HospitalInspections.org

Based on a review of facility documents, medical records (MR), video observation, and employee interviews (EMP), it was determined the facility failed to follow their policy in monitoring a patient's condition in one of ten medical records reviewed (MR1).

Findings include:

Review of facility policy "Restraints and Seclusion" with a review date of July 10. 2023, revealed "... III. DOCUMENTATION A. Appropriate documentation is to be made for each patient placed in restraint or seclusion as part of a modified plan of care. B. For each episode of restraint or seclusion use, all assessments and all interventions are to be documented ... IX. Use of restraints or Seclusion for Violent of Self-Destructive Behavior (Previously identified as "Behavioral Management") ... E. ONGOING PATIENT ASSESSMENT AND CARE INTERVENTIONS ... 4. Patients in restraint or seclusion for Violent or Self-Destructive behavior will be continuously observed and reassessed. The continued need for the use of restraints/seclusion will be reassessed and documented in the medical record at the following frequencies or more often as the patient condition requires. a. For Violent or Self-Destructive behavior - every 15 minutes ... F. DISCONTINUATION OF RESTRAINT/SECLUSION 1. The RN or physician, CRNP or PA may discontinue restraint/seclusion if the criteria for discontinuation have been met. 2. The time and criteria for release will be documented when the restraint is removed and/or seclusion discontinued ... "

Review of facility policy "UPMC Pinnacle Hospitals Nursing Standards of Care "revealed "I. Title: Unit Standard of Care for Emergency Dept Actions. II Goals/Expected Outcomes and Nursing Actions ... c. Ongoing assessment for medical patient: ... 6) Vital signs to be documented following the standards below for medical patients. During the course of treatment and evaluation in the ED ...b. ESI {Emergency Severity Index] 2 - at least q 1 hr [every hour] ..."

Review of MR1 on August 12, 2024, revealed patient was brought in by police to the Emergency Department on July 28, 2024, at 12:40 AM with an admitting diagnosis of alcohol intoxication. At 1:11 AM the physician gave an order for one-to-one supervision and physical restraints. At 1:26 AM the physician ordered labs including ETOH (Ethanol - alcohol level). At 2:00 AM the patient's Blood Alcohol Content (BAC) resulted in 379 mg/dl (over 400 is at risk for serious complications including coma and death). Partial restraints were released at 2:43 AM, and the last extremity was released at 3:30 AM from restraints. Restraint ordered discharged but one to one supervision order remained. At 4:38 AM the Physician wrote "... ETOH elevated at 379; will be sober around 1500 [3:00 PM] this afternoon but will monitor." MR1 showed the patient was classified as an ESI 2 (emergency service index) which would result in vitals being monitored at least every hour. At 3:50 AM Registered Nurse documented that Oxygen saturation was at 87% on 2 liters of oxygen and patient was increased to 4 liters. At 4:10 AM Oxygen saturation decreased to 80% and patient oxygen was again increased to 6 liters of oxygen. At 7:07 AM the Registered Nurse entered the room and found the patient unresponsive. Emergency Medical code was started at 7:15 AM. Patient was pronounced dead at 7:31 AM.
Further review of MR1 revealed that restraint monitoring was documented as completed at 1:45 AM, 2:00 AM, 2:15 AM, 2:30 AM, 2:45 AM, 3:00 AM, 3:15 AM, and 3:30 AM.

On August 13, 2024, observation of video recording of the hallway directly outside the patient's room on July 28, 2024, showed nursing exiting the patient room at 3:32 AM. During the time period that was documented in MR1 as the patient being observed and oxygen increased, no one was seen entering MR1's room. Further review of the video revealed no nursing staff entering or exiting the room between 3:33 AM and 7:07 AM.

Interview conducted on August 13, 2024, with EMP9 (physician) revealed that they were not made aware of the low oxygen saturation change in condition.

Interview conducted on August 13, 2024, with EMP8 confirmed that no one entered the patient room to assess the patient or take vital signs according to policy. In addition, EMP8 confirmed that no one was assigned to the patient to provide the one-to-one observation per order and the video observation did not match what was documented in the medical record.