HospitalInspections.org

Based on document review and interview, it was determined for 1 of 1 (Pt #1) clinical record reviewed for patients who required close supervision, the Hospital failed to ensure that physician orders were followed.


Findings include:


1. The Hospital's policy titled, "Authorized Provider Orders" (dated 8/6/19), was reviewed on 10/10/19, and required, "Authorized provider orders are to be entered into the electronic health record and promptly and accurately and communicated to the proper department/ and or personnel."

2. The Hospital's Job Description: Registered Nurse, was reviewed on 10/10/19, and included, "Adheres to the Illinois State Nurse Practice Act and other criteria designated by regulatory/credentialing bodies. Provides care in a safe, timely, and ethical manner."

3. The clinical record for Pt #1 was reviewed on 10/9/19. Pt #1's Report of Psychiatric Consultation (dated 5/24/19 at 10:52 AM), documented by the Psychiatrist MD #2, included, "Addendum: Ordered 1:1 sitter [continuous supervision] for safety because of his severe dementia. He keeps getting up and will wander. Plan is for discharge tomorrow at 10 AM." Pt #1's clinical record lacked documentation that a sitter was provided for patient safety.

-The Psychiatrist's (MD #2) Order (dated 5/24/19) included, "Sitter at bedside."

4. On 10/9/19 at 11:15 AM, an interview was conducted with MD #2. MD # 2 stated, "I saw [Pt #1] for irritability and impulsivity. The patient also saw the Neuro Psychiatrist. [Pt #1] had severe Dementia. He was on meds [medications] for the behavior. Eventually, I ordered a sitter for the patient [on May 24th]. I would recommend 24-hour supervision for patients with severe Dementia."

5. On 10/9/19 at 2:25 PM, an interview was conducted with the CTU (Cardiactelemetry) Unit Director (E #9). E #9 stated, "[Pt #1] never had a sitter. It would be our [unit] responsibility to get a sitter. There wasn't a sitter for Pt # 1 because of staffing. We made a clinical decision to not have a sitter."

6. On 10/9/19 at approximately 2:15 PM, the CTU 7 staffing and assignments were reviewed from 5/23/19 at 7:00 AM through 5/25/19 at 11:00 PM. Staffing and assignments did not include a sitter for Pt #1 from 1:42 PM (time of order for sitter) through 5/25/19 at 10:58 AM (time of Pt #1's discharge).

7. On 10/9/19 at 2:30 PM, a phone interview was conducted with the CTU Registered Nurse/(E #8). E #8 stated, "I took care of Pt #1 on May 24th. He did not have a sitter during my shift. The doctor ordered the sitter because the day before, he was aggressive with the wife, and he was jumping up out of the chair. The sitter was needed for the patient, due to his behavior."

8. On 10/9/19 at 2:35 PM, an interview was conducted with the System Manager Regulatory and Accreditation (E # 2). E #2 stated that the Hospital does not have a "Sitter Policy."

9. On 10/9/19 at 11:15 AM, an interview was conducted with E # 9. E #9 stated that nurses are expected to follow physician's orders.