HospitalInspections.org

Based on policy review, medical record review, review of the hospital staff schedule, and interview, the hospital failed to follow a physician's order for staff to sit with the patient to ensure safety for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the hospital's policy, "Patient Care Attendants (Previously known as Sitters) or Supplemental Private Duty Personnel," revealed, "...Purpose: To provide a standard process for obtaining and utilizing patient care attendants in [Hospital #1] and related entities...Policy: [Hospital #1] provides appropriate staff to meet the individualized holistic needs of all patients...Procedures...The provider orders sitter services prior to requesting patient care attendant services from [Home Care Service #1]...If [Home Care Service #1] cannot meet the requested needs for patient care attendants, each entity will utilize their system process to meet the provider order..."

2. Medical record review for Patient #1 revealed an admission date of 6/13/2021 with diagnoses which included Closed Fracture of Temporal Bone, Traumatic Brain Injury, Scalp Laceration, Acute Respiratory Failure with Hypercapnia, Impulse Disorder, Delirium, and Opioid Use Disorder.

A Psychiatry progress note dated 6/23/2021 revealed, "Patient [Patient #1] is still in and out of consciousness and has impairments in attention when awake (reflecting delirium).

A physician's order dated 6/24/2021 revealed, "Sitter at bedside...sit with patient to ensure safety..."

A physician's progress note dated 6/25/2021 revealed, "Impulse disorder...shouting profanities at staff...Opioid use disorder, severe, dependence...Active withdrawal leading to severe agitation...Assessment: Moderate/severe cognitive-communication deficits consistent with Rancho V [Rancho Los Amigos Levels of Cognitive Functional Scale is a clinical tool used to rate how people with brain injury are recovering. Level V indicates patient is confused, inappropriate non-agitated requiring maximal assistance] secondary to TBI [traumatic brain injury]...Recommendations: 24 hour supervision/assistance...Medical Decision Making...Problem risk: high-delirium with risk for self-harm requiring physician restraint, traumatic brain injury..."

3. Review of the hospital staff schedule from 6/25/2021-7/1/2021 revealed there was no staff scheduled to sit with Patient #1 to ensure safety during the following:
6/25/2021 AM shift (7:00 AM-7:00 PM)
6/25/2021 PM shift (7:00 PM-7:00 AM)
6/26/2021 AM shift (7:00 AM-7:00 PM)
6/27/2021 AM shift (7:00 AM-7:00 PM)
6/27/2021 PM shift (7:00 PM-7:00 AM).

4. In an interview via Zoom Video on 7/19/2021 at 1:45 PM, Physician #1 stated Patient #1 has suffered a traumatic brain injury from a motor vehicle crash. Physician #1 stated Patient #1 had cognitive deficits which caused him to have issues with inhibition. Physician #1 stated Patient #1 had issues with substance abuse which compounded his impulsiveness and agitation.

In a phone interview on 7/22/2021 at 7:00 AM, the Administrative Director of Nursing stated that the patient care attendants were assigned to patients on each floor. The Administrative Director of Nursing stated suicide patients took priority and were assigned the patient care attendants first. The Administrative Director of Nursing stated if a patient who was not a suicide patient was ordered a sitter, the patient might not have one if staff was not available. The Administrative Director of Nursing confirmed there were patients who did not have a sitter at times even though a sitter was ordered by the physician. When asked if the physician was notified that the hospital did not meet the provider order, the Administrative Director of Nursing stated, "I'm not sure."