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A. Based on medical record review, review of policy and staff interview it was determined the registered nurse (RN) failed to supervise the care of newly admitted patients per policy and expectation. This was noted in one of two records reviewed which included elopements and/or elopement attempts (pt. # 1). This creates the potential for an adverse impact on the care and condition of all newly admitted patients. Findings are:

1. The policy for "Nursing Documentation," last revised 4/12, was provided for review. The policy states in part: "RN's will document the patient assessment on new admissions every shift for 48 hours then once every 24 hours."

2. Review of the medical record for patient # 1 revealed the patient was admitted on 3/15/16 and arrived on the nursing unit at 11:00 p.m. Review of nursing documentation revealed Licensed Practical Nurse # 1 (LPN) documented the dayshift nursing assessment note at 2:52 p.m. for 3/17/16. The LPN documented the patient was being checked every thirty (30) minutes. There was no RN assessment documented for this patient on dayshift on 3/17/16. The record indicated the patient eloped on 3/18/16.

3. This record was reviewed and discussed with the Nurse Executive at 9:15 p.m. on 3/18/16. He acknowledged the RN failed to document a dayshift assessment on 3/17/16. He also stated the hospital expectation is that all patients are checked every fifteen minutes (15) and that thirty (30) minute checks are not acceptable.

B. Based on observation, medical record review and staff interview it was determined the registered nurse failed to supervise care and documentation of care for patients who had orders for a higher level of supervision while off unit and/or were not permitted off the unit. This failure impacted three (3) of eleven (11) patients who were observed to leave the unit for fresh air (pt's #10, 11, 12). This failure increases the risk of harm to all patients who leave the unit. Findings are:

1. Observation on the G 2 Unit between 11:30 a.m. and 12:00 p.m. on 3/30/16 revealed Patient #12 was in four (4) point restraints and was removed from restraints at 11:50 a.m. Patient #10, patient #11 and patient #12 were observed to join the group of patients which left the unit at approximately 12:00 p.m. with unit staff.

The surveyors accompanied the group, which was joined by security staff during the walk through the hospital to the N 1 courtyard for fresh air. As the group passed the inner courtyard, security guard #1 opened the door and asked how many patients were coming in for fresh air. LPN#3 stated none of the patients were going in the inner courtyard.

All patients, and both unit and security staff were observed to go to the N 1 courtyard for fresh air. At approximately 12:20 p.m. patient #12 was observed to exhibit self-injurious behavior as the group walked back to the unit.

2. A review of the medical record for patient #10 revealed a 3/24/16 order, written at 12:24 p.m. which stated "Patient can have fresh air in inner courtyard only."

3. A review of the medical record for patient #11 revealed a 3/28/16 order, written at 11:19 a.m., which stated "fresh air in inner court with security staff."

4. These observations were discussed with the Interim Nurse Manager for the E 2 Unit at 1:35 p.m. on 3/30/16. The Manager stated both patients #10 and #11 were ordered to use the inner courtyard only and should not have gone with the group to the N 1 courtyard (which is less secure). She also confirmed patient #12, is Status 1 level and was not permitted to leave the unit.

5. A review of the fresh air sheet for the above observed fresh air session revealed it incorrectly indicated patient #12 did not participate. It was also noted to have been completed by Health Service Worker #1 (HSW) who was not present for the fresh air session.

Review of the 3/30/16 dayshift checklist for patient #12, completed by HSW #4 at 1:30 p.m. revealed the documentation incorrectly indicated the patient declined fresh air.