HospitalInspections.org

Based on document review and interview, it was determined that for 2 of 4 patients' (Pt. #1 and Pt. #2) clinical records reviewed requiring constant observation/one-to-one monitoring (one staff assigned to one patient providing monitoring), the hospital failed to ensure constant observation/one-to-one monitoring, was implemented as ordered.

Findings include:

1. On 5/28/2024, the hospital's policy titled, "Care for Patient with Behavioral Health Needs" (7/2023) reviewed and indicated, " ... To assure that patients who need psychiatric care will be safely cared for ... 6. Emergency Department (ED) procedure as follows ... 6.1.2 The ED Charge Nurse will complete the Constant Observer request form ... Addendum ... Constant Observer Roles and Responsibilities ... Patients' nurse will assign level of constant observation for patient. One-to-One observation: One competent Constant Observer to one patient within line of sight, in close proximity with no physical barriers in the same room ...Document on Constant Observer Flow Sheet every 15 minutes ..."

2. On 5/28/2024, the clinical record for Pt. #1 was reviewed. On 3/12/2024, Pt. #1 was brought to the hospital by paramedics due to hearing voices and having homicidal ideation. A physician's order dated 03/12/24 at 9:35 PM, was placed to start Pt. #1 on constant observation (one to one observation) and suicide precaution.The constant observation sheet was also left blank from Pt. #1's arrival to the ED through discharge from approximately 10:00 PM on 3/12/2024 through 4:30 AM on 3/13/2024 (six hours and 30 minutes).

3. On 5/28/2024, the clinical record for Pt. #2 was reviewed. On 5/26/2024, Pt. #2 was brought to the ED due to suicidal attempt. On 5/26/2024 at 11:00 AM, a physician's order was placed to start patient on constant observation/one-to-one monitoring. However, on 5/26/2024, the constant monitoring sheet was left blank from 7:15 PM through 8:30 PM (one hour and fifteen minutes).

4. On 5/28/2024 at approximately 2:00 PM, an interview was conducted with E #3 (ED Director). E #3 confirmed that there was no documentation to demonstrate that Pt. #1 was placed on one-to-one monitoring. To ensure safety of patient in the ED, E #3 stated that there is no other mechanism to identify who was monitoring Pt. #1 since the constant observation monitoring sheet was left blank/incomplete. E #3 also added that the ED assignment sheet do not reflect who was assigned to monitor Pt. #1. E #3 stated that the monitoring sheet should be completed every-15 minutes.