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Based on medical record review, document review, and staff interview it was determined the Nurse Manager failed to ensure patient safety checks were completed as ordered. This failure has the potential for all patients to be at risk for self-harm (See Tag A 144).

Cross Reference:

§482.13(c)(2) - The patient has the right to receive care in a safe setting.

Based on document review, medical record review, and staff interview it was determined the Nurse Manager failed to ensure patient safety checks were completed as ordered on seven (7) our of ten (10) medical records reviewed (Patient #1,2,4,5,6,7,and 8). This failure has the potential for all patients to be at risk for self-harm.

A review of the policy titled "CRC [Chestnut Ridge Center] Special Precautions and Room Check Policy". With a last revised date of 01/2022, states in part, "Policy: Chestnut Ridge Center inpatient staff will use the level of precautions deemed necessary to provide the appropriate level of safety. The acute patient will be evaluated on admission and daily by the attending physician or covering physician and placed on the least restrictive precaution level to maintain the patient's safety ...A. Admission/Transfer: 1. Upon arrival to the unit, the patient's belongings are secured and the patient is placed on a minimum, precautions that require 15 [fifteen] minute location/safety rounds record special precautions form. A higher level of precaution may be indicated to meet each individual patient safety needs based upon clinical assessment and ASQ [Ask Suicide-Screening Questions.] ...3. The clinical therapist will complete the SAFE-T [Suicide Assessment Five-Step Evaluation and Triage] protocol and the C-SSRS (Columbia Riska and Protective Factors) recent with the patient within 72 [seventy-two] hours of admission ...B. Precaution levels ...2. (CVs) Constant Visual-Line of sight, Maintaining patient within a designated staff person's visual field is used when a patient gives specific evidence that a suicide/homicide attempt, or self/other-harm act is considered imminent ...3. (SP) Suicide/Self-Harm Precautions (Eps) Escape Precautions (HPs) Homicide Precautions- The area of risk is specified, and the patient is placed on 15 [fifteen] minute checks. Used when a patient is judged to be at risk for specific impulsive acts. Patient will be restricted to unit and visually monitored at least every 15 [fifteen] minutes. 15 [fifteen] minute checks are approximations and may be completed plus or minus three [3] minutes every quarter of an hour ...C. For patient safety, room and unit checks will be completed by unit staff at least every shift and documented on the Q15 [fifteen] check sheet ..."

A review of the medical record for patient #1 revealed the patient was ordered fifteen (15) minute safety checks. The patient had no documentation of safety checks on 05/21/25 from 9:00 p.m. through 9:22 p.m.

A review of the medical record for patient #3 revealed the patient was ordered CV. The patient had no documentation of safety checks or CV on 05/21/25 from 9:08 p.m. through 9:45 p.m.

A review of the medical record for patient #4 revealed the patient was ordered CV. The patient had no documentation of safety checks or CV on 05/21/25 from 9:09 p.m. through 9:45 p.m.

A review of the medical record for patient #5 revealed the patient was ordered fifteen (15) minute safety checks. The patient had no documentation of safety checks on 05/21/25 from 9:00 p.m. through 9:22 p.m.

A review of the medical record for patient #6 revealed the patient was ordered fifteen (15) minute safety checks. The patient had no documentation of safety checks on 05/21/25 from 9:09 p.m. through 9:45 p.m.

A review of the medical record for patient #7 revealed the patient was ordered fifteen (15) minute safety checks. The patient had no documentation of safety checks on 05/21/25 from 9:12 p.m. through 9:32 p.m.

A review of the medical record for patient #8 revealed the patient was ordered fifteen (15) minute safety checks. The patient had no documentation of safety checks on 05/21/25 from 9:10 p.m. through 9:45 p.m.

An interview was conducted on 06/04/25 at 9:55 a.m. with employee #1. They concurred that no safety checks were completed for patient #1,3, 4, 5, 6, 7, and 8.