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Based on observation, interview, and record review, the facility failed to uphold the right of 5 of 10 sampled patients to care in a safe setting [Patients IDs: 4, 5, 7, 8, 10 ] .

The facility failed to ensure that these five (5) patients were placed on special safety observation levels as ordered by their attending physician.

This deficient practice placed all patients admitted to the Senior Care Unit at risk for serious harm and injury.

Findings included:

TX00397920

Review of a facility policy titled "Patient Bill of Rights," dated 09/20, showed: "Patient Rights:...as a patient at OakBend Medical center you have the right to....17. To receive care in a a safe setting..."

Review of facility policy titled "Observation of Patients,"dated 11/10/2020, showed the following:

* Purpose: to maintain the safety of each patient.
* All patients are monitored as to their location and activity at regular intervals.
* All patients admitted to the hospital will be assigned routine level of observation unless physician orders a special level of observation.
* Staff assigned to the chart on patients will include documentation in the nursing progress notes as to the location and frequency of checks.

Line-of-Sight Observation: "... a patient is maintained in community areas where they can be observed at all times... when the order for line-of-sight observations is received, the primary nurse will place a teal arm band on the patient's wrist and ensure the observation level is correctly recorded on the "patient close observation record."

One-to-One Supervision: "...this is an extreme level of observation reserved for patients who are (sic) an imminent suicide risk or whose psychiatric state is such that safety cannot be maintained otherwise. When the order for one-to-one supervision is received, the primary nurse will place a lime green arm band on the patient's wrist and ensure the observation level is correctly recorded on the "patient close observation record."

Record review on 11/03/2021 of 5 sampled patient medical records with Staff ID F, Quality Coordinator, showed the following:

Patient ID # 10:

Physician order dated 8/3/2021 for " 1:1 supervision." Review of Patient # 10's "Patient Close Observation Record" showed "1:1 observation" was not documented as performed on August 4, 5, 6, 7, 8, 9, 10, 11 and 24, 2021.

Physician order dated 8/10/2021 for "Line-of-sight observation." Review of Patient # 10's "Patient Close Observation Record" showed "Line-of-sight" was not documented as performed on August 4, 5, 6, 7, 8, 9, 12, 13, 14, 15, 16 ,17,18, 19, 20,21, 23, 2021.

Patient ID # 7:

Physician order dated 9/23/2021 for "Line-of-sight observation." Review of Patient # 7's "Patient Close Observation Record" showed "Line-of-sight" was not documented as performed on September 23, 24, 27, 28, 29, 30, and October 1 and 2, 2021.

Patient ID # 5:

Physician order dated 10/06/2021 for " 1:1 supervision." Review of Patient # 5's "Patient Close Observation Record" showed "1:1 observation" was not documented as performed on October 6, 7, 8, 9, 10, 11,12, 13, 14, 15, 2021.


Patient ID # 8:

Physician order dated 9/23/2021 for "Line-of-sight observation." Review of Patient # 8's "Patient Close Observation Record" showed "Line-of-sight" was not documented as performed on September 22 & 23, 2021.

Patient ID # 4 :

Physician order dated 10/23/2021 for "Line-of-sight observation." Review of Patient # 4's current "Patient Close Observation Record" showed "Line-of-sight" was not documented as performed on November 3, 2021.

All record review findings were verified by Staff F, Quality Coordinator.