HospitalInspections.org

Based on document review and interview, it was determined for 1 of 3 (Pt. #3) patients requiring one on one observation (sitter), the hospital failed to ensure that a sitter was provided for patient safety in accordance with a physician order.

Findings include:

1. Hospital policy titled, "One on One Observation for: Patient with Suicidal Ideation (revised July 2013)" required, "Suicidal Ideation: ... This patient requires a continuous One on One Observer. ... Responsibility: ... B. The One on One Observer will directly visualize (without distraction) the patient at all times. ... Documentation: 1. The nurse will document in the electronic medical record that a One on One Observer is present."

2. The clinical record of Pt. #1 was reviewed on 7/1/15. Pt. #3 was 35 year old female who presented to the emergency department (ED) on 6/30/15 at 1:05 PM with the diagnoses of depression and anxiety. An ED physician order was written on 6/30/15 at 10:45 PM for "one on one observer for suicidal ideation". The order was discontinued on 7/1/15 at 9:38 AM The documentation lacked inclusion of a one on one observer being present at bedside.

3. During the record review of Pt. #3 (approximately 9:40 AM) the charge nurse (E#2) stated, "Our staff (the nurse) would have been the 1:1 sitter." The nurse had 3 patients and would not have been able to continuously monitor the patient.

4. During an interview on 7/1/15 at 11:30 AM, the Regulatory and Policy Manager stated, "We are unable to find documentation of the sitter being present; however, assessments were completed every 2 hours by staff as required."

Based on document review and interview it was determined for 2 of 7 (Pt. #1 and Pt. #4) patients with orders for restraints, the hospital failed to ensure orders were renewed every four hours as required.

Findings include:

1. Hospital policy titled, "Restraint use: *Non-Violent and Non-Self Destructive Behavior, *Violent and Self Destructive Behavior (reviewed January 2013)" required, "...B. Obtaining a Restraint order ... Violent and Self-Destructive Behavior - time limited order applies and may not exceed 4 hours for adults ages 18 years and older."

2. The clinical record of Pt. #1 was reviewed on 7/1/15. Pt. #1 was a 24 year old male who presented to the emergency department on 6/1/15 at 11:27 AM with the diagnosis of psychosis. The clinical record included a physician's order written on 6/1/15 at 11:45 AM for restraints due to "harmful to others". Pt. #1 remained in restraints until 11:53 PM with no restraint order renewal (8 hours late).

3. The clinical record of Pt. #4 was reviewed on 7/1/15. Pt. #4 was a 75 year old female admitted on 5/11/15 with the diagnosis of chest pain. The clinical record included an order for restraints on 5/13/15 at 11:30 PM due to "harmful to other" and the next order was on 5/14/15 at 5:50 AM (2 hours and 20 minutes late). Pt. #4 remained in restraints the entire time with no restraint order renewal.

4. During an interview on 7/1/15 at 2:30 PM, the Regulatory and Policy Manager stated they were unable to find additional restraint orders to comply with policy.