HospitalInspections.org

Based on policy review, document review, medical record review, and interview, it was determined that the nursing staff failed to adhere to policies and procedures of the hospital for the following:

1) Nursing staff failed to notify a provider when the blood glucose results were outside of reference range per facility parameters for 1 of 13 medical records reviewed. (Patient #1)

2) Nursing staff failed to complete hourly in person one-to one observation documentation for 4 (Patient #1, #9, #10, and #11) out of 13 patient medical records reviewed and failed to document initiation and discontinuation of in person one-to one observations for 3 (Patient #9, #10, and #11) out of 13 patients.

Review of the policy "Nursing Process and Documentation Guideline", last revised February 2024, revealed that "Progress notes are utilized to address all variances from the desired outcomes of the plan of care and must reflect the status of the patient problem identified and should be written when information required is not easily documented in other areas of the medical record or the information is not easily synthesized. In general nursing documentation in the medical record is completed for a change in the patient condition or behavior, and notification of a provider including the time of notification and the corresponding nursing intervention."

Findings #1:

Review of the medical record for Patient #1, dated 01/27/25 to 02/06/25, revealed the following:
-On 01/28/25 at 01:03 AM, a Lispro insulin order by Staff (L), Nurse Practitioner, revealed the provider was to be notified if the fingerstick blood sugar was greater than 400.
-On 01/28/25 at 05:18 PM, the fingerstick blood glucose result was 428 and there was no documentation found that the provider was notified of the blood glucose being greater than 400.
-On 01/29/25 at 12:36 AM, the fingerstick blood glucose result was 443 and there was no documentation found that the provider was notified of the blood glucose being greater than 400.
-On 01/29/25 at 05:54 AM, the lab blood glucose result was 446 and there was no documentation found that the provider was notified of the blood glucose being greater than 400.
-On 02/03/25 at 01:07 AM, the lab blood glucose result was 591 and there was no documentation found that the provider was notified of the blood glucose being greater than 400.
-On 02/03/25 at 06:24 AM, the fingerstick blood glucose result was 460 and there was no documentation found that the provider was notified of the blood glucose being greater than 400.

Interview on 03/17/25 at 10:30 AM with Staff (F), Registered Nurse, revealed that if they are taking a fingerstick blood glucose and it reads out of expected range (less than 70 or greater than 120) they would recheck it and notify the provider. If the reading is "HI" (greater than 400), they would recheck and contact the provider.

Interview on 03/17/25 at 02:40 PM with Staff (J), Registered Nurse, revealed that if a patient's blood sugar in greater than 400 and the insulin parameters state to notify the provider, it would be documented in a progress note or in the medication administration record.

Interview on 03/17/25 at 04:00 PM with Staff (E), Performance Improvement Coordinator, verified these findings.

Findings #2:

Review of the policy "Utilization of Staff and Staffing," last revised February 2023, revealed "the initiation of a one-to-one observation for patients that have delirium, or behavioral conditions are assessed and categorized from tier one to five. Tiers one to three receive the highest priority for one to one-to-one coverage. Tier one is patients on suicide precautions, tier two is behavioral patients for substance abuse, tier three is for patients that are at risk for harming themselves or others, tier four is for patients that have a previous history of falls, and tier five is for patients that are at risk for falls. One-to-one coverage may be provided by a patient care technician or a companion observer. Documentation of observations for behaviors of the patient are made hourly by the staff observing the patients. The decision to discontinue the one-to-one coverage is made based on clinical judgement by the nurse however, if the one-to-one coverage was ordered by a provider, nursing must consult with the provider to determine if the patient is appropriate for discontinuation of the one-to-one observation."

Review of the medical record for Patient #1, dated 01/27/25 to 02/06/25, revealed on 01/27/25 at 11:56 PM, Patient #1 was admitted to the hospital for congestive heart failure. On 01/29/25 at 12:30 AM, Staff (P), Registered Nurse, documented Patient #1 was confused, impulsive, and attempting to get out of bed. Patient #1 fell out of bed after their bed alarm sounded sustaining multiple injuries. At 04:47 AM, Staff (N), Physician Assistant, ordered for a one-to-one bedside sitter for behavior after the fall. On 02/03/25 at 05:52 PM, Staff (EE), Physician Assistant, discontinued the order for a one-to-one bedside sitter.

Review of the "One-to-one daily staffing assignment," revealed Patient #1 was assigned to have a one-to-one sitter or virtual sitter from 01/29/25 to 02/03/25 for impulsiveness and was scored a tier four (previous history of falls). However, no hourly in person one-to-one observation documentation was found for the following timeframes: on 01/29/25 from 04:47 AM to 03:47 PM and from 06:20 PM to 12:00 AM; on 01/30/25 from 12:00 AM to 08:00 AM, 02:00 PM to 04:00 PM, and 07:00 PM to 12:00 AM; 01/31/25 for the entire day; on 02/01/25 from 12:00 AM to 11:00 AM and 07:25 PM to 12:00 AM; and on 02/02/25 at 12:00 AM to 02/03/25 at 05:52 PM.

Review of the medical record for Patient #9, dated 02/01/25 to 02/14/25, revealed on 02/01/25, Patient #9 was admitted to the hospital for Right Internal Jugular Thrombosis (blood clot in vein in neck) and Cervical Lymphadenopathy (swollen lymph nodes in neck). On 02/02/25 at 01:16 PM, Staff (NN), Physician, progress note revealed that Patient #9 had a one-to-one bedside sitter due to aggression earlier that day. On 02/08/25 at 07:11 AM, Staff (OO), Physician, revealed that Patient #9 was on a one-to-one bedside sitter as they were more confused. There was no nursing documentation when the one-to-one bedsitter was initiated or discontinued.

Review of the "One-to-one daily staffing assignment," revealed Patient #9 was assigned to have a one-to-one sitter or virtual sitter from 02/02/25 to 02/04/25 for attempting to get out of bed and pulling at lines and was scored a tier three (at risk for harming themselves or others). However, no hourly in person one-to-one observation documentation was found for the following timeframes: on 02/02/25 from 12:00 AM to 10:00 AM and from 07:00 PM to 12:00 AM; and on 02/03/25 from 12:00 AM to 11:11 AM.

Review of the medical record for Patient #10, dated 12/26/24 to 01/11/25, revealed on 12/26/24, Patient #10 was admitted to the hospital for orthostatic hypotension (sudden drop in blood pressure when you stand up). On 01/01/25 at 04:15 PM, Staff (PP), Physician Assistant, progress note revealed that Patient #10 had a one-to-one bedside sitter due to a witnessed fall and Patient #10 needed to continue to have the one-to-one bedside sitter. There was no nursing documentation when the one-to-one bedsitter was initiated or discontinued.

Review of the "One-to-one daily staffing assignment," revealed Patient #10 was assigned to have a one-to-one sitter or virtual sitter from 01/01/25 to 01/02/25 for attempting to get out of bed and pulling at lines and was scored a tier four (previous history of falls). However, no hourly in person one-to-one observation documentation was found for the following timeframes: on 01/01/25 from 12:00 AM to 03:00 PM and from 05:00 PM to 06:00 PM; and on 01/02/25 for the entire day.

Review of the medical record for Patient #11, dated 12/26/24 to 01/27/25, revealed on 12/26/24, Patient #11 was admitted to the hospital for congestive heart failure exacerbation (worsening of heart failure symptoms). On 12/26/24 at 12:37 PM, Staff (QQ), Physician Assistant, ordered for a one-to-one bedside sitter for agitation and confusion. On 01/13/25 at 10:39 AM, Staff (RR), Physician Assistant, discontinued the order for a one-to-one bedside sitter. There was no nursing documentation when the one-to-one bedsitter was initiated or discontinued.

Review of the "One-to-one daily staffing assignment," that began on 01/01/25 revealed Patient #11 was assigned to have a one-to-one sitter or virtual sitter from 01/01/25 to 01/02/25 for fall risk and impulsiveness and was scored a tier three (at risk for harming themselves or others). However, no hourly in person one-to-one observation documentation was found for the following timeframes: on 01/01/25 from 12:00 AM to 10:00 AM and from 11:00 PM to 12:00 AM; and on 01/02/25 for the entire day.

Interview on 03/17/25 at 10:30 AM with Staff (F), Registered Nurse, revealed that if they believed that a patient needed a one-to-one bedside sitter, they would have one of the patient care technicians stay with the patient while they contacted the patient ' s provider and nursing supervisor to arrange for a sitter to be assigned to the patient. Sitters document on patient safety once an hour, or if there are any changes. This documentation is typically entered into the electronic medical record by the sitter, but there are instances where the sitter fills out a paper form which is latter scanned and uploaded into the electronic medical record.

Interview on 03/17/25 at 02:40 PM with Staff (J), Registered Nurse, revealed that if a patient is impulsive, agitated, and a fall risk Staff (J) would either obtain an in person one-to-one sitter or a virtual sitter to attempt to keep the patient safe. If a patient is on a one-to-one sitter there would be documentation in the electronic medical record by the sitter and the nurse caring for the patient.

Interview on 03/18/25 at 09:15 AM with Staff (DD), Patient Care Technician, revealed they were actively observing a patient who was currently on a one-to-one sitter for behavior from 03:00 AM to 09:15 AM. Staff (DD) was not aware they had to document in the electronic medical record behavioral observation flowsheet for patients on a one-to-one sitter for behavior until that morning at 08:00 AM.

Interview on 03/18/25 at 01:30 PM with Staff (E), Performance Improvement Coordinator, revealed they were unable to locate any other one-to-one in person sitter paper documentation forms for Patient #1, #9, #10, and #11. Staff (E) verified that a one-to-one in person sitter for behavior is a nurse driven decision for safety and does not need an order to obtain. The nurse would communicate the need to their manager, or the nursing supervisor and the sitter assignments are kept on a staffing log and are evaluated every four hours to determine the continued need for the one-to-one sitter.

Interview on 03/18/25 at 01:35 PM with Staff (T), Companion Observer, remembered Patient #1 and they were assigned on 01/29/25 to monitor Patient #1 who was on a one-to-one sitter for behavior after they fell. Staff (T) revealed that Patient #1 was confused, agitated, and they would not sit still. Staff (T) sat with Patient #1 and attempted to keep them calm, but Patient #1 continued to attempt to get out of bed. Staff (T) revealed documentation is completed every hour when a patient in on a one-to-one in person sitter for behavior but revealed that they did not complete the documentation per policy for Patient #1. Staff (T) obtains report from the sitter before their shift, the patient care technician, or the nurse before they begin to monitor the patient in person.