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A. Based on medical record review, staffing review, policy review and staff interviews, it was determined that the George Washington University Hospital nursing staff failed to follow the hospital policy to ensure patient safety.


The findings include:


The George Washington University Hospital policy titled, 'Sitter: Care and Observation of the Patient by Sitter,' effective March 2016 stipulates, " ...II. Purpose It is the policy of the George Washington University Hospital to provide a safe and secure environment for patients during their hospitalization. A continuous level of observation may be required to ensure that safety ...III. Definitions C. Line of Sight Observation: The sitter may be assigned to observe one or two patients in the same room or two adjacent rooms; the sitter should not be assigned to observe more than two patients. The sitter positions him/herself to maintain an unobstructed view of both patients at all times. Additional staff must be provided if patient activity prevents the sitter from simultaneously observing both patients. D. 1:1 Sitter: One sitter continuously observes one patient ... IV. Policy ... D ... Patient Care ...13.The sitter must document on the Sitter Observation Flowsheet every 15 minutes ... E. General Guidelines for Sitters ...3.The role of the sitter is to provide continuous observations for patients at risk for harm and the sitters should not be involved in any non-patient care related activities while the sitter is on duty..."


The George Washington University Hospital policy entitled, 'Suicide: Management of the Patient at Risk for Suicide,' effective March 2016 stipulates, "II. Purpose ...To provide guidance for the early identification of patients at risk for suicide and self-harm, the implementation of interventions intended to prevent suicide attempts and self-inflicted injuries ...Policy B. Caring for Patients on Suicide Precautions: The following precautions will be implemented when an individual expresses suicidal ideation, initiates an action with the intention of causing his/her own death ...4.Modify the patient's environment to increase safety and reduce risk ...a. Remove and/or inhibit any access to equipment not being used in direct care ...Appendix A The Warning Signs of Suicide: 1. Irritability, 2. Increased anxiety (in addition to panic), ...10. Requesting early discharge ...Danger signs of Suicide ...1.Talking or joking about suicide ...4. Suddenly happier or calmer. 5. Unusual visiting or calling people one cares about ...Appendix C. Elements of a comprehensive suicide risk assessment must include but are not limited to: 1.Evidence suicidal ideation 2. Level of suicidal intent 3. History of attempted suicide a. Primary suicide method in plan b. Means readily available to implement plan ..."


Patient #1 was admitted to George Washington University Hospital with a diagnosis of Suicidal Ideation.


Review of the medical record conducted on June 30, 2016 at approximately 12:00 PM revealed a physician order on June 29, 2016 at 10:41 AM for a sitter at all times, after Patient #1 reported that s/he attempted suicide overnight, by wrapping a sheet around his/her neck and tying it to the bed.


On June 29, 2016 at 10:49 AM, the physician's note revealed, "...Patient reports that he tried to hang himself with a sheet overnight. "Physician documentation revealed, when Patient #1 was informed that [s/he] had to have a 1:1 sitter and could not shave, unless there was the presence of a security officer, [s/he] stated, "I'm going to kill myself, I'll find another way and you can' t stop me."


On June 29, 2016 at 10:53 AM, a physician note revealed, the Nurse Manager was made aware of the situation and requested that Patient #1 be moved closer to the nurses' station "for closer monitoring."


There was no documentation to indicate that the patient was moved closer to the nursing station. There was no documentation to indicate that sheets were removed from the patient ' s room.


A review of the 6 South day shift (7:00 AM - 7:00 PM) assignment sheet for June 29, 2016 conducted on June 30, 2016 at approximately 3:00 PM revealed that Employee #4 was the assigned Charge Nurse, was assigned a patient and the first admission, was responsible for the exercise group, patient safety checks for all 11 patients on the unit, environmental rounds, and was responsible for escorting patients to testing and discharge.


Further review of the 'Sitter Direct Observation Flowsheet' revealed there was no documentation to indicate that 1:1 sitter observation was performed on June 29, 2016 for Patient #1.


On June 30, 2016 at approximately 2:20 PM, a face to face interview was conducted with Employee #4, in the presence of Employee #1, regarding 1:1 sitter observation for Patient #1. Employee #4 shared s/he called the House Supervisor on June 29, 2016 to arrange for a 1:1 sitter, and since the nurse assigned to the patient was busy, s/he assumed responsibility as the 1:1 sitter and "kept the patient in line of site. "S/he continued to explain that the patient was upset about the need for a sitter and the physician made the decision for the patient to have a 1:1 sitter on the night shift only [7:00 PM to 7:00 AM]; instead, the patient would check in at the nursing station every 15 minutes. Employee #4 explained that at 12:05 PM the patient was being helpful and asked to help put the juices away. S/he later saw the patient on the phone and at approximately 12:18 PM, s/he went to check on the patient and couldn ' t find him/her. Employee #4 explained, s/he opened the bathroom door and "a body with a blue face fell on my feet." She continued explaining that s/he removed the sheet from around the patient ' s neck, started Cardiopulmonary Resuscitation and called for help.


On June 30, 2016 at approximately 4:38 PM, a face to face interview was conducted with Employee #3, regarding Employee #4's role as a 1:1 sitter, in conjunction with his/her other assigned responsibilities. Employee #3 explained that s/he was unaware that Employee #4 was assigned a patient and assigned to perform the 15 minute safety checks for all patients on the unit, in addition to the 1:1 sitter responsibility. S/he communicated, "You cannot have an RN [registered nurse] doing a 1:1 sitter and doing 15 minute checks because you [the nurse performing 15 minute checks] have to be able to navigate the unit ...You would not be a sitter, have an assignment and do 15 minute checks. You would distribute your patients to another nurse."



There was no indication that Employee #4 performed 1:1 sitter observation and identified the danger signs of suicide exhibited by Patient #1.


The GWUH staff failed to ensure Patient #1's safety. Employee #2 and 4 acknowledged the findings.


B. Based on observations and staff interviews, it was determined that the George Washington University Hospital medical staff failed to ensure the door to the Behavioral Health Unit was closed, after exiting, for patient safety.


The findings include:


District of Columbia Municipal Regulations for Hospitals (DCMR), Title 22, 2035.24 stipulates, "... (b) Doors may prevent escape and create seclusion where therapeutically required, such as emergency protective custody, detoxification and psychiatric locations... "


On July 1, 2016 at approximately 12:05 PM, a tour was conducted on Unit 6 South. Upon entering the Behavioral Health Unit (6 South), the left door of the double doors was left open and Employee #11 was observed exiting the door, without ensuring that it was closed. A sign was posted on the door that directed staff to ensure the doors closed behind them. Closer observation revealed the door was wedged open by the floor. The observation was made in the presence of Employee #13.


On July 1, 2016 at approximately 12:07 PM, a face to face interview was conducted with Employee #11, in the presence of Employee #13. Employee #11 was asked if the door should be left open to the Behavioral Health Unit. Employee #11 explained that the doors should be closed to the unit and s/he didn't look behind because s/he thought the door "would close on its own ".


On July 1, 2016 at approximately 1:05 PM, Employee #17 presented security camera footage, displaying Employee #11 exiting the door to the Behavioral Health unit, without ensuring that it was closed.


The observations failed to demonstrate that Employee #11 ensured patient safety. Employees #1 and 17 acknowledged the findings.





35131

Based on medical record review, policy review and staff interview, it was determined the nursing staff failed to follow hospital policy to ensure a physician or licensed practitioner ordered the bilateral wrist restraints that were observed on Patient #1.


The findings include:


The George Washington University Hospital policy titled, 'Seclusion & Restraints' effective April 2016 stipulates, "IV. Policy ... F. The use of restraint must be in accordance with the order of a physician or physician's assistant ...G. A restraint or seclusion may be initiated without an order when a patient or staff is at risk for imminent harm. When restraint or seclusion is ¿initiated without an order: An RN initiates the restraints based on an assessment that justifies the use of restraint and then obtains a verbal order from the attending or treating physician or physician assistant and document immediately. If a verbal order is not obtained from the attending or treating physician or physician assistant within fifteen (15) minutes, the restraints or seclusion shall be terminated ... J. Ongoing Monitoring ...2.Non-Violent/Non-Self Destructive: ...b. Monitoring is expected to occur at a minimum of every 2 hours..."


Patient #1 was admitted to George Washington University Hospital (GWUH) with a diagnosis of Suicidal Ideation.


On June 30, 2016 at approximately 12:00 PM, Patient #1 was observed in the Intensive Care Unit (ICU). S/he was on a ventilator, on cardiac monitoring, and had bilateral soft wrist restraints in place. An order revealed the patient was admitted to the ICU on June 29, 2016 at 12:51PM.


A review of the medical record conducted on June 30, 2016 at approximately 12:05 PM lacked documented evidence of a physician order for the use of bilateral wrist restraints.


A face to face interview was conducted on June 30, 2016 at approximately 12:15 PM with Employee #10, in the presence of Employee's #8 and 9. Employee #10 was asked to provide a patient assessment. S/he provided a head to toe assessment and explained the patient was in bilateral wrist restraints for safety purposes. When asked when the restraints were applied, s/he stated when the patient arrived to the unit yesterday [June 29, 2016] and added s/he received the patient in restraints. Employees #8, 9 and 10 were asked to provide documentation of a physician order. They could provide no order or any documentation for the use of restraints on Patient #1.


The staff failed to follow the hospital's policy to obtain an order for the use of restraints. Employees #8, 9 and 10 acknowledged the findings.

Based on medical record review, policy review and staff interview, it was determined the nursing staff failed to follow hospital policy to document the use of bilateral wrist restraints (Patient #1).


The findings include:


The George Washington University Hospital policy titled, 'Seclusion & Restraints' effective April 2016 stipulates, "IV. Policy ... F. The use of restraint must be in accordance with the order of a physician or physician ' s assistant ...G. A restraint or seclusion may be initiated without an order when a patient or staff is at risk for imminent harm. When restraint or seclusion is ¿initiated without an order: An RN initiates the restraints based on an assessment that justifies the use of restraint and then obtains a verbal order from the attending or treating physician or physician assistant and documented immediately. If a verbal order is not obtained from the attending or treating physician or physician assistant within fifteen (15) minutes, the restraints or seclusion shall be terminated ... J. Ongoing Monitoring ...2. Non-Violent/Non-Self Destructive ...b. Monitoring is expected to occur at a minimum of every 2 hours. d. Documentation of Monitoring: Episodes of restraint shall be documented ... M. Documentation related to restraint or seclusion includes: 1.The initial assessment of the patient related to restraint or seclusion use; 2. Documentation of each episode of restraint or seclusion includes: a.The circumstances that led to the use of restraint or seclusion ...b. Consideration or failure of less restrictive interventions c. The rationale for use and continued use of restraint or seclusion ...e. Orders for use - including each order for continuation ...g. Time of initiation and termination of restraint or seclusion ..."


Patient #1 was admitted to George Washington University Hospital (GWUH) with a diagnosis of Suicidal Ideation.


On June 30, 2016 at approximately 12:00 PM, Patient #1 was observed in the Intensive Care Unit (ICU). He was on a ventilator, on cardiac monitoring, and had bilateral soft wrist restraints in place. An order revealed the patient was admitted to the ICU on June 29, 2016 at 12:51PM.


A review of the medical record conducted on June 30, 2016 at approximately 12:05 PM lacked evidence of documentation of the initiation and monitoring of bilateral wrist restraints.


A face to face interview was conducted on June 30, 2016 at approximately 12:15 PM with Employee #10, in the presence of Employee's #8 and 9. Employee #10 was asked to provide a patient assessment. S/he provided a head to toe assessment and explained the patient was in bilateral wrist restraints for safety purposes. When asked when the restraints were applied, s/he stated when the patient arrived to the unit yesterday [June 29, 2016] and added s/he received the patient [7:00 AM June 30, 2016] in restraints. Employees #8, 9 and 10 were asked to provide documentation for restraint initiation, patient behavior and monitoring. They could provide no documentation for the use of bilateral wrist restraints on Patient #1.


The staff failed to follow the hospital's documentation policy for the use of restraints. Employees #8, 9 and 10 acknowledged the findings.

Based on medical record review, policy review and staff interview, it was determined the nursing staff failed to follow hospital policy to monitor the use of bilateral wrist restraints (Patient #1).


The findings include:


The George Washington University Hospital policy titled, 'Seclusion & Restraints' effective April 2016 stipulates, "IV. Policy ... F. The use of restraint must be in accordance with the order of a physician or physician ' s assistant ...G. A restraint or seclusion may be initiated without an order when a patient or staff is at risk for imminent harm. When restraint or seclusion is ¿initiated without an order: An RN initiates the restraints based on an assessment that justifies the use of restraint and then obtains a verbal order from the attending or treating physician or physician assistant and documented immediately. If a verbal order is not obtained from the attending or treating physician or physician assistant within fifteen (15) minutes, the restraints or seclusion shall be terminated ... J. Ongoing Monitoring ...2.Non-Violent/Non-Self Destructive: ...b. Monitoring is expected to occur at a minimum of every 2 hours. d. Documentation of Monitoring: Episodes of restraint shall be documented ... M. Documentation related to restraint or seclusion includes: 1. The initial assessment of the patient related to restraint or seclusion use; 2. Documentation of each episode of restraint or seclusion includes: a. The circumstances that led to the use of restraint or seclusion ...b. Consideration or failure of less restrictive interventions c. The rationale for use and continued use of restraint or seclusion ...e. Orders for use - including each order for continuation ...g. Time of initiation and termination of restraint or seclusion ..."


Patient #1 was admitted to George Washington University Hospital (GWUH) with a diagnosis of Suicidal Ideation.


On June 30, 2016 at approximately 12:15 PM, Patient #1 was observed in the Intensive Care Unit at George Washington University Hospital. He was intubated on a ventilator, on cardiac monitoring, and had bilateral soft wrist restraints in place.


A review of the medical record conducted on June 30, 2016 at approximately 12:00 PM revealed the patient was admitted to the ICU on June 29, 2016 at 12:51PM. The record lacked evidence of ongoing monitoring for the use of bilateral wrist restraints.


A face to face interview was conducted on June 30, 2016 at approximately 12:30 PM with Employee #10, in the presence of Employee's #8 and 9. Employee #10 was asked to provide a patient assessment. S/he provided a head to toe assessment and explained the patient was in bilateral wrist restraints for safety purposes. When asked when the restraints were applied, s/he stated when the patient arrived to the unit yesterday [June 29, 2016] and added s/he received the patient [7:00 AM June 30, 2016] in restraints. Employees #8, 9 and 10 were asked to provide documentation of a physician order and documentation of restraint initiation and monitoring. They could provide no documentation that the patient was monitored, while in bilateral wrist restraints.


The staff failed to follow the hospital's policy for patient monitoring, for the use of restraints. Employees #8, 9 and 10 acknowledged the findings.