HospitalInspections.org

Based on review of Hospital policy, observation, clinical record review, and staff interview, it was determined that for 1 of 1 (Pt #2) clinical record reviewed of a patient on 1:1 observation, the Hospital failed to ensure staff were within arms reach as required. Thus placing all patients and staff on the unit at risk.

Findings include:

1. Hospital policy entitled, "Precautions and Observations," (revision 8/11) required, "1:1 Observation - Will be instituted when a patient is unable to maintain safe control of his/her behavior on a lesser level of observation. Staff will remain at an arms length from patient at all times ..."

2. During the tour of the 1 South Unit on 7/12/12 at approximately 9:15 AM, one patient (Pt #2) was identified as a 1:1 observation status patient.

3. The clinical record of Pt #2 was reviewed on 7/12/12 at approximately 9:20 AM. Pt #2 was a 30 year old female admitted on 6/28/12 with a diagnosis of Schizoaffective Disorder. An admission order dated 6/28/12, that as a result of Pt #2's risk of assault, required that Pt #2 be placed on Assault, Fall, Elopement, and Seizure Precautions. On 7/1/12 a physician's order was written at 6:25 AM that required Pt #2 be placed on "1:1 RTC (round the clock) until further notice". The staff assigned to Pt #2 was sitting in the hall, approximately 10 feet from the patient, not at arms length as required.

4. The Chief Compliance/Nursing Officer (CNO) was interviewed on 7/12/12 at approximately 9:30 AM. The CNO stated that the Hospital is aware the sitter is not at arms length. The CNO stated that Pt #2 becomes agitated easily and has injured various staff so to keep her quiet and not get her agitated, the staff sits in the hall, while she is in bed.