HospitalInspections.org

Based on a review of clinical records, facility documentation, facility policies, and staff interviews, for 1 of 3 patients who required 1:1 supervision (Patient #1) the hospital failed to ensure that adequate supervision was provided by an appropriately trained staff member. The finding includes:

Patient (P) #1 arrived to the hospital Emergency Department on 3/12/20 with diagnoses that included anorexia, jejunostomy tube in situ, severe protein calorie malnutrition, post traumatic stress PTSD and borderline personality disorder.

Review of the patient's history and physical dated 3/12/20 identified that the patient had a history of eating disorder with a prolonged history of trauma. The patient reported multiple self-injurious behaviors and suicide attempts in the past. The patient reported that he/she stopped engaging in self-injurious behaviors after a traumatic event where he/she had blunt trauma to the abdomen and ended up with severe medical consequences. Review of the history and physical included a Columbia Suicide Severity Risk Scale that identified that the patient had past suicide attempts with no current wish to be dead, suicidal thoughts or plans. MD #1's plan included admission to the EDU, continue wellburtin secondary to anorexia, RD assessment, every 15 minute checks and individual and group therapy.
On 3/14/20 the patient was admitted to the Hospital's Eating Disorder Unit.

Review of (P#1's) treatment plan dated 3/15/20 identified, in part, that the patient was at risk for violence (self directed) as evidenced by a history of self directed acts. The treatment plan directed every 15 minute checks and individual and group therapy.

Review of the patient's clinical record for the period of 3/1/20 to 3/28/20 identified that the patient had episodes of scratching self, biting self during PTSD. Review of the patient's record dated 3/28/20 identified that the patient had thoughts of self harm and was placed on one to one observation. Review of the patient's record dated 5/8/20 at 8:00 AM identified that a suicide risk assessment was conducted remained a low risk for suicide.

Review of the patient's monitoring sheet dated 5/8/20 identified that the patient was on 1:1 constant observation and for the period of 10:00 AM to 10:15 AM the patient was in the bathroom.

Review of Psychiatrist (MD) #1's progress note dated 5/8/20 identified that the morning of 5/8/20 P#1 had attempted suicide. The progress note identified that the patient went into the bathroom and wrapped the cord of his/her feeding pump around his/her neck and was found unresponsive by the staff member assigned to conduct 1:1 observation. The patient was evaluated by the rapid response team, and a CT scan was ordered. CT scan results reported no acute abnormalities.

Interview with Technician (Tech) #1 on 6/9/20 at 11:15 AM identified that on 5/8/20 she was assigned to provide continuous one on one observation to P#1 for the period of 7:00 AM to 3:00 PM. Tech #1 identified that this was the first time she was working on that unit and with P#1. Tech #1 identified that she was oriented to the unit by Unit Manager (UM) #1 and recalled that she was informed that the patient required one on one continuous observation which required her to stay in arm's reach of the patient at all times. Tech #1 stated that she did not recall being informed that she had to have constant visualization on the patient when s/he was in the bathroom. Tech # 1 identified at approximately 10:00 AM she accompanied the patient to the bathroom. Tech #1 indicated that although she did not have constant visual observation on the patient in the bathroom, she was standing at the door, with the door cracked open, and she was within arm's reach of the patient. Tech #1 further identified that the patient and she were talking during the time that the patient was in the bathroom. Tech #1 stated that for a period of approximately 30 seconds there was no conversation and then Tech #1 heard a "thud". She immediately opened the door fully and saw the patient on the floor gripping a cord that was wrapped around his/her neck.

Tech #1 identified P#1 did not respond to Tech #1, however, s/he was still holding the cord. Tech #1 immediately removed the cord, called for help, and an emergency rapid response was initiated.

Interview with (MD) #1 on 6/9/20 at 11:15 AM identified that the patient did not have suicidal ideation and was low risk for suicide based on the ongoing risk assessments and evaluations, however, was on continuous observation for safety related to the patient's behavior of thrashing and self-injury related to his/ her post traumatic stress disorder, not risk of suicide. MD#1 identified that on 5/8/20 when P#1 made a suicide attempt by putting a cord around his/her neck, the patient was assessed, had a pulse, was breathing, and soon became responsive after the use of smelling salt. P#1 was evaluated by the Emergency Department (ED) physician and a CT scan was performed with no acute abnormalities identified. MD #1 stated that due to a gap in constant visualization the patient had the opportunity to initiate the suicide attempt. MD #1 stated that she felt confident that the 1:1 continuous observation was an appropriate intervention for P#1 to maintain P#1's safety.

Interview with the Vice President of Quality (VP #1) on 6/3/20 identified that all staff is educated on the procedure of constant visualization, however, Tech #1 did not follow the procedure as she allowed a gap in visualization of the patient. VP#1 identifed that following the event, Tech #1 was removed from the assignment and reeducated on the details of the constant observation policy.

Interview with VP #1 and review of personnel files, on 6/15/20 at 1:45 PM identified that on 5/8/20 Tech #1 was deployed to the EDU from another area of the hospital and was educated on the expectations for 1:1 observation prior to caring for Patient #1, however the facility was unable to provide documentation of the EDU specific education provided to Tech #1 by Manager #1. Manager #1 was no longer employed at the hospital and attempts to interview Manager #1 during the investigation were unsuccessful. VP #1 identified that it was the expectation that Tech #1's orientation would have been documented.

VP#1 identifed that all EDU staff's orientation included the role and responsibilities of 1:1 observation, including constant visualization of the patient. VP #1 identified that subsequent to the incident with P#1 on 5/8/20 all staff, including Tech #1, were immediately reeducated on the facility's policy and procedure for constant supervision, including constant visualization of a patient.

Review of the hospital's continuous observation policy identified that the purpose of the policy was to provide observation and increase safety measures for any patient who poses significant risk of injury to self or others. The policy identified, in part, that a patient must remain in the sitter's site at all times. The policy identified that while privacy and respect for personal space is important the safety of the patients comes first. This includes the use of the bathroom for toileting, showering, during visits from family and friends, and when using the phone.

The policy identified that qualified sitters include nurse's, mental health counselors, technicians, nurses aids, social workers, or other staff who are oriented to the role and responsibilities.