HospitalInspections.org

Based on observation and document review, the facility did not ensure orders for one to one (1:1) observation of patients was implemented as per the facility's policy.

These findings may have placed patients at risk for injury.


Findings:

Observation in the facility's six (6) South Unit, Room 610, on 5/12/21 between 11:00 AM and 1:30 PM revealed the following: Patient #4 and Patient #5 were noted with orders for 1:1 observation. Staff K, Nurse Tech, was assigned to provide care to Patient #'s 4 and #5 along with Patients #6 and Patient #7.

Staff K was observed taking the vital signs and providing assistance to Patient #6 and
Patient #7, in addition to providing 1:1 observation for Patients #4 and Patient #5.

These observations were made in the presence of Staff J, Assistant Nurse Manager and Staff C, Director of Risk Management, who confirmed that Staff K, should not have been providing care to more than one patient at a time.

The facility's Policy and Procedure titled " One to One Observation for Adults and Pediatric patients at risk to self or others," last revised 11/2019, states, " Remain with the patient, positioned within arm's length plus ten (10) inches, at all times ....maintain constant observation... It is not appropriate to read, use a cell phone, watch television, etc., during a 1:1 observation assignment."