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Based on observation, record review and interviews the facility failed to promote care in a safe setting for unit 5's census of 7 of 7 adult patients #(G, I, J, L, M, P & Q) on Unit 5. Specifically, the facility failed to ensure that the round sheets for patients #( I, J, L, & M) contained the patient's physician ordered precautions.

The findings include:

Employee #10 a Unit Coordinator was doing rounds when sheets were checked at 11:15 am. The Rounds sheets for patients # I, J, L, & M failed to include the prescribed safety precautions for each patient. Patient #I was on Suicide precautions, Assault precautions and Elopement precautions. Patient #J was on Assault Precautions, Suicide Precautions, Elopement precautions and Unit restrictions. Patient # L was on Suicide Precautions and Unit restrictions. Patient #M was on Suicide Precautions and Unit restrictions. Every 15 - minute rounds were completed from midnight through time of check at 11:15 am without the precautions listed.

POLICY: "Level of Observations" POC-N149 Revised: 5/2020, Last Review Date:7/2023

Action Steps:
Any patient placed on these precautions shall be identified to assigned staff.
In addition to recording the whereabouts of patients at ordered intervals, the purpose of observations is to provide a system of progressive intensity of patient observation, precaution and oversight based on patient acuity, severity, type of symptoms, and overall needs.
Staff will be vigilant for potential risk factors identified for specific patients (levels of precautions).

During an interview 09/12/23 at 11:25 am Employee # 8 RN, was asked if the precautions were to be indicated on the round's sheets. Employee # 8 stated "Yes." Employee #8 stated that the night shift nurse is responsible for adding the precautions and that patients # I, J, L, & M resided on the unit when sheets were prepared. Employee #8 added "I don't know why she didn't fill those out."

During an interview 09/12/23 at 11:35 am Employee # 4 Administrative RN confirmed precautions for patients # I, J, L, & M were missing.