HospitalInspections.org

Based on document review, observation, and interview, it was determined that for 1 of 3 patients (Pt. #3) who required 1:1 sitters, the Hospital failed to provide care in a safe setting, by failing to ensure one-to-one (1:1) observations were implented as ordered.

Findings include:

1. On 4/20/2022, the Hospital's policy titled, "One-to-One Supervision" revised by the Hospital on 10/21, was reviewed. The policy required, "...It is the policy of Nursing Services to institute One-to-One Supervision of patient when: 1. The patient has intractable (difficult to treat/resolve) suicidal ideation or behavior; or when the patient's psychosis or level of confusion and disorganization makes him/her an imminent dagger to him/herself or others, and when a patient is placed in restraints."

2. On 4/20/2022, the Hospital's policy titled, "Utilization of Human Restraints" revised by the Hospital 8/21, was reviewed. The policy required, "...Utilization of Human Restraint for Behavioral Management...Care of the patient in physical restraints...2. A member of the facility staff must remain with the patient in Locked Restraint at all times, unless the patient has been placed in locked seclusion."

3. On 4/20/2022, Pt. #3's clinical record was reviewed. Pt. #3 presented to the Emergency Department on 4/19/2022, with a chief complaint of bizarre behavior and a diagnosis of acute psychosis. The physician order dated 4/19/2022 at 11:07 PM, included an order for 1:1 observation. The physician order dated 4/20/22 at 9:12 AM, included an order for full (all four extremities) locked restraints, for aggresive behaivor with a threat of the safety to self and others. The restraint flow sheet dated 9/20/2022, included documentation that full locked restraints were applied to Pt. #3 at 9:12 AM.

4. On 4/20/2022 between 9:35 AM - 10:00 AM, an observational tour of the Emergency Department's triage 2/Behavioral Health holding room (locked area separate from the main Emergency Department). There were fourteen (14) beds with curtain dividers and three (3) Behavioral Health patients with 1:1 observations ordered. The three (3) Behavior Health patients (Bed #2, Bed #5, and Bed #6) on 1:1 observation were within line of sight and being monitored by two Crisis Workers/Sitters, instead of the required three sitters. In bed #6 (Pt. #3) was in full locked restraints and did not have a 1:1 sitter assigned for continuous monitoring.

5. On 4/20/2022 at 9:38 AM, an interview was conducted with an Emergency Department Registered Nurse (E #7). E #7 stated that one-to-one (1:1) means that the care is one staff to one patient.

6. On 4/20/2022 at 1:00 PM, an interview was conducted with the Director of Nursing (E #1). E #1 stated that each 1:1 patient should be assigned a sitter and that Pt. #3 should have a 1:1 sitter while in full locked restraints.