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Based on medical record review, staff interview and review of policy and procedures it was determined the facility failed to ensure the registered nurse supervised and evaluated the nursing care for one (# 2) of six records reviewed.

Findings include:

Review of the medical record for patient #2 revealed the patient arrived to the facility's emergency room on 9/15/11 at 2:37 a.m. via ambulance for an overdose. A medical screening exam was performed at 2:46 a.m. There were risk factors documented by the physician as prior suicide attempt, alcohol and drug abuse. Review of the record revealed the patient was Baker Acted by the emergency room physician.

Review of the physician's admitting orders for 9/15/11 at 6:00 a.m. read telemetry monitoring, consult psychiatry, routine vital signs, SCD's (Sequential Compression Device) to bilateral lower extremities, seizure and fall precautions and sitter at bedside.

Review of the record revealed the patient was monitored by telemetry, vital signs were monitored per unit standards and a psychiatric consultation was completed on 9/15/11. Review of the nursing documentation did not reveal the SCD's were applied as ordered. Review of the record revealed no documentation that seizure precautions and interventions were initiated as ordered.

Review of the record indicated the patient was located in ER hold until 8:00 p.m. on 9/15/11. The patient was then transferred to the 3 North nursing unit, to a semi private room, in the bed located next to the door. Review of the patient's medical record and the staffing sheets did not indicate a sitter was assigned to the patient from 8:00 p.m. to 11:00 p.m. Review of the 3 North nursing unit staffing sheets for 9/15/11 and 9/16/11 revealed on 9/15/11, on the 11:00 p.m. to 7:00 a.m. shift, a sitter was assigned to the patient's room. Documentation revealed the patient who was located in the same room, in the window bed, was also assigned to a sitter. The staffing sheets indicated the same sitter was assigned to both the door and window patients. Review of the staffing sheets for 9/16/11 from 7:00 a.m. to 7:00 p.m. revealed a sitter was assigned to both patients. Review of patient #2's record revealed documentation on 9/16/11 at 4:27 p.m. that the patient eloped.

Interview with the risk manager and CNO (Chief Nursing Officer) on 12/16/11 at 2:40 p.m. stated patient's at risk for suicide or self-harm will have a sitter assigned. The sitter is to maintain a constant 1:1 observation with the patient in sight at all times. The sitter is to stay at least an arm's length from the patient and is to never leave the patient unattended. Review of the sitter orientation packet confirmed this was the facility's standard of practice for monitoring patient's at risk of suicide or self-harm.

Review of patient #2's medical record revealed a physician's order dated 9/15/11 at 11:20 a.m. for neurological checks every 2 hours times 48 hours. Review of the nursing documentation revealed a neurological check was completed on 9/15/11 at 9:40 p.m., and on 9/16/11 at 1:00 a.m. There was a partial neurological check completed on 9/15/11 at 3:00 p.m., 6:30 p.m., and on 9/16/11 at 8:00 a.m. and 3:00 p.m. Review of the documentation revealed neurological checks were not completed every 2 hours as ordered by the physician. Interview on 12/15/11 at 3:30 p.m. with the CNO confirmed the neurological checks were not completed as ordered by the physician.

Based on medical record review and staff interview it was determined the facility failed to ensure the nursing staff developed an individualized nursing care plan for one (#2) of six patients sampled.

Findings include:

Review of the medical record for patient #2 revealed the patient arrived to the facility's emergency room on 9/15/11 at 2:37 a.m. via ambulance for an overdose. A medical screening exam was performed at 2:46 a.m. There were risk factors documented by the physician as prior suicide attempt, alcohol and drug abuse. Review of the record revealed the patient was Baker Acted by the emergency room physician.

Review of the medical record revealed a physician's order dated 9/15/11 at 6:00 a.m. for seizure and fall precautions. Review of the record indicated fall precautions were identified on the patient's plan of care and interventions were documented. Review of the patient's plan of care did not indicate seizure precautions were identified and review of the record indicated no interventions for seizure precautions were initiated.

Review of the medical record revealed a physician's order dated 9/15/11 at 11:20 a.m. for neurological checks every 2 hours times 48 hours. Review of the nursing documentation revealed a neurological check was completed on 9/15/11 at 9:40 p.m., and on 9/16/11 at 1:00 a.m. There was a partial neurological check completed on 9/15/11 at 3:00 p.m., 6:30 p.m., and on 9/16/11 at 8:00 a.m. and 3:00 p.m. Review of the documentation revealed neurological checks were not completed every 2 hours as ordered by the physician. Interview on 12/15/11 at 3:30 p.m. with the CNO confirmed the above findings.