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Based upon record review and interview, the nursing personnel failed to provide one to one (1:1) sitters per physician's order for one sampled patients (SP) #2, to respond to call bells in 2 sampled patients # 2 and #3.

The findings include:

1. On 11/22/14 at 11:45 AM during observation of the 5th floor, the surveyor was approached by sampled patient (SP#2) family member. The patient family member stated the patient was supposed to have a (one to one)1:1 sitter but many times when I came to the facility, the patient was left by herself. The family member also stated that when I visit the patient, no one came in the room to take care of the patient. The family member then stated that when the family comes, the sitter leaves the patient's room.

Review of sampled patient (SP)# 2 Adult Shift Assessment record, dated 12/19/2014 showed the patient had a history of a fall in the last three months, with the month and year of the last fall: Dec 14. The patient was also noted to be a high risk for falls. The record further report that on 12/14/14 at 8:57 AM, the Physician's ordered a 1:1 sitter. The Sitter Record noted that 1:1 sitters was not started until 12/14/14 at 7:00 PM. There was no documentation that a sitter or a family member was at the bedside on 12/16/14 from 8:00 PM to 7:00 AM.

On 12/22/14 at 12:12 PM, Staff F- RN (registered nurse) stated that SP#2 always had a sitter at the bedside. He stated that the nursing assistants rotate turns sitting with patients every hour.

On 12/22/14 at 12:15 PM, Staff E-RN stated that if there are blank spaces on the Sitter record, it could be that the patient went for a test.


The duties on the Sitter's Record for 1:1 sitters include: the patient is never to be left unattended.

2. On 11/22/14 at 11:45 AM SP #2 family member stated that while she was assisting SP#2 to the bathroom, SP#2 felt weak and she was able to lower the patient to the floor. However, when she pulled the emergency light in the bathroom, no one answered or came to assist and that she had to leave the patient alone on the floor and go in the hallway and yell for help.


On 12/22/14 at 11:20 AM, SP#3 stated that last night (12/21/14) when she called for assistance with the call light, no one answered. She stated that she had to go up to the nursing station three times in order to get assistance with her meal.

Based upon record review and interview, the facility failed to ensure the patient is reassessed per the facility's policy in one sampled patient (SP#2) of thirteen sampled patients.


The findings include:

Review of the facility's policy titled: "Reassessment", (review/revised 12/11) showed that all patients shall be reassessed by nursing staff at regular specified intervals related to the patients level of care. The policy state that medical/surgical patient shall be reassessed every shift, and as needed.

Review of sampled patient (SP) #2 nursing assessments showed that there were no nursing assessments completed between 8:30 PM on 12/17/14 and 8:00 PM on 12/18/14.

On 12/22/14 at 11:31 AM, Staff B-RN ( registered nurse) stated that for medical surgical patients, nursing assessments are completed every shift and more frequently, depending on the patient's condition.

On 12/22/14 at 12:15 PM, Staff E- RN stated that nursing assessments are completed once per shift and if something happens.

On 12/23/14 at 10:36 AM, Staff- RN stated that nursing assessments are completed once per shift for medical surgical patients.