HospitalInspections.org

Based on medical record review, document review, and interview, in one (1) of twelve (12) medical records reviewed, the facility failed to implement its policy and procedure on "One to One (1:1) Observation" to ensure patient's safety. Specifically, the facility failed to:
(1) Renew 1:1 observation order every 24 hours following the evaluation of the patient.
(2) Implement monitoring every 15 minutes for a patient on 1:1 observation.

Findings include:

Review of the facility policy titled "One to One Observation and Close Observation," last revised November 2019 states: "One to one observation coverage is to be implemented upon the physician's order entered into the Electronic Medical Record (EMR). This order, entered into the EMR, must be renewed every 24 hours following the evaluation of the patient ... A physician's written order is required to terminate 1:1 observation...Registered Nurse will document reason for the 1:1 observation in the EMR. Employee assigned to 1:1 observation will document every 15 minutes into the EMR by completing the Observation Flow Sheet ... The physician will evaluate patients on 1:1 every 24 hours and reorder or discontinue said 1:1 observation."

Review of medical record for Patient #1 identified a 56-year-old female, admitted for Acute Respiratory Failure and Pneumonia due to COVID-19. On 5/6/20 at 11:05 AM, a physician order noted "1:1 observation daily." The patient was placed on 1:1 observation on 5/7/20 at 11PM.

The order for 1:1 observation was not renewed for 5/7, 5/8, 5/9, 5/10 and 5/11/2020 and there were no orders to terminate the 1:1 observation as per the facility's policy.

On 5/12/20 at 2:27 AM, a new order noted "1:1 observation, Stat Daily". The patient was discharged on 6/9/2020.

Similarly, there was no documented evidence of a daily renewal of the 1:1 observation order from 5/13 to 6/9/20.


2. Review of the patient's "Observation Flow Sheet" revealed that for the initial order for 1:1 monitoring written on 5/6/20 at 11:05 AM, the monitoring of the patient every 15 minutes did not begin until 5/07/20 at 11:00 PM. On 5/8/20, 1:1 monitoring was documented during the night shift from 12:59 AM to 8:17 AM, but were omitted during the day shift from 8:32 AM to 06:48 PM. On 5/9/20, only one set of 1:1 monitoring data was entered at 11:00 AM. There was no documented evidence of 1:1 monitoring in the patient's chart on 5/10 and 5/11/2020. Starting 5/12/20 at 3:16 AM, 1:1 observation checks were documented more frequently but were not consistently done every 15 minutes as per the facility's protocol.

Per interview with Staff A, Director of Risk management and Staff M, Vice President of Nursing on 1/22/20 at 10:45 AM, staff acknowledged the findings. Staff M was not able to provide documented evidence that 1:1 observation was performed and documented appropriately as per the facility's policy.