HospitalInspections.org

Based on surveyor observation, record review and staff interview, it has been determined that the hospital failed to protect the patient's right to care in a safe setting related to providing appropriate observation.

Findings are as follows:

The hospital failed to follow their own policies and provide appropriate observation to protect a patient's physical safety, refer to A-0144.











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Based on surveyor observation, record review, and staff interview, it has been determined that the hospital failed to follow its own policies for patients who had an order for a Patient Sitter, for 2 of 9 patients reviewed, Patient ID #s 1 and 2.

Findings are as follows:

The hospital's policy titled, "Suicidal Risk Assessment", effective 3/6/2023, states in part,

"III. Definition...
(2) Where a patient has been deemed to be at high risk of suicide, the Patient Sitter is required to maintain a 1:1 Sitter/Patient ratio. (Also referred to as 1:1 observer or 1:1 observation)..."

The hospital's policy titled, "Patient Sitter Role", effective 6/20/2022, states in part,

"III. Policy:...Patient Sitters are utilized to ensure patient safety in selected circumstances including suicidal precautions, elopement potential and patients who demonstrate behaviors that are harmful to themselves or others and are not able to follow safety precautions.
a. Patient Sitters provide continuous observation of patients for purposes of patient safety.
b. Patient on suicidal precaution require 1:1 sitter...

IV. Definitions:
a. Patient Sitter: A staff member assigned to perform continuous observation of a patient for purpose of patient safety.
b. 1:1 Patient Sitter: one Patient Sitter observe one patient...

V. Procedure:...
b. The Patient Sitter must be continuously attentive to patient safety status.
i. The Patient Sitter must always have a full continuous view of the patient and be able to intervene without delay if necessary...
iii. The Patient Sitter accompanies the patient to the bathroom and remains with the patient while in the bathroom to provide constant observation. The Patient Sitter calls for assistance if needed.
iv. The Patient Sitter is never to leave the patient alone...
e. The Patient Sitter is to alert RN [Registered Nurse] if relief or assistance is needed. If there is an emergency, the Patient Sitter should call out for help or activate the emergency call system (pulling the call light)...

g. Exceptions:
i. A single Patient Sitter is to be assigned to a single patient requiring 1:1 observation in most situations.
ii. With rare exception, and only with approval by the Nursing Supervisor, Risk Management, or the Administrator on call, a Patient Sitter may be assigned to observe more than one patient at a time..."

1. Record review revealed Patient ID #1 has a past medical history including, but not limited to, anxiety and borderline personality disorder. The patient was discharged from a psychiatric hospital in June of 2023 after being admitted for abnormal behavior. Further record review revealed that 2 days later, the patient presented to the hospital's Emergency Department (ED) by emergency certification. Per the record, the patient reported psychological abuse by his/her parent and endorsed suicidal thoughts.

Record review revealed the patient had a physician's order dated 6/25/2023 for, "...Patient Sitter...Observe Reason Moderate suicide risk..."

Review of the Discharge Summary *Final Report* dated 6/26/2023 revealed "...After several attempts, pt [patient] eloped early morning on 6/26/23 and was found shortly thereafter, naked in the woods near the hospital...When found (s/he) had scrapes on (his/her) knees and arms as well as a chipped tooth..."

Review of the hospital Event Information/Event Description dated 6/26/2023 revealed that on 6/26/2023 at 5:23 AM, after requesting to use the bathroom, the patient walked out of the ambulance entrance door of the hospital. The Patient Sitter immediately alerted security staff who followed the patient but were unable to apprehend (him/her) before (s/he) disappeared into the neighboring woods. The police were notified and located the patient and returned him/her to the ED at 5:40 AM.

During an interview with the ED Assistant Clinical Manager on 6/28/2023 at 1:31 PM, she revealed that Patient Sitter, Nursing Assistant, Employee A was assigned to observe Patient ID #1.

During a surveyor observation of the ED accompanied by the Assistant Clinical Manager and the Director of Risk Management on 6/28/2023 at 1:57 PM. The observation revealed (Care Team 3) where Patient ID #1 was assigned, is approximately 20-25 feet from the bathroom and the bathroom is approximately 15-20 feet from the ambulance entrance door.

During telephone interviews with the Patient Sitter, Employee A in the presence of the Director of Risk Management, on 6/28/2023 at 3:25 PM and again at 4:01 PM, Employee A revealed she was assigned to observe Patient ID #1, along with four additional patients (a total of 5 patients) in Care Team 3 from 11:00 PM on 6/25/2023 through 2:30 AM on 6/26/2023. Employee A further revealed that she was assigned to observe Patient ID # 1, along with 3 additional patients (a total of 4 patients) from 2:30 AM to 7:00 AM on 6/26/2023.

During the above interview, Employee A revealed that during the night shift on 6/26/2023, Patient ID #1 was very restless, frequently standing at the doorway of care team 3, looking out at the ambulance entrance door. Employee A further revealed that Patient ID #1 frequently requested to use a bathroom, approximately every 45 minutes, since she was assigned to observe him/her. Employee A revealed that when Patient ID #1 was using the bathroom, she did not accompany him/her because she had to observe the other patients in care team 3. When questioned, Employee A revealed she was aware that she was supposed to accompany Patient ID #1 when s/he was using the bathroom. Additionally, Employee A revealed she did not ask for assistance when Patient ID #1 requested to use the bathroom.

During a surveyor interview with the Director of Risk Management on 6/28/2023 at 4:15 PM, she acknowledged that Patient ID #1 was left alone while he/she used the bathroom.

During a telephone interview with Registered Nurse, Employee B in the presence of the Risk Manager on 6/29/2023 at 9:58 AM, she revealed Employee A was assigned to observe Patient ID #1 along with 4 other patients from 11:00 PM on 6/25/2023 through 2:30 AM on 6/26/2023. Employee B also revealed that Employee A was assigned to observe Patient ID #1 along with 3 other patients on 6/26/2023 from 2:30 AM until Patient ID #1 eloped from the hospital at 5:23 AM. Employee B further indicated that she was aware that Patient ID #1 was restless, using the bathroom several times and was in the bathroom alone. Employee B further stated she offered the patient medication for symptoms of agitation and restlessness and he/she refused. Employee B revealed she did not recall if Employee A asked for assistance or not when Patent ID #1 requested to use the bathroom. Employee B further revealed she was unaware that the Patient Sitter must accompany the patient to the bathroom and should remain with the patient while in the bathroom.

2. Record review revealed that Patient ID #2 presented to the hospital ED in July 2023 for alcohol intoxication and reported suicidal ideation.

Review of the Triage Columbia Suicide Safety Risk Assessment revealed the patient was at high suicidal risk.

Further record review revealed the patient had a physician's order dated 7/5/2023 for "Sitter requested: alcohol intoxication, suicidal ideation---EXTREME FLIGHT RISK, DANGER WANTING TO FIGHT STAFF"

During a surveyor observation and interview with the Assistant Clinical Manager on 7/5/2023 at approximately 11:00 AM, she revealed 3 Patient Sitters were assigned to observe Patient ID #2 along with 3 additional patients located in Care Team 3. During this observation, Patient Sitter, Employee C was noted to be the only Patient Sitter in the Care Team 3.

During a subsequent interview with Employee C in presence of the Assistant Clinical Manager, she revealed, Patient Sitter Employee D was currently in the small nursing station and the third Patient Sitter was on her break. During this interview, both Employee C and the Assistant Clinical Manager acknowledged that Patient ID #2 was not provided with 1:1 Patient Sitter.

During a surveyor interview with the Director of Risk Management on 7/5/2023 at 1:30 PM, she was unable to provide evidence that the above hospital policies were followed for both Patient ID #s 1 and 2.







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