HospitalInspections.org

Based on record review, observation, and staff interview, the hospital failed to ensure adequate staffing to implement physician orders for 1:1 (1 to 1) staff-to-patient ratio for 2 (#1 & 2) of 2 (#1 & 2) sampled patients at risk for falls. This failed practice was likely to put the patients at an increased risk for injury due to falls. The findings are:

A. Record review for Patient #1 with admission date of 03/04/11 revealed a diagnosis of stroke with left-sided weakness.
1. Record review of a 03/09/11 at 7:30 am physician order revealed, "Please place on 1:1 for safety." This order was rewritten on 03/09/11 at 8:10 am, "Please provide med/tech [technician]/mental health tech or CNA [certified nurses aide] to provide 1:1 for patient. Unit/secretary, clerk without training for patient care - does not have scope of practice for patient care."
2. Review of the nurses notes dated from 03/15/11 through 03/24/11 revealed no documentation to verify that 1:1 was provided for Patient #1.

B. Observation conducted on 03/24/11 at 1:30 pm, revealed Patient #1 was in bed resting with no 1:1 staffing.

C. Review of the facility daily "Assignment Sheet" revealed no staff was assigned to Patient #1 for the 1:1 for the following dates, 03/18/11 pm, 03/19/11 am & pm, 03/20/11 am & pm, 03/21/11 am & pm, 03/22/11 am & pm, 03/23/11 am & pm, and 03/24/11 am. The order for 1:1 for Patient #1 was written on 03/09/11 and the discontinuation of the order was not written until 03/24/11 at 1:30 pm, after an interview with the surveyor.

D. On 03/24/11 at 10:30 am, an interview was conducted with Mental Health Technician #1. When asked if Patient #1 was on 1:1 she stated, "No, he isn't."

E. On 03/24/11 at 10:50 am, an interview was conducted with Licensed Practical Nurse (LPN) #2. When asked if Patient #1 was still a 1:1, she stated, "I was verbally told by my director that he was not a 1:1 any longer." LPN #2 was asked what the procedure was to place someone on a 1:1. She stated, "The only way a 1:1 can be done is if the doctor has written an order to put them on and take them off." After she confirmed he was not a 1:1 she was asked if there was a physician order to stop the 1:1. After she looked through the record she stated, "There isn't one, no there sure isn't." When LPN #2 was asked what it means if there is not an order to discontinue 1:1, she stated, "He should still, honestly, be a 1:1."

F. On 03/23/11 at 2:20 pm, an interview was conducted with the Psychiatric Nursing Director for the unit. She was asked when the 1:1 stopped for Patient #1. She stated, "What it looks like was they took an order, but I'm not finding anything. We should have kept him as a 1:1."

G. Record review for Patient #2 revealed a physician's order dated 03/09/11 for 1:1 for safety.
1. Review of the nurses' notes revealed on 03/14/11 there was no entry to indicate that the patient had 1:1 for safety.
2. On 03/24/11 at 2:00 pm, during an interview, the Psychiatric Nursing Director confirmed no documentation of 1:1 with this patient for this day. When asked, she stated that there should have been 1:1 and documentation to confirm this.