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Based on interview and record review, the facility failed to provide a safe setting for 4 of 7 patients (#2, #3, #4, #5) requiring 15-minute safety observations resulting in patients #2, #3, #4, and #5 not being monitored in a timely manner placing them at risk for potential harm and poor treatment outcomes. Findings include:

On 08/04/20 at 1122 with registered nurse (RN) L present, a review of the inpatient psychiatric unit 15-minute safety observation flowsheet documentation dated 08/04/20 was completed. This review revealed patients #2, #3, #4 did not have any documentation completed for 15-minute safety observation checks at the 1045, 1100, and 1115 time intervals. Also, patient #5 did not have any documentation completed for 15-minute safety observation checks at the 1045 time interval.

Review of patient medical records on 08/04/20 at 1245 revealed patients #2, #3, #4, and #5 had orders to be monitored every 15-minutes for safety observations.

During an interview with RN L on 08/04/20 at 1125, RN L indicated patients #2, #3, and #4 were accompanied by staff at a scheduled group located outside the unit. RN L indicated facility staff accompanied the patients to this group and were expected to complete safety observations during the group. RN L indicated patient #5 remained on the unit. RN L could not provide an answer why the 15-minute safety observations were not documented for these patients during the identified time intervals.

During interviews with the inpatient psychiatric unit nurse manager (RN H) on 08/04/20 at 1140 and 08/04/20 at 1310, RN H indicated the 15-minute safety observation checks were completed by staff electronically and staff were expected to document the 15-minute safety observations at the time of the actual observation.

On 08/04/20 at 1330 a review of the facility policy and procedure titled "Patient Observation/Rounds" was completed. This policy and procedure had an effective date of 01/09/12 and indicated, "Behavioral Medicine nursing staff shall provide observation and supervision of patients at all times to ensure the safety of patients, staff and visitors.". This policy and procedure also indicated, "4. Routine patient rounds occur at irregular intervals, but not exceeding 15 minutes apart for patients monitored as "Close Observations" during all shifts", and "5. Documentation of observations is entered on each patient's individual BH patient safety check flowsheet utilizing status and location codes as indicated on the flowsheet.".