HospitalInspections.org

Based on record reviews and interview, the hospital failed to ensure the patient received care in a safe setting. This deficient practice was evidenced by failing to ensure a patient was observed in accordance with physician orders for 1 of 5 sampled patients (#1).
Findings:

Review of Patient #1's medical record revealed an admit date of 04/16/2021 and a diagnosis of Bipolar Disorder.

Review of Patient #1's Practitioner Order Sheet dated 04/20/2021 at 1354 revealed, in part, an order for Q (every) 5 minute checks while asleep for sexually acting out. Precautions to renew: Sexually acting out, suicide, assault, and self-harm.

Review of Patient #1's Patient Observation Record dated 04/20/2021 revealed, in part, Q15 minute checks were done while asleep from 2145 to 2355. Further review revealed the boxes for sexual and suicide precautions were not checked.

In an interview on 04/21/2021 at 11:23 a.m., S2Director of Risk Management confirmed Patient #1 did not have Q5 minute checks while asleep on 04/20/2021 from 2145 to 2355. S2Director of Risk Management confirmed the boxes for sexual and suicide precautions were not checked.