should have had documentation on the "BCA Patient Observation" record indicating that patient #1 was accounted for at 6:45am and 7:00am on 3/16/11.