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JOHNSON MEMORIAL HOSPITAL
PATIENT RIGHTS
Tag No.: A0115
Based on document review, observation, and interview, the facility failed to provide a safe environment for 1 of 1 patients (Patient 11).
The cumulative effect of this systemic problem resulted in the hospitals inability to promote Patient Rights in a safe setting.
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on document review, interview, and observation, the facility failed to provide a safe care setting for 1 of 1 patients (Patient 11) medical records reviewed.
Findings include:
1. Facility Policy titled, Patient Rights and Responsibilities, Code RI.10.25, last Reviewed/Revised on 05/2024, indicated under Policy Statement: The patient has: f. The right to receive care in a safe setting.
2. Review of Patient 11's medical record indicated on 08/18/2024 at approximately 2:02 p.m. the patient was taken from the facility by Family Member #1 (Father of Patient 11). Patient 11's medical record indicated on 08/18/2024 day shift nursing assessment and on 08/19/2024 day shift nursing assessment, lacked documentation of infant security tag.
3. Review of the Root Cause Analysis dated 08/20/2024 indicated that Family Member #1 was able to walk off the unit with Patient 11 and the Maternity Care Unit doors failed to lock.
4. Observation of video footage on 08/21/2024 at approximately 4:40 p.m. confirmed Family Member #1 was able to open secure doors and exit the Maternity Care Unit and leave the facility with Patient 11.
5. Interview with S4 (Registered Nurse) on 08/22/2024 at approximately 4:38 p.m. confirmed that Family Member #1 exited the Maternity Care Unit with Patient 11 and left the facility with Patient 11.
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on documentation review and interview, nursing failed to complete and document 2 out of 6 infant security checks in 1 of 1 (Patient 11) patient medical records reviewed.
Findings include:
1. Review of Patient 11's medical record indicated on 08/18/2024 day shift nursing assessment and on 08/19/2024 day shift nursing assessment, lacked completion and documentation of infant security tag checks.
2. Interview with S5 (Clinical Analyst) on 08/21/2024 at approximately 3:40 p.m. confirmed Patient 11's medical record lacked the above documentation.