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Based on interview and record review, the facility failed to ensure that 2 of 2 current patients (#1 and #2) were provided with 1:1 observation as ordered by a physician and according to facility policy resulting in increased risk of patient injuries. Findings include:

Policy:

Facility policy 2.15, #05, titled " Protocol for 1:1 Continuous Observation, " undated, states:
6. " The assigned staff is to be free of all responsibilities with the exception of the patient requiring 1:1 observation. "

Record Review, 2 North Unit:

1. On 10/25/11 at approximately 1000 hours 2 current patients were listed as on 1:1 staff supervision on the 2 North Unit, patients #1 and #2.
2. On 10/25/11 at approximately 1415, record review revealed that patient #1 had a physician ' s order for 1:1 supervision around the clock dated 10/15/11 at 0630 hours and an order for 1 to 1 continuous supervision dated 10/16/11 at 0900 hours.
3. On 10/16/11 the " Daily Assignment Sheet " for the 11:30-0730 shift on patient #1 ' s unit (2 North) indicated that the patient was assigned to Nurse #1 who was also assigned responsibility for supervision of 3 other patients as well as assisting with admissions, administering medications, doing accu-checks, completing chart audits, covering a Mental Health Assistant ' s break, cleaning and checking the refrigerator and other duties.
4. On 10-16-11 the 1130-0730 Daily Assignment Sheet indicated that CNAs (Certified Nursing Assistants) #1 and #2 each had 1:1 assignments but listed 2 patients assigned to each staff. CNA #1 was assigned to patients in rooms 220 and 211-1 and CNA #2 was assigned to patients in rooms 210-1 and 205.
5. From the Daily Assignment Sheet for 2 North Unit dated 10/23/11, and timed 0700-0330 hours, it is impossible to decipher which patients were provided with 1:1 supervision. There are 5 names listed as 1:1 ' s but no notations of specific staff:patient assignments. On 10/25/11 at approximately 1430 the CNO verified these findings.
6. Per the Daily Assignment Sheet, on 10/23/11 from 1500-2300 hours, the staff (#5) assigned to 1:1 supervision of patient #2 from 1500-2330 hours, was also assigned to provide break coverage for a MHA who was responsible for supervising 5 patients.
7. On 10/25/11 from 1400-1500 hours the CNO (Chief Nursing Officer) verified these findings.