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Based on medical record review, interview and policy review, the facility failed to ensure that medical records were accurate because a staff member documented that Patient #1 was on the unit when the patient had been transferred to an acute care hospital.

Findings Include:

Review of the medical record for Patient #1 on 03/04/19 at 11:06 a.m. in a conference room revealed that documentation on a Daily Observation Q10 Min record dated 02/24/19 from 10:35 to 14:30 indicated Patient #1 was coded as a 2O or off the unit by S#9 and S#18 and from 19:10 to 22:00 by S#14. Further review of the same record indicated that S#19 documented that the patient was coded as a 1Q or on the unit on 02/24/19 from 14:40 thru 18:40 when in fact the patient had been transferred out of the facility to an acute care hospital and had not returned. At 18:50 and 19:00, S#19 documented that the patient was off the unit.

During an interview of S#19 on 03/14/19 at 11:30 a.m. in a conference room, S#19 reviewed the documentation made by S#9 and S#18 on a Daily Observation Q10 Min record for Patient #1 dated 02/24/19 from 10:35 to 14:30 and by S#14 from 19:10 to 22:00 that indicated Patient #1 was coded as a 2O or off the unit. S#19 reviewed the documentation that she had made on the same record on the same day from 14:40 thru 18:40 that included her initials and noted the patient was coded as a 1Q or was on the unit. After her review of the record, S#19 confirmed that the patient was not on the unit but had been transferred to an acute care hospital and was gone the whole time. S#19 stated, "It was my mistake. I thought the patient was someone else. I was not aware it was someone else."

During an interview of S#1 on 03/18/19 at 3:00 p.m. in a closed rehab area after her own review of the Daily Observations - Q10 min record dated 02/24/19 for Patient #1 for the time period of 10:35 to 22:00, she confirmed that S#19 had documented that Patient #1 was on the unit from 14:40 thru 18:40 when in fact the patient had left the facility and was at an acute care hospital.

The hospital policy entitled, "Nursing Rounds," and last reviewed January 2012 and identified by S#1 as also referred to as the "q's" completed by the mental health techs (MHT's) was reviewed on 03/05/19 at 12:50 p.m. in an open rehab area and revealed the following in part:

POLICY:

1. The Charge Nurse is responsible for assigning nursing staff to make unit rounds in order to account for all patients' whereabouts and ensure a safe environment.

PROCEDURE/TEXT:
C. The assigned staff member (s) personally locates each patient listed and documents the patient's location on the Rounds Sheet under the appropriate time column. The staff member places his/her initials at the top of the column above the time. At the time of joint rounds, staff members initial the Rounds Sheet.
D. While making rounds, the staff member observes the environment for unsafe conditions and check all Exit doors to assure they are locked.
E. Significant behavioral observations of patients and environmental problems are reviewed and reported to the Charge Nurse immediately.