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Based on record review and staff interview, it has been determined that the facility failed to provide care in a safe setting relative to 15-minute safety checks for 7 of 12 patients. (Patient ID #1, 2, 3, 4 ,5, 6 and 7)

Findings are as follows:

Patient ID #1 is a 74-year-old who was admitted to the hospital in March 2020 with a medical history including, but is not limited to, alcohol use disorder, COPD (chronic obstructive pulmonary disease), depression and anxiety. A provider order for 15-minute safety checks was written on 4/5/2020 at 7:59PM. Surveyor review of the Patient Fifteen Minute Safety Checks document from 4/13/2020 revealed the patient safety check was performed at 9:45 AM and the following safety check was performed at 11:15 AM resulting in 1 hour and 30 minutes of safety checks not being performed.

Patient ID #2 is an 80-year-old who was admitted to the hospital in April 2020 with a medical history including, but not limited to, dementia, depression and anxiety. A provider order for 15-minute safety checks was written on 4/5/2020 at 7:59PM. Surveyor review of the Patient Fifteen Minute Safety Checks document from 4/13/2020 revealed the patient safety check was performed at 9:45 AM and the following safety check was performed at 11:15 AM resulting in 1 hour and 30 minutes of safety checks not being performed.

Patient ID #3 is a 64-year-old who was admitted to the hospital in March 2020 with a medical history including, but not limited to, opioid use disorder, depression, anxiety and psychosis. A provider order for 15-minute safety checks was written on 4/8/2020 at 10:21 PM. Surveyor review of the Patient Fifteen Minute Safety Checks document from 4/12/2020 revealed the patient safety check was performed at 11:45 PM and the following safety check was performed at 4:00 PM resulting in 16 hours and 15 minutes of safety checks not being performed. Furthermore, review of the document from 4/13/2020 revealed the patient safety check was performed at 9:45 AM and the following safety check was performed at 11:15 AM resulting in 1 hour and 30 minutes of safety checks not being performed.

Patient ID #4 is a 64-year-old who was admitted to the hospital in March 2020 with a medical history including, but not limited to, schizophrenia and auditory hallucinations. A provider order for 15-minute safety checks was written on 4/5/2020 at 7:58PM. Surveyor review of the Patient Fifteen Minute Safety Checks document from 4/13/2020 revealed the patient safety check was performed at 9:45 AM and the following safety check was performed at 11:15 AM resulting in 1 hour and 30 minutes of safety checks not being performed.

Patient ID #5 is a 63-year-old who was admitted to the hospital in March 2020 with a medical history including, but not limited to, suicidal ideation, depression and anxiety. A provider order for 15-minute safety checks was written on 4/5/2020 at 7:58 PM. Surveyor review of the Patient Fifteen Minute Safety Checks document from 4/13/2020 revealed the patient safety check was performed at 9:45 AM and the following safety check was performed at 11:15 AM resulting in 1 hour and 30 minutes of safety checks not being performed.

Patient ID #6 is a 71-year-old who was admitted to the hospital in March 2020 with a medical history including, but not limited to, dementia with behavioral disturbances. A provider order for 15-minute safety checks was written on 4/5/2020 at 7:59 PM. Surveyor review of the Patient Fifteen Minute Safety Checks document from 4/13/2020 revealed the patient safety check was performed at 9:45 AM and the following safety check was performed at 11:15 AM resulting in 1 hour and 30 minutes of safety checks not being performed.

Patient ID #7 is a 65-year-old who was admitted to the hospital in March 2020 with a medical history including, but not limited to, bipolar disorder and schizophrenia. A provider order for 15-minute safety checks was written on 4/5/2020 at 9:55 PM. Surveyor review of the Patient Fifteen Minute Safety Checks document from 4/13/2020 revealed the patient safety check was performed at 9:45 AM and the following safety check was performed at 11:15 AM resulting in 1 hour and 30 minutes of safety checks not being performed.

On 4/13/2020 at 11:15 AM, Staff #1 acknowledged that she did not complete the patient fifteen-minute safety checks as ordered for Pt ID's 1,2,3,4,5,6 and 7 because she was busy helping other patients.

On 4/13/2020 at 12:15 PM, The Risk Management Coordinator was unable to provide evidence verifying that safety checks were performed for patient ID # 3 on 4/12/2020 from 12 AM- 3:45 PM.

On 4/13/2020 at 2:00 PM, surveyor interviewed the Clinical Manager for the Geri-Psych Unit. She acknowledged that the incomplete documentation is unacceptable and does not meet standard of care.