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LOUIS A WEISS MEMORIAL HOSPITAL
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on document review, observational tour, and interview, it was determined, for 3 of 4 patients (Pts #2, 3, & 4) on the Gero Psych (geriatric psychiatric) unit, the Hospital failed to ensure psychiatric patients on safety precautions were monitored as frequently as required by policy. This could potentially effect the 11 patients on census on the Gero Psych unit on 10/3/16.
Findings include:
1. On 10/3/16 at 12:40 PM, Hospital policy GP-P-25, titled: "Patient Rounds", revised January 2014, was reviewed. The policy required, "2. Patients admitted to the psychiatric unit are immediately added to the Precaution Document Record. a. The patient is monitored every 15 minutes for special precautions."
2. On 10/3/16 at 10:55 AM, during an observational tour of the Gero Psych unit, the Precaution Document Records (PDR) dated 10/3/16 were reviewed and included incomplete 15 minute observations for 3 patients:
- Pt. #2 was a 78 year old female, admitted on 9/14/16, with diagnoses of dementia and Alzheimer's with behavior disturbances. Pt. #2's physician's order dated 9/14/16 at 1:30 AM, included assault, elopement, and choking/ aspiration precautions. Pt. #2's PDR dated 10/3/16 was last completed at 9:45 AM, over 1 hour earlier, not every 15 minutes.
- Pt. #3 was a 73 year old male, admitted on 9/30/16, with diagnoses of dementia with depression, and constipation. Pt. #3's physician's order dated 9/30/16 at 8:30 PM, included assault and choking/ aspiration precautions. Pt. #3's PDR dated 10/3/16 was last completed at 9:45 AM, over 1 hour earlier, not every 15 minutes.
- Pt. #4 was a 70 year old female, admitted on 9/23/16, with diagnoses of dementia and bipolar disorder. Pt. #4's physician's order dated 9/23/16 at 11:00 PM, included assault precautions. Pt. #4's PDR dated 10/3/16 was last completed at 9:45 AM, over 1 hour earlier, not every 15 minutes.
3. On 10/3/16 at 11:00 AM, an interview was conducted with the Gero Psych Manager (E #7). E #7 stated the Technician assigned to PDR safety rounds this morning had been assisting with wound care, but should have completed PDR rounds every 15 minutes.