HospitalInspections.org

Based on the review of 11 medical records, it was determined the Hospital failed to ensure 1 patient in need of 1:1 observation for safety was promptly placed on 1:1 observation (Patient #3).

Findings included:

Medical record documentation indicated Pateint #3 was brought to the Hospital's ED with self-inflicted left wrist lacerations requiring sutures. During triage Pateint #3 denied suicidal ideation and was assessed at low risk for suicide. Patient #3's lacerations were sutured and a behavioral health assessment was performed. Following the behavioral health assessment, the Social Worker requested further psychiatric evaluation and identified the need for 1:1 observation. Patient #3 eloped prior to the Social Worker requesting an order for 1:1 observation because the Social Worker could not connect with the ED physician.

The Hospital policy that addressed 1:1 observation indicated 1:1/constant observation was to be instituted whenever a physician/LIP believed a patient to be unsafe if unattended. The policy also indicated a RN could initiate 1:1/constant observation if he/she believed a patient to be a danger to him/herself or others. The RN must notify the nurse manager/nursing supervisor/clinical leader. The patient's attending or covering physician or LIP will be notified within one hour of the decision. The physician/LIP will provide a physician's order. The Policy did not address how if/when a physician was not available a social worker, who had performed a behavorial health assessment and determined 1:1 observation was needed, ensures the 1:1 observation is promptly initiated.