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Tag No.: A0117
Based on record review and interview the hospital failed to inform the patients or patients' representative of the patients' rights in advance of providing patient care for 2 (# 4 and #8) of the 11 (#1-#11) patients sampled.
Findings:
A review of the hospital policy titled, "Patient Rights, Responsibilities, Advocacy", revealed in part, upon receipt and review of information at admission to any program, the patient is given forms to sign acknowledging receipt and understanding of the information presented by the admission staff. The condition of the patient or the absence of the parent/guardian may prevent the obtaining of signatures at the time of admission. In these cases, it becomes the responsibility of the assigned social worker/case manager to obtain the required signatures. Signatures will be obtained as soon as possible, but in no case later than ten days after admission.
Patient # 4
Review of medical record on 2/28/2023, revealed no documentation evidence of a signed acknowledgement of Patient Rights.
In an interview with S4Risk and S2DON on 2/28/2023 at 1:45 p.m., both confirmed there was no evidence of a signed acknowledgement of Patient Rights in the patient's medical record.
Patient #8
Review of medical record on 2/28/2023, revealed no documentation evidence of a signed acknowledgement of Patient Rights.
In an interview with S2DON and S3ADON on 2/28/2023 at 2:15 p.m., both confirmed there was no evidence of a signed acknowledgement of Patient Rights in the patient's medical record.
Tag No.: A0144
Based on record review and interview the hospital failed to ensure the patients received care in a safe setting for 4 (# 1, #2, #3, and #9) of the 11 (#1-#11) patients sampled. As evidence by
1.) Failure to document every 10 minute observations on patients who the MD ordered CSS observation
2.) Failure to follow MD orders for level of observation. MD ordered VC observation, but patient was monitored on a CSS observation'
Findings:
A review of the hospital policy titled, "Level of Observation and Precaution", revealed in part, purpose is to reduce the risk of patient harm to self or others as needed for patient condition, using active supervision. 1. Assignment of observation levels and precautions occur through doctor's orders as appropriate per assessments, re-assessments and recommendations of the Treatment Team, 2. The RN charge nurse is directly responsible for monitoring observation levels and precautions, and for assigning staff to carry out the ordered observations and precautions.
Patient #1
On review of the medical record dated 01/12/2023 RN Progress note MD notified of sexual behaviors, Observation changed from CSS- Close Staff Sight- Q 10 min. to Visual Contact. Reflected in the MR.
Level of Observation Sheets completed; however, RN did not complete the top portion- Date, Precautions, Interventions, Reason and Room/ bed number blank.
In an interview on 03/01/2023 at 10:00 a.m. S3ADON verified the above findings.
Patient #2
On review of the patient's medical records the patient's level of observation throughout her hospital stay was CSS. The observation forms were reviewed. Two observation checks were missed during her stay 1/17/2023 at 0710 and 0720.
In an interview on 3/1/2023 at 10:40 a.m. S4Risk verified findings.
Patient #3
On review of the patient's medical records the patient placed on CSS observation throughout her hospital stay. Observation sheets reviewed for completion. On 12/28/2023 CSS observation sheet was missing every 10 minute checks from 6:10 a.m. to 7:00 a.m. S4Risk and S3ADON both verified that the observation checks were missing and should have been completed. On 12/31/2023 CSS observation sheet was missing every 10 minute checks from 12:50 p.m. to 1:40 p.m.
In an interview on 3/1/2023 at 10:45 a.m. S4Risk and S4ADON verified findings.
Patient #9
Review of patient's medical record, the patient placed on CSS observation at admission until 2/24/2023 at 1:00 p.m. when MD ordered VC observation until 2/27/2023 at 10:15 when MD ordered 1:1 observation. Observation sheets reviewed. MD orders followed except on 2/25/2023 when MD ordered VC observation, patient was only receiving CSS observation which every 10 minutes observation from 7:00 a.m. until 11:00 a.m. instead of VC observation which is direct visual contact at all times.
In an interview on 3/1/2023 at 10:50 a.m. S4Risk and S3ADON verified findings.