HospitalInspections.org

Based on review of medical records, policies and procedures, the "Nurse to Sitter Hand-Off Communication Form", the "One-to-One Sitter Observation Record", Unit 11A's staffing from 09/01/11 through 09/07/11, protocols, staff interviews, the Maintenance Department's corrective action plan, and the Nursing Department's corrective action plan, the facility failed to have an adequate number of nursing staff available to monitor and provide a safe setting for 1 of 4 sampled patient's medical records (#1). Cross refer to A0144.

Based on review of medical records, policies and procedures, the "Nurse to Sitter Hand-Off Communication Form", the "One-to-One Sitter Observation Record", Unit 11A's staffing from 09/01/11 through 09/07/11, protocols, staff interviews, the Maintenance Department's corrective action plan, and the Nursing Department's corrective action plan, the facility failed to have an adequate number of nursing staff available to monitor and provide a safe setting for 1 of 4 sampled patient's medical records (#1).


Findings were:

Review of 1 of 4 sampled patient's medical records (#1) revealed the patient was admitted to the facility to receive treatment for seizures and alcohol withdrawal. A plan of care was initiated upon admission (hospital day #1) and updated on hospital days #2, #3, #4, #5, #11, #12, and #13. The patient's plan of care included risk of injuries related to seizures. Review of the nurse's notes revealed the patient was placed on seizure precautions, was to receive anti-convulsant medications, was to have his/her neurological status monitored, and was to be placed on the long term video monitor while in the intensive care unit and while on the 8th floor NeuroScience (study of the nervous system) unit. In addition, the patient's plan of care included risk of injuries related to falls. Review of the nurse's notes also revealed that the patient was placed on fall precautions which included, bed in lowest position, side rails up times two (2), nurse call bell within reach, bed alarms on, patient's room close to the nurse's station, and patient rounds at least every two (2) hours.

Review of the physician's notes revealed the patient had fallen on hospital day #8 and that the patient's gait was unsteady. According to the nurse's notes, the patient was confused. At 10:14 p.m., the nurse documented in the nurse's notes that the patient had attempted to get out of bed without calling for assistance and that an order had been obtained to apply a posey vest restraint for the patient's safety. On hospital days #9 through #13, physician orders revealed the patient was to be on 1:1 monitoring.

On hospital day #14 at 1:00 a.m., the nurse noted that the patient was awake, oriented to person, confused but followed commands, and had full lower extremity movement. At 1:20 a.m., the nurse noted that the patient was sitting on the side of the bed watching television. The nurse also noted that the patient seemed confused and kept asking "who put me in here, is it my sister?" The nurse documented that he/she informed the patient that the patient had been admitted in order to get better. A late entry entered at 6:59 a.m., indicated that between 1:30 a.m. and 2:00 a.m. the nurse was making rounds and noticed that the patient's 11th floor window was open. The nurse documented that he/she and the Charge Nurse, who had been at the nurse's station, could not find the patient in the patient's room or bathroom. He/she looked out the window and saw the patient's body on the street. The nurse noted that the physician, Security Officer, and Nursing Administrator were notified. There was no documentation in the patient's medical record except by the physician on hospital day #10 that referred to the patient's sitter. There was no documented evidence of the patient having a sitter in the nurse's notes or in the patient's plan of care. There were no "Nurse to Sitter Hand-Off Communication Forms" and no "One-to-One Sitter Observation Records" in the patient's medical record.

Three (3) additional patient medical records were reviewed and revealed one (1) of three (3) patient's (#2) was ordered 1:1 observation. There was no documented evidence of the patient having a sitter in the nurse's notes or in the patient's plan of care. There were no "Nurse to Sitter Hand-Off Communication Forms" and no "One-to-One Sitter Observation Records" in the patient's medical record.

Review of the facility's policy entitled "One-to-One Sitter Observation Policy", no policy number, last revised 04/08, revealed it was the facility's policy to provide appropriate staff to meet the individualized needs of all patients. The policy stipulated that if a PGY-2 (second year resident) or Registered Nurse (RN) determined a need to provide 1:1 observation based on clinical data, potential patient safety concerns, or unique patient care needs such as non-accidental trauma, potential danger to self or others, a request for "sitter" support would be facilitated through the facility's staffing office. According to the policy, the purpose was to provide a physical, social, and cultural environment that utilized sitters in clinically appropriate and adequately justified situations in order to provide for the health and safety of the patient. The policy specified that the use of sitters would be a temporary nursing intervention that could be used to protect patients from harming themselves, others, or interfering with medical treatment. The policy defined a sitter as an employee designated to provide continuous observation of a patient while maintaining a safe environment. According to the policy, the Senior Vice President and Chief Nursing Officer, Patient Care, Vice President - Patient Care, Directors, Clinical Managers, and Supervisors were responsible for nursing compliance with this policy and for ensuring that staff were available to function as sitters. The policy required that a RN would modify the patient's plan of care to include the use of a sitter on the Interdisciplinary Care Plan.

The facility used a "Nurse to Sitter Hand-Off Communication Form", the purpose of the sitter report sheet was to give the sitter brief, pertinent information about the patient. The form included the names of the nurse and nursing assistant assigned to the patient. The nurse was to complete the form and give the sitter a verbal report. In addition, the sitter was required to complete the "One-to-One Sitter Observation Record" which required the sitter to document the patient's activity and their initials every 30 minutes .

Review of the facility's policy entitled, "Clinical Scope of Care & Services", Plan Year: 2011/2012, Description/Location of Department/Unit, Neurology - (11A), revealed staffing was to be based upon workload that was defined by volume and acuity. The policy required a core staffing plan to be budgeted for each year. The policy indicated that a supplementary staffing of pool nurses were to augment call outs and increased workloads.

Review of Unit 11A's staffing revealed the following shifts were understaffed for 20 of 21 shifts or 95% of the time from 9/01/2011 through 9/07/2011.

Review of the facility's policy entitled "Interdisciplinary", no policy number, last revised 02/10, revealed the RN and/or other members of the interdisciplinary team were to review, revise, and update the plan and goals for care, treatment, and services based on the patient's needs.

Review of the facility's policy entitled "Fall Injury Prevention and Management Policy", no policy number, last revised 11/10, revealed the purpose of the policy was to ensure the prevention and management of falls within the facility, to ensure that all staff understood and adhered to the procedures related to fall prevention, and to ensure that staff members would perform on-going surveillance activities as appropriate.

The facility's "Physiologic Monitoring/Hygiene/Comfort Management Protocol", no protocol number and no date, revealed staff were to use the two (2) upper side rails only as needed to protect patients from falls. In addition, staff were to make rounds every two (2) hours and/ or as required by the standard of care and/or protocol, and set equipment alarms to the loudest setting.

The facility's "Fall/Injury Prevention Protocol", no protocol number, sent for review and approval 07/11, revealed this protocol was to be implemented on all patients at risk for falls. This protocol required staff to perform daily/shift assessments which included the patient's neurological, psychological, and musculoskeletal status.

During a telephone interview at 1:05 p.m. on 09/08/11 in the conference room, the Certified Nursing Assistant (CNA - interview #3) stated that he/she checked the patient's glucose (blood sugar) level at 9:00 p.m. on hospital day #13. The CNA also stated that about 11:00 p.m. he/she found the patient asleep when he/she went to check the patient's vital signs (temperature, pulse, respirations, and blood pressure). The CNA stated that at 12:00 a.m. on hospital day #14 he/she checked on the patient and that the patient was asleep. The CNA further stated that the patient did not have a sitter at that time.

During a telephone interview at 1:15 p.m. on 09/08/11 in the conference room, the RN (interview #4) assigned to care for the patient on hospital day #13 from 11:00 p.m. until hospital day #14 at 7:00 a.m. stated that the patient did have a sitter until 11:30 p.m. The RN explained that there were no available sitters for the 11:00 p.m. to 7:00 a.m. shift and that the staff were going to check on the patient as often as possible. The nurse stated that he/she went into the patient's room between 1:00 a.m. and 2:00 a.m. and that the patient had been watching television. The nurse stated that around 1:50 a.m. he/she went to the patient's room to check on the patient and found that the patient was not in the room or bathroom. The RN explained that he/she and the Charge Nurse (CN) noticed that the patient's window was open, looked out of the window, and saw something on the street. The nurse stated that after he/she and the CN went downstairs and found the patient's body on the street. The physician, Administrator- on-duty, and the Security Officer were notified. The nurse also stated that the patient had been ambulatory that evening and that the physician had ordered 1:1 monitoring of the patient.

During a telephone interview at 1:30 p.m. on 09/08/11 in the conference room, the CN (interview #5) stated that the patient was suppose to have had a sitter but that there had not been any available. The CN stated he/she had four (4) patients and was sitting at the nurse's station charting around 1:00 a.m. to 1:30 a.m. The CN also stated that Unit 11A had a unit secretary that usually sat at the nursing station but that the secretary had been covering additional units. According to the CN the patient in room 11A18 had also had 1:1 monitoring ordered but did not have a sitter. The CN stated that around 2:00 a.m. the patient in room 11A18 came out of his/her room and nearly fell. The CN explained that he/she took the patient back to room 11A18 and put the patient in bed and gave the patient a snack and some juice. The CN stated, "when I got back to the nurse's station, patient #1's nurse informed me that the patient was not in his/her room or bathroom." The CN further stated that he/she and the patient's nurse noticed that the patient's window was opened, looked out and saw something on the ground, went down and found the patient's body on the street. The CN stated that they had then notified the physician, Administrator on duty, Unit Manager, and Security Officer. The CN stated that earlier in the evening the patient had walked in the hall with the sitter and that the patient's gait had been steady. The CN explained that around 1:00 a.m. the patient had been sitting in a chair by the closet. The CN stated that sitters were required to fill out a monitoring form when they sat with patients.

The following corrective actions were taken by the facility:

Maintenance Department

09/06/11 - A meeting was held to detail the protocol for facility-wide inpatient room window assessment.

The facility's Management staff was deployed throughout the facility to assess all operable windows in inpatient rooms to include checking each window for locked and unlocked condition, unlocking the window, opening the window, checking the window restrictor arm, closing the window, ensuring that all factory locking points were locked, installing two (2) 2 1/2 inch hex screws to the bottom of the window frame, and documenting findings.

09/07/11 - Standard screws were replaced with tamper proof screws in all patient care and non-patient care areas on all operable windows.

Results of the operable window survey found that the facility had 566 operable windows, 21 (3.54%) of the windows were found unlocked upon inspection, one (1) retractor arm (in the patient's room) was found broken.

Nursing Department's corrective actions:

Lack of sitter/staff coverage - 09/06/11 - The Chief Nursing Officer (CNO)) held an emergency meeting with the Nursing Leadership Team (NLT), reviewed sitter policy and compliance to policy.

The Unit Directors immediately added staff (additional clerk on days and an additional NA on nights) to the medical-surgical units.

The CNO immediately authorized overtime for unlicensed staff to work as sitters.

The 11A Unit Director instructed his/her staff to notify him/her when or if there were any potential opportunity where the sitter needs were not met/filled.

09/07/11 - The Unit Director of Nurse Staffing reviewed sitter expectations with staffing specialists.

09/08/11 - The staffing specialist was informed to alert the unit Director/Health System Administrators four (4) hours prior to the shift if unable to fill sitter needs.

The Unit Director of Staffing Office is to provide education and training sessions for sitters regarding safety and compliance to sitter documentation logs.

The CNO authorized the increase in NA positions on the unit and the positions were to be posted on 09/09/11. The posting of open RN and LPN positions was to continue to be ongoing.

Monitoring and Documentation: "Nurse to Sitter Handoff "form and "Sitter Report Sheets" missing:

09/06/11 - The Unit Director of Staffing Office is responsible for verifying sitter competencies, guidelines, and appropriate documentation in files.

09/06/11 through 09/08/11 - The 11A Unit Director held shift huddles for every shift to cover: 1. Documentation in real time; 2. Completion of rounding sheets; 3. Timely vital signs; and 4. NA (nursing assistant) documentation of assistance with daily living (bath and grooming for example), intake and outputs, and the Rounding Logs.

09/07/11 - The Nursing Executive Council (NEC) approved walking rounds; shift report at the bedside policy and expectations communicated. E-mailed to Nursing Leadership distribution list on 09/08/11.

The NEC reviewed and updated Daily Rounding for Excellence and Compliance Nursing Leader checklist. E-mailed to Nursing Leadership distribution list on 09/08/11.

09/08/11 - The NEC reviewed the two (2) hour Rounding Log for the four (4) Ps (potty, pain, position, and periphery/surroundings). E-mailed to Nursing Leadership distribution list 09/08/11.

09/08/11 - Process changed so that sitters now receive the 1:1 Sitter Observation Record from the staffing office when their assignment has been made, instead of from the CN on the unit.

The Unit Director of Nursing Staffing will revise sitter log from every 30 minutes observation documentation to every 15 minutes observations.

Process changed so that sitters now receive the Nurse to Sitter Hand -Off Communication form from the staffing office where their assignments are made, instead of from the CN on the unit.

The communication expectations that the sitter will now leave the 1:1 Sitter Observation Record and the Nurse to Sitter Hand-Off Communication form with the CN on the units rather than returning the forms to the staffing office.

09/07/11 and 09/08/11 - The Unit Director held staff meetings and covered: 1. Documentation in real time in the electronic medical record at the bedside; 2. Staff accountability, including sitters; 3. Supporting and working as a team; 4. Ensuring completion of the Sitter Logs; and 5. Completion of two (2) hour Rounding Logs.

Based on review of medical records, policies and procedures, the "Nurse to Sitter Hand-Off Communication Form", the "One-to-One Sitter Observation Record", Unit 11A's staffing from 09/01/11 through 09/07/11, protocols, staff interviews, and the Nursing Department's corrective action plan, the facility failed to have an adequate number of nursing staff available to provide 1:1 monitoring for 2 of 4 sampled patient's medical records (#1 and #2).
Cross refer to A0386.

Based on review of medical records, policies and procedures, the "Nurse to Sitter Hand-Off Communication Form", the "One-to-One Sitter Observation Record", Unit 11A's staffing from 09/01/11 through 09/07/11, protocols, staff interviews, and the Nursing Department's corrective action plan, the facility failed to have an adequate number of nursing staff available to provide 1:1 monitoring for 2 of 4 sampled patient's medical records (#1 and #2). Cross refer to A0392.

Based on review of medical records, policies and procedures, the "Nurse to Sitter Hand-Off Communication Form", the "One-to-One Sitter Observation Record", Unit 11A's staffing from 09/01/11 through 09/07/11, protocols, staff interviews, and the Nursing Department's corrective action plan, the facility failed to ensure that patient care plans were updated as the patients conditions changed for 2 of 4 sampled patient's medical records (#1 and #2). Cross refer to A0396.

Based on review of medical records, policies and procedures, the "Nurse to Sitter Hand-Off Communication Form", the "One-to-One Sitter Observation Record", Unit 11A's staffing from 09/01/11 through 09/07/11, protocols, staff interviews, and the Nursing Department's corrective action plan, it was determined that the facility failed to ensure that patient care assignments were made according to physician's orders for 2 of 4 sampled patient's medical records (#1 and #2). Cross refer to A0397.

Based on review of medical records, policies and procedures, the "Nurse to Sitter Hand-Off Communication Form", the "One-to-One Sitter Observation Record", Unit 11A's staffing from 09/01/11 through 09/07/11, protocols, staff interviews,and the Nursing Department's corrective action plan, the facility failed to have an adequate number of nursing staff available to provide 1:1 monitoring for 2 of 4 sampled patient's medical records (#1 and #2).

Findings were:


Review of 1 of 4 sampled patient's medical records (#1) revealed the patient was admitted to the facility to receive treatment for seizures and alcohol withdrawal. A plan of care was initiated upon admission (hospital day #1) and updated on hospital days #2, #3, #4, #5, #11, #12, and #13. The patient's plan of care included risk of injuries related to seizures. Review of the nurse's notes revealed the patient was placed on seizure precautions, was to receive anti-convulsant medications, was to have his/her neurological status monitored, and was to be placed on the long term video monitor while in the intensive care unit and while on the 8th floor NeuroScience (study of the nervous system) unit. In addition, the patient's plan of care included risk of injuries related to falls. Review of the nurse's notes also revealed that the patient was placed on fall precautions which included, bed in lowest position, side rails up times two (2), nurse call bell within reach, bed alarms on, patient's room close to the nurse's station, and patient rounds at least every two (2) hours.

Review of the physician's notes revealed the patient had fallen on hospital day #8 and that the patient's gait was unsteady. According to the nurse's notes, the patient was confused. At 10:14 p.m., the nurse documented in the nurse's notes that the patient had attempted to get out of bed without calling for assistance and that an order had been obtained to apply a posey vest restraint for the patient's safety. On hospital days #9 through #13, physician orders revealed the patient was to be on 1:1 monitoring.

On hospital day #14 at 1:00 a.m., the nurse noted that the patient was awake, oriented to person, confused but followed commands, and had full lower extremity movement. At 1:20 a.m., the nurse noted that the patient was sitting on the side of the bed watching television. The nurse also noted that the patient seemed confused and kept asking "who put me in here, is it my sister?" The nurse documented that he/she informed the patient that the patient had been admitted in order to get better. A late entry entered at 6:59 a.m., indicated that between 1:30 a.m. and 2:00 a.m. the nurse was making rounds and noticed that the patient's 11th floor window was open. The nurse documented that he/she and the Charge Nurse, who had been at the nurse's station, could not find the patient in the patient's room or bathroom. He/she looked out the window and saw the patient's body on the street. The nurse noted that the physician, Security Officer, and Nursing Administrator were notified. There was no documentation in the patient's medical record except by the physician on hospital day #10 that referred to the patient's sitter. There was no documented evidence of the patient having a sitter in the nurse's notes or in the patient's plan of care. There were no "Nurse to Sitter Hand-Off Communication Forms" and no "One-to-One Sitter Observation Records" in the patient's medical record.

Three (3) additional patient medical records were reviewed and revealed one (1) of three (3) patient's (#2) was ordered 1:1 observation. There was no documented evidence of the patient having a sitter in the nurse's notes or in the patient's plan of care. There were no "Nurse to Sitter Hand-Off Communication Forms" and no "One-to-One Sitter Observation Records" in the patient's medical record.

Review of the facility's policy entitled "One-to-One Sitter Observation Policy", no policy number, last revised 04/08, revealed it was the facility's policy to provide appropriate staff to meet the individualized needs of all patients. The policy stipulated that if a PGY-2 (second year resident) or Registered Nurse (RN) determined a need to provide 1:1 observation based on clinical data, potential patient safety concerns, or unique patient care needs such as non-accidental trauma, potential danger to self or others, a request for "sitter" support would be facilitated through the facility's staffing office. According to the policy, the purpose was to provide a physical, social, and cultural environment that utilized sitters in clinically appropriate and adequately justified situations in order to provide for the health and safety of the patient. The policy specified that the use of sitters would be a temporary nursing intervention that could be used to protect patients from harming themselves, others, or interfering with medical treatment. The policy defined a sitter as an employee designated to provide continuous observation of a patient while maintaining a safe environment. According to the policy, the Senior Vice President and Chief Nursing Officer, Patient Care, Vice President - Patient Care, Directors, Clinical Managers, and Supervisors were responsible for nursing compliance with this policy and for ensuring that staff were available to function as sitters. The policy required that a RN would modify the patient's plan of care to include the use of a sitter on the Interdisciplinary Care Plan.

The facility used a "Nurse to Sitter Hand-Off Communication Form", the purpose of the sitter report sheet was to give the sitter brief, pertinent information about the patient. The form included the names of the nurse and nursing assistant assigned to the patient. The nurse was to complete the form and give the sitter a verbal report. In addition, the sitter was required to complete the "One-to-One Sitter Observation Record" which required the sitter to document the patient's activity and their initials every 30 minutes.

Review of the facility's policy entitled, "Clinical Scope of Care & Services", Plan Year: 2011/2012, Description/Location of Department/Unit, Neurology - (11A), revealed staffing was to be based upon workload that was defined by volume and acuity. The policy required a core staffing plan to be budgeted for each year. The policy indicated that a supplementary staffing of pool nurses were to augment call outs and increased workloads.

Review of Unit 11A's staffing revealed the following shifts were understaffed for 20 of 21 shifts or 95% of the time from 9/01/2011 through 9/07/2011.

Review of the facility's policy entitled "Interdisciplinary", no policy number, last revised 02/10, revealed the RN and/or other members of the interdisciplinary team were to review, revise, and update the plan and goals for care, treatment, and services based on the patient's needs.

During a telephone interview at 1:05 p.m. on 09/08/11 in the conference room, the Certified Nursing Assistant (CNA - interview #3) stated that he/she checked the patient's glucose (blood sugar) level at 9:00 p.m. on hospital day #13. The CNA also stated that about 11:00 p.m. he/she found the patient asleep when he/she went to check the patient's vital signs (temperature, pulse, respirations, and blood pressure). The CNA stated that at 12:00 a.m. on hospital day #14 he/she checked on the patient and that the patient was asleep. The CNA further stated that the patient did not have a sitter at that time.

During a telephone interview at 1:15 p.m. on 09/08/11 in the conference room, the RN (interview #4) assigned to care for the patient on hospital day #13 from 11:00 p.m. until hospital day #14 at 7:00 a.m. stated that the patient did have a sitter until 11:30 p.m. The RN explained that there were no available sitters for the 11:00 p.m. to 7:00 a.m. shift and that the staff were going to check on the patient as often as possible. The nurse stated that he/she went into the patient's room between 1:00 a.m. and 2:00 a.m. and that the patient had been watching television. The nurse stated that around 1:50 a.m. he/she went to the patient's room to check on the patient and found that the patient was not in the room or bathroom. The RN explained that he/she and the Charge Nurse (CN) noticed that the patient's window was open, looked out of the window, and saw something on the street. The nurse stated that after he/she and the CN went downstairs and found the patient's body on the street. The physician, Administrator-on-duty, and the Security Officer were notified. The nurse also stated that the patient had been ambulatory that evening and that the physician had ordered 1:1 monitoring of the patient.

During a telephone interview at 1:30 p.m. on 09/08/11 in the conference room, the CN (interview #5) stated that the patient was suppose to have had a sitter but that there had not been any available. The CN stated he/she had four (4) patients and was sitting at the nurse's station charting around 1:00 a.m. to 1:30 a.m. The CN also stated that Unit 11A had a unit secretary that usually sat at the nursing station but that the secretary had been covering additional units. According to the CN the patient in room 11A 18 had also had 1:1 monitoring ordered but did not have a sitter. The CN stated that around 2:00 a.m. the patient in room 11A 18 came out of his/her room and nearly fell. The CN explained that he/she took the patient back to room 11A18 and put the patient in bed and gave the patient a snack and some juice. The CN stated, "when I got back to the nurse's station, patient #1's nurse informed me that the patient was not in his/her room or bathroom." The CN further stated that he/she and the patient's nurse noticed that the patient's window was opened, looked out and saw something on the ground, went down and found the patient's body on the street. The CN stated that they had then notified the physician, Administrator on duty, Unit Manager, and Security Officer. The CN stated that earlier in the evening the patient had walked in the hall with the sitter and that the patient's gait had been steady. The CN explained that around 1:00 a.m. the patient had been sitting in a chair by the closet. The CN stated that sitters were required to fill out a monitoring form when they sat with patients.


The following corrective action was taken by the facility:

Lack of sitter/staff coverage - 09/06/11 - The Chief Nursing Officer (CNO)) held an emergency meeting with the Nursing Leadership Team (NLT), reviewed sitter policy and compliance to policy.

The Unit Directors immediately added staff (additional clerk on days and an additional NA on nights) to the medical-surgical units.

The CNO immediately authorized overtime for unlicensed staff to work as sitters.

The 11A Unit Director instructed his/her staff to notify him/her when or if there were any potential opportunity where the sitter needs were not met/filled.

09/07/11 - The Unit Director of Nurse Staffing reviewed sitter expectations with staffing specialists.

09/08/11 - The staffing specialist was informed to alert the unit Director/Health System Administrators four (4) hours prior to the shift if unable to fill sitter needs.

The Unit Director of Staffing Office is to provide education and training sessions for sitters regarding safety and compliance to sitter documentation logs.

The CNO authorized the increase in NA positions on the unit and the positions were to be posted on 09/09/11. The posting of open RN and LPN positions was to continue to be ongoing.

Monitoring and Documentation: "Nurse to Sitter Handoff "form and "Sitter Report Sheets" missing:

09/06/11 - The Unit Director of Staffing Office verifying sitter competencies, guidelines, and appropriate documentation in files.

09/06/11 through 09/08/11 - The 11A Unit Director held shift huddles for every shift to cover: 1. Documentation in real time; 2. Completion of rounding sheets; 3. Timely vital signs; and 4. NA (nursing assistant) documentation of assistance with daily living (bath and grooming for example), intake and outputs, and the Rounding Logs.

09/07/11 - The Nursing Executive Council (NEC) approved walking rounds; shift report at the bedside policy and expectations communicated. E-mailed to Nursing Leadership distribution list on 09/08/11.

The NEC reviewed and updated Daily Rounding for Excellence and Compliance Nursing Leader checklist. E-mailed to Nursing Leadership distribution list on 09/08/11.

09/08/11 - The NEC reviewed the two (2) hour Rounding Log for the four (4) Ps (potty, pain, position, and periphery/surroundings). E-mailed to Nursing Leadership distribution list 09/08/11.

09/08/11 - Process changed so that sitters now receive the 1:1 Sitter Observation Record from the staffing office when their assignment has been made, instead of from the CN on the unit.

The Unit Director of Nursing Staffing will revise sitter log from every 30 minutes observation documentation to every 15 minutes observations.

Process changed so that sitters now receive the Nurse to Sitter Hand -Off Communication form from the staffing office where their assignments are made, instead of from the CN on the unit.

The communication expectations that the sitter will now leave the 1:1 Sitter Observation Record and the Nurse to Sitter Hand-Off Communication form with the CN on the units rather than returning the forms to the staffing office.

09/07/11 and 09/08/11 - The Unit Director held staff meetings and covered: 1. Documentation in real time in the electronic medical record at the bedside; 2. Staff accountability, including sitters; 3. Supporting and working as a team; 4. Ensuring completion of the Sitter Logs; and 5. Completion of two (2) hour Rounding Logs.

Based on review of medical records, policies and procedures, the "Nurse to Sitter Hand-Off Communication Form", the "One-to-One Sitter Observation Record," Unit 11A's staffing from 09/01/11 through 09/07/11, protocols, staff interviews, and the Nursing Department's corrective action plan, the facility failed to have an adequate number of nursing staff available to provide 1:1 monitoring for 2 of 4 sampled patient's medical records (#1 and #2).

Findings were:


Review of 1 of 4 sampled patient's medical records (#1) revealed the patient was admitted to the facility to receive treatment for seizures and alcohol withdrawal. A plan of care was initiated upon admission (hospital day #1) and updated on hospital days #2, #3, #4, #5, #11, #12, and #13. The patient's plan of care included risk of injuries related to seizures. Review of the nurse's notes revealed the patient was placed on seizure precautions, was to receive anti-convulsant medications, was to have his/her neurological status monitored, and was to be placed on the long term video monitor while in the intensive care unit and while on the 8th floor NeuroScience (study of the nervous system) unit. In addition, the patient's plan of care included risk of injuries related to falls. Review of the nurse's notes also revealed that the patient was placed on fall precautions which included, bed in lowest position, side rails up times two (2), nurse call bell within reach, bed alarms on, patient's room close to the nurse's station, and patient rounds at least every two (2) hours.

Review of the physician's notes revealed the patient had fallen on hospital day #8 and that the patient's gait was unsteady. According to the nurse's notes, the patient was confused. At 10:14 p.m., the nurse documented in the nurse's notes that the patient had attempted to get out of bed without calling for assistance and that an order had been obtained to apply a posey vest restraint for the patient's safety. On hospital days #9 through #13, physician orders revealed the patient was to be on 1:1 monitoring.

On hospital day #14 at 1:00 a.m., the nurse noted that the patient was awake, oriented to person, confused but followed commands, and had full lower extremity movement. At 1:20 a.m., the nurse noted that the patient was sitting on the side of the bed watching television. The nurse also noted that the patient seemed confused and kept asking "who put me in here, is it my sister?" The nurse documented that he/she informed the patient that the patient had been admitted in order to get better. A late entry entered at 6:59 a.m., indicated that between 1:30 a.m. and 2:00 a.m. the nurse was making rounds and noticed that the patient's 11th floor window was open. The nurse documented that he/she and the Charge Nurse, who had been at the nurse's station, could not find the patient in the patient's room or bathroom. He/she looked out the window and saw the patient's body on the street. The nurse noted that the physician, Security Officer, and Nursing Administrator were notified. There was no documentation in the patient's medical record except by the physician on hospital day #10 that referred to the patient's sitter. There was no documented evidence of the patient having a sitter in the nurse's notes or in the patient's plan of care. There were no "Nurse to Sitter Hand-Off Communication Forms" and no "One-to-One Sitter Observation Records" in the patient's medical record.

Three (3) additional patient medical records were reviewed and revealed one (1) of three (3) patient's (#2) was ordered 1:1 observation. There was no documented evidence of the patient having a sitter in the nurse's notes or in the patient's plan of care. There were no "Nurse to Sitter Hand-Off Communication Forms" and no "One-to-One Sitter Observation Records" in the patient's medical record.

Review of the facility's policy entitled "One-to-One Sitter Observation Policy", no policy number, last revised 04/08, revealed it was the facility's policy to provide appropriate staff to meet the individualized needs of all patients. The policy stipulated that if a PGY-2 (second year resident) or Registered Nurse (RN) determined a need to provide 1:1 observation based on clinical data, potential patient safety concerns, or unique patient care needs such as non-accidental trauma, potential danger to self or others, a request for "sitter" support would be facilitated through the facility's staffing office. According to the policy, the purpose was to provide a physical, social, and cultural environment that utilized sitters in clinically appropriate and adequately justified situations in order to provide for the health and safety of the patient. The policy specified that the use of sitters would be a temporary nursing intervention that could be used to protect patients from harming themselves, others, or interfering with medical treatment. The policy defined a sitter as an employee designated to provide continuous observation of a patient while maintaining a safe environment. According to the policy, the Senior Vice President and Chief Nursing Officer, Patient Care, Vice President - Patient Care, Directors, Clinical Managers, and Supervisors were responsible for nursing compliance with this policy and for ensuring that staff were available to function as sitters. The policy required that a RN would modify the patient's plan of care to include the use of a sitter on the Interdisciplinary Care Plan.

The facility used a "Nurse to Sitter Hand-Off Communication Form", the purpose of the sitter report sheet was to give the sitter brief, pertinent information about the patient. The form included the names of the nurse and nursing assistant assigned to the patient. The nurse was to complete the form and give the sitter a verbal report. In addition, the sitter was required to complete the "One-to-One Sitter Observation Record" which required the sitter to document the patient's activity and their initials every 30 minutes .

Review of the facility's policy entitled, "Clinical Scope of Care & Services", Plan Year: 2011/2012, Description/Location of Department/Unit, Neurology - (11A), revealed staffing was to be based upon workload that was defined by volume and acuity. The policy required a core staffing plan to be budgeted for each year. The policy indicated that a supplementary staffing of pool nurses were to augment call outs and increased workloads.

Review of Unit 11A's staffing revealed the following shifts were understaffed for 20 of 21 shifts or 95% of the time from 9/01/2011 through 9/07/2011.

Review of the facility's policy entitled "Interdisciplinary", no policy number, last revised 02/10, revealed the RN and/or other members of the interdisciplinary team were to review, revise, and update the plan and goals for care, treatment, and services based on the patient's needs.

During a telephone interview at 1:05 p.m. on 09/08/11 in the conference room, the Certified Nursing Assistant (CNA - interview #3) stated that he/she checked the patient's glucose (blood sugar) level at 9:00 p.m. on hospital day #13. The CNA also stated that about 11:00 p.m. he/she found the patient asleep when he/she went to check the patient's vital signs (temperature, pulse, respirations, and blood pressure). The CNA stated that at 12:00 a.m. on hospital day #14 he/she checked on the patient and that the patient was asleep. The CNA further stated that the patient did not have a sitter at that time.

During a telephone interview at 1:15 p.m. on 09/08/11 in the conference room, the RN (interview #4) assigned to care for the patient on hospital day #13 from 11:00 p.m. until hospital day #14 at 7:00 a.m. stated that the patient did have a sitter until 11:30 p.m. The RN explained that there were no available sitters for the 11:00 p.m. to 7:00 a.m. shift and that the staff were going to check on the patient as often as possible. The nurse stated that he/she went into the patient's room between 1:00 a.m. and 2:00 a.m. and that the patient had been watching television. The nurse stated that around 1:50 a.m. he/she went to the patient's room to check on the patient and found that the patient was not in the room or bathroom. The RN explained that he/she and the Charge Nurse (CN) noticed that the patient's window was open, looked out of the window, and saw something on the street. The nurse stated that after he/she and the CN went downstairs and found the patient's body on the street. The physician, Administrator-on-duty, and the Security Officer were notified. The nurse also stated that the patient had been ambulatory that evening and that the physician had ordered 1:1 monitoring of the patient.

During a telephone interview at 1:30 p.m. on 09/08/11 in the conference room, the CN (interview #5) stated that the patient was suppose to have had a sitter but that there had not been any available. The CN stated he/she had four (4) patients and was sitting at the nurse's station charting around 1:00 a.m. to 1:30 a.m. The CN also stated that Unit 11A had a unit secretary that usually sat at the nursing station but that the secretary had been covering additional units. According to the CN the patient in room 11A18 had also had 1:1 monitoring ordered but did not have a sitter. The CN stated that around 2:00 a.m. the patient in room 11A18 came out of his/her room and nearly fell. The CN explained that he/she took the patient back to room 11A18 and put the patient in bed and gave the patient a snack and some juice. The CN stated, "when I got back to the nurse's station, patient #1's nurse informed me that the patient was not in his/her room or bathroom." The CN further stated that he/she and the patient's nurse noticed that the patient's window was opened, looked out and saw something on the ground, went down and found the patient's body on the street. The CN stated that they had then notified the physician, Administrator-on-duty, Unit Manager, and Security Officer. The CN stated that earlier in the evening the patient had walked in the hall with the sitter and that the patient's gait had been steady. The CN explained that around 1:00 a.m. the patient had been sitting in a chair by the closet. The CN stated that sitters were required to fill out a monitoring form when they sat with patients.


The following corrective action was taken by the facility:

Lack of sitter/staff coverage - 09/06/11 - The Chief Nursing Officer (CNO)) held an emergency meeting with the Nursing Leadership Team (NLT), reviewed sitter policy and compliance to policy.

The Unit Directors immediately added staff (additional clerk on days and an additional NA on nights) to the medical-surgical units.

The CNO immediately authorized overtime for unlicensed staff to work as sitters.

The 11A Unit Director instructed his/her staff to notify him/her when or if there were any potential opportunity where the sitter needs were not met/filled.

09/07/11 - The Unit Director of Nurse Staffing reviewed sitter expectations with staffing specialists.

09/08/11 - The staffing specialist was informed to alert the unit Director/Health System Administrators four (4) hours prior to the shift if unable to fill sitter needs.

The Unit Director of Staffing Office is to provide education and training sessions for sitters regarding safety and compliance to sitter documentation logs.

The CNO authorized the increase in NA positions on the unit and the positions were to be posted on 09/09/11. The posting of open RN and LPN positions was to continue to be ongoing.

Monitoring and Documentation: "Nurse to Sitter Handoff "form and "Sitter Report Sheets" missing:

09/06/11 - The Unit Director of Staffing Office verifying sitter competencies, guidelines, and appropriate documentation in files.

09/06/11 through 09/08/11 - The 11A Unit Director held shift huddles for every shift to cover: 1. Documentation in real time; 2. Completion of rounding sheets; 3. Timely vital signs; and 4. NA (nursing assistant) documentation of assistance with daily living (bath and grooming for example), intake and outputs, and the Rounding Logs.

09/07/11 - The Nursing Executive Council (NEC) approved walking rounds; shift report at the bedside policy and expectations communicated. E-mailed to Nursing Leadership distribution list on 09/08/11.

The NEC reviewed and updated Daily Rounding for Excellence and Compliance Nursing Leader checklist. E-mailed to Nursing Leadership distribution list on 09/08/11.

09/08/11 - The NEC reviewed the two (2) hour Rounding Log for the four (4) Ps (potty, pain, position, and periphery/surroundings). E-mailed to Nursing Leadership distribution list 09/08/11.

09/08/11 - Process changed so that sitters now receive the 1:1 Sitter Observation Record from the staffing office when their assignment has been made, instead of from the CN on the unit.

The Unit Director of Nursing Staffing will revise sitter log from every 30 minutes observation documentation to every 15 minutes observations.

Process changed so that sitters now receive the Nurse to Sitter Hand -Off Communication form from the staffing office where their assignments are made, instead of from the CN on the unit.

The communication expectations that the sitter will now leave the 1:1 Sitter Observation Record and the Nurse to Sitter Hand-Off Communication form with the CN on the units rather than returning the forms to the staffing office.

09/07/11 and 09/08/11 - The Unit Director held staff meetings and covered: 1. Documentation in real time in the electronic medical record at the bedside; 2. Staff accountability, including sitters; 3. Supporting and working as a team; 4. Ensuring completion of the Sitter Logs; and 5. Completion of two (2) hour Rounding Logs.

Based on review of medical records, policies and procedures, the "Nurse to Sitter Hand-Off Communication Form", the "One-to-One Sitter Observation Record", Unit 11A's staffing from 09/01/11 through 09/07/11, protocols, staff interviews, and the Nursing Department's corrective action plan, the facility failed to ensure that patient care plans were updated as patient's conditions changed for 2 of 4 sampled patient's medical records (#1 and #2).

Findings were:

Review of 1 of 4 sampled patient's medical records (#1) revealed the patient was admitted to the facility to receive treatment for seizures and alcohol withdrawal. A plan of care was initiated upon admission (hospital day #1) and updated on hospital days #2, #3, #4, #5, #11, #12, and #13. The patient's plan of care included risk of injuries related to seizures. Review of the nurse's notes revealed the patient was placed on seizure precautions, was to receive anti-convulsant medications, was to have his/her neurological status monitored, and was to be placed on the long term video monitor while in the intensive care unit and while on the 8th floor NeuroScience (study of the nervous system) unit. In addition, the patient's plan of care included risk of injuries related to falls. Review of the nurse's notes also revealed that the patient was placed on fall precautions which included, bed in lowest position, side rails up times two (2), nurse call bell within reach, bed alarms on, patient's room close to the nurse's station, and patient rounds at least every two (2) hours.

Review of the physician's notes revealed the patient had fallen on hospital day #8 and that the patient's gait was unsteady. According to the nurse's notes, the patient was confused. At 10:14 p.m., the nurse documented in the nurse's notes that the patient had attempted to get out of bed without calling for assistance and that an order had been obtained to apply a posey vest restraint for the patient's safety. On hospital days #9 through #13, physician orders revealed the patient was to be on 1:1 monitoring.

On hospital day #14 at 1:00 a.m., the nurse noted that the patient was awake, oriented to person, confused but followed commands, and had full lower extremity movement. At 1:20 a.m., the nurse noted that the patient was sitting on the side of the bed watching television. The nurse also noted that the patient seemed confused and kept asking "who put me in here, is it my sister?" The nurse documented that he/she informed the patient that the patient had been admitted in order to get better. A late entry entered at 6:59 a.m., indicated that between 1:30 a.m. and 2:00 a.m. the nurse was making rounds and noticed that the patient's 11th floor window was open. The nurse documented that he/she and the Charge Nurse, who had been at the nurse's station, could not find the patient in the patient's room or bathroom. He/she looked out the window and saw the patient's body on the street. The nurse noted that the physician, Security Officer, and Nursing Administrator were notified. There was no documentation in the patient's medical record except by the physician on hospital day #10 that referred to the patient's sitter. There was no documented evidence of the patient having a sitter in the nurse's notes or in the patient's plan of care. There were no "Nurse to Sitter Hand-Off Communication Forms" and no "One-to-One Sitter Observation Records" in the patient's medical record.

Three (3) additional patient medical records were reviewed and revealed one (1) of three (3) patient's (#2) was ordered 1:1 observation. There was no documented evidence of the patient having a sitter in the nurse's notes or in the patient's plan of care. There were no "Nurse to Sitter Hand-Off Communication Forms" and no "One-to-One Sitter Observation Records" in the patient's medical record.

Review of the facility's policy entitled "One-to-One Sitter Observation Policy", no policy number, last revised 04/08, revealed it was the facility's policy to provide appropriate staff to meet the individualized needs of all patients. The policy stipulated that if a PGY-2 (second year resident) or Registered Nurse (RN) determined a need to provide 1:1 observation based on clinical data, potential patient safety concerns, or unique patient care needs such as non-accidental trauma, potential danger to self or others, a request for "sitter" support would be facilitated through the facility's staffing office. According to the policy, the purpose was to provide a physical, social, and cultural environment that utilized sitters in clinically appropriate and adequately justified situations in order to provide for the health and safety of the patient. The policy specified that the use of sitters would be a temporary nursing intervention that could be used to protect patients from harming themselves, others, or interfering with medical treatment. The policy defined a sitter as an employee designated to provide continuous observation of a patient while maintaining a safe environment. According to the policy, the Senior Vice President and Chief Nursing Officer, Patient Care, Vice President - Patient Care, Directors, Clinical Managers, and Supervisors were responsible for nursing compliance with this policy and for ensuring that staff were available to function as sitters. The policy required that a RN would modify the patient's plan of care to include the use of a sitter on the Interdisciplinary Care Plan.

Review of the facility's policy entitled "Interdisciplinary", no policy number, last revised 02/10, revealed the RN and/or other members of the interdisciplinary team were to review, revise, and update the plan and goals for care, treatment, and services based on the patient's needs.

The following corrective action was taken by the facility:

Lack of sitter/staff coverage - 09/06/11 - The Chief Nursing Officer (CNO)) held an emergency meeting with the Nursing Leadership Team (NLT), reviewed sitter policy and compliance to policy.

The Unit Directors immediately added staff (additional clerk on days and an additional NA on nights) to the medical-surgical units.

The CNO immediately authorized overtime for unlicensed staff to work as sitters.

The 11A Unit Director instructed his/her staff to notify him/her when or if there were any potential opportunity where the sitter needs were not met/filled.

09/07/11 - The Unit Director of Nurse Staffing reviewed sitter expectations with staffing specialists.

09/08/11 - The staffing specialist was informed to alert the unit Director/Health System Administrators four (4) hours prior to the shift if unable to fill sitter needs.

The Unit Director of Staffing Office is to provide education and training sessions for sitters regarding safety and compliance to sitter documentation logs.

The CNO authorized the increase in NA positions on the unit and the positions were to be posted on 09/09/11. The posting of open RN and LPN positions was to continue to be ongoing.

Monitoring and Documentation: "Nurse to Sitter Handoff "form and "Sitter Report Sheets" missing:

09/06/11 - The Unit Director of Staffing Office verifying sitter competencies, guidelines, and appropriate documentation in files.

09/06/11 through 09/08/11 - The 11A Unit Director held shift huddles for every shift to cover: 1. Documentation in real time; 2. Completion of rounding sheets; 3. Timely vital signs; and 4. NA (nursing assistant) documentation of assistance with daily living (bath and grooming for example), intake and outputs, and the Rounding Logs.

09/07/11 - The Nursing Executive Council (NEC) approved walking rounds; shift report at the bedside policy and expectations communicated. E-mailed to Nursing Leadership distribution list on 09/08/11.

The NEC reviewed and updated Daily Rounding for Excellence and Compliance Nursing Leader checklist. E-mailed to Nursing Leadership distribution list on 09/08/11.

09/08/11 - The NEC reviewed the two (2) hour Rounding Log for the four (4) Ps (potty, pain, position, and periphery/surroundings). E-mailed to Nursing Leadership distribution list 09/08/11.

09/08/11 - Process changed so that sitters now receive the 1:1 Sitter Observation Record from the staffing office when their assignment has been made, instead of from the CN on the unit.

The Unit Director of Nursing Staffing will revise sitter log from every 30 minutes observation documentation to every 15 minutes observations.

Process changed so that sitters now receive the Nurse to Sitter Hand -Off Communication form from the staffing office where their assignments are made, instead of from the CN on the unit.

The communication expectations that the sitter will now leave the 1:1 Sitter Observation Record and the Nurse to Sitter Hand-Off Communication form with the CN on the units rather than returning the forms to the staffing office.

09/07/11 and 09/08/11 - The Unit Director held staff meetings and covered: 1. Documentation in real time in the electronic medical record at the bedside; 2. Staff accountability, including sitters; 3. Supporting and working as a team; 4. Ensuring completion of the Sitter Logs; and 5. Completion of two (2) hour Rounding Logs.

Based on review of medical records, policies and procedures, the "Nurse to Sitter Hand-Off Communication Form", the "One-to-One Sitter Observation Record", Unit 11A's staffing from 09/01/11 through 09/07/11, protocols, staff interviews, and the Nursing Department's corrective action plan, the facility failed to ensure that patient care assignments were made according to physician's orders for 2 of 4 sampled patient's medical records (#1 and #2).


Findings were:

Review of 1 of 4 sampled patient's medical records (#1) revealed the patient was admitted to the facility to receive treatment for seizures and alcohol withdrawal. A plan of care was initiated upon admission (hospital day #1) and updated on hospital days #2, #3, #4, #5, #11, #12, and #13. The patient's plan of care included risk of injuries related to seizures. Review of the nurse's notes revealed the patient was placed on seizure precautions, was to receive anti-convulsant medications, was to have his/her neurological status monitored, and was to be placed on the long term video monitor while in the intensive care unit and while on the 8th floor NeuroScience (study of the nervous system) unit. In addition, the patient's plan of care included risk of injuries related to falls. Review of the nurse's notes also revealed that the patient was placed on fall precautions which included, bed in lowest position, side rails up times two (2), nurse call bell within reach, bed alarms on, patient's room close to the nurse's station, and patient rounds at least every two (2) hours.

Review of the physician's notes revealed the patient had fallen on hospital day #8 and that the patient's gait was unsteady. According to the nurse's notes, the patient was confused. At 10:14 p.m., the nurse documented in the nurse's notes that the patient had attempted to get out of bed without calling for assistance and that an order had been obtained to apply a posey vest restraint for the patient's safety. On hospital days #9 through #13, physician orders revealed the patient was to be on 1:1 monitoring.

On hospital day #14 at 1:00 a.m., the nurse noted that the patient was awake, oriented to person, confused but followed commands, and had full lower extremity movement. At 1:20 a.m., the nurse noted that the patient was sitting on the side of the bed watching television. The nurse also noted that the patient seemed confused and kept asking "who put me in here, is it my sister?" The nurse documented that he/she informed the patient that the patient had been admitted in order to get better. A late entry entered at 6:59 a.m., indicated that between 1:30 a.m. and 2:00 a.m. the nurse was making rounds and noticed that the patient's 11th floor window was open. The nurse documented that he/she and the Charge Nurse, who had been at the nurse's station, could not find the patient in the patient's room or bathroom. He/she looked out the window and saw the patient's body on the street. The nurse noted that the physician, Security Officer, and Nursing Administrator were notified. There was no documentation in the patient's medical record except by the physician on hospital day #10 that referred to the patient's sitter. There was no documented evidence of the patient having a sitter in the nurse's notes or in the patient's plan of care. There were no "Nurse to Sitter Hand-Off Communication Forms" and no "One-to-One Sitter Observation Records" in the patient's medical record.

Three (3) additional patient medical records were reviewed and revealed one (1) of three (3) patient's (#2) was ordered 1:1 observation. There was no documented evidence of the patient having a sitter in the nurse's notes or in the patient's plan of care. There were no "Nurse to Sitter Hand-Off Communication Forms" and no "One-to-One Sitter Observation Records" in the patient's medical record.

Review of the facility's policy entitled "One-to-One Sitter Observation Policy", no policy number, last revised 04/08, revealed it was the facility's policy to provide appropriate staff to meet the individualized needs of all patients. The policy stipulated that if a PGY-2 (second year resident) or Registered Nurse (RN) determined a need to provide 1:1 observation based on clinical data, potential patient safety concerns, or unique patient care needs such as non-accidental trauma, potential danger to self or others, a request for "sitter" support would be facilitated through the facility's staffing office. According to the policy, the purpose was to provide a physical, social, and cultural environment that utilized sitters in clinically appropriate and adequately justified situations in order to provide for the health and safety of the patient. The policy specified that the use of sitters would be a temporary nursing intervention that could be used to protect patients from harming themselves, others, or interfering with medical treatment. The policy defined a sitter as an employee designated to provide continuous observation of a patient while maintaining a safe environment. According to the policy, the Senior Vice President and Chief Nursing Officer, Patient Care, Vice President - Patient Care, Directors, Clinical Managers, and Supervisors were responsible for nursing compliance with this policy and for ensuring that staff were available to function as sitters. The policy required that a RN would modify the patient's plan of care to include the use of a sitter on the Interdisciplinary Care Plan.

The facility used a "Nurse to Sitter Hand-Off Communication Form", the purpose of the sitter report sheet was to give the sitter brief, pertinent information about the patient. The form included the names of the nurse and nursing assistant assigned to the patient. The nurse was to complete the form and give the sitter a verbal report. In addition, the sitter was required to complete the "One-to-One Sitter Observation Record" which required the sitter to document the patient's activity and their initials every 30 minutes .

Review of the facility's policy entitled, "Clinical Scope of Care & Services", Plan Year: 2011/2012, Description/Location of Department/Unit, Neurology - (11A), revealed staffing was to be based upon workload that was defined by volume and acuity. The policy required a core staffing plan to be budgeted for each year. The policy indicated that a supplementary staffing of pool nurses were to augment call outs and increased workloads.

Review of Unit 11A's staffing revealed the following shifts were understaffed for 20 of 21 shifts or 95% of the time from 9/01/2011 through 9/07/2011.

Review of the facility's policy entitled "Interdisciplinary", no policy number, last revised 02/10, revealed the RN and/or other members of the interdisciplinary team were to review, revise, and update the plan and goals for care, treatment, and services based on the patient's needs.

During a telephone interview at 1:05 p.m. on 09/08/11 in the conference room, the Certified Nursing Assistant (CNA - interview #3) stated that he/she checked the patient's glucose (blood sugar) level at 9:00 p.m. on hospital day #13. The CNA also stated that about 11:00 p.m. he/she found the patient asleep when he/she went to check the patient's vital signs (temperature, pulse, respirations, and blood pressure). The CNA stated that at 12:00 a.m. on hospital day #14 he/she checked on the patient and that the patient was asleep. The CNA further stated that the patient did not have a sitter at that time.

During a telephone interview at 1:15 p.m. on 09/08/11 in the conference room, the RN (interview #4) assigned to care for the patient on hospital day #13 from 11:00 p.m. until hospital day #14 at 7:00 a.m. stated that the patient did have a sitter until 11:30 p.m. The RN explained that there were no available sitters for the 11:00 p.m. to 7:00 a.m. shift and that the staff were going to check on the patient as often as possible. The nurse stated that he/she went into the patient's room between 1:00 a.m. and 2:00 a.m. and that the patient had been watching television. The nurse stated that around 1:50 a.m. he/she went to the patient's room to check on the patient and found that the patient was not in the room or bathroom. The RN explained that he/she and the Charge Nurse (CN) noticed that the patient's window was open, looked out of the window, and saw something on the street. The nurse stated that after he/she and the CN went downstairs and found the patient's body on the street. The physician, Administrator on duty, and the Security Officer were notified. The nurse also stated that the patient had been ambulatory that evening and that the physician had ordered 1:1 monitoring of the patient.

During a telephone interview at 1:30 p.m. on 09/08/11 in the conference room, the CN (interview #5) stated that the patient was suppose to have had a sitter but that there had not been any available. The CN stated he/she had four (4) patients and was sitting at the nurse's station charting around 1:00 a.m. to 1:30 a.m. The CN also stated that Unit 11A had a unit secretary that usually sat at the nursing station but that the secretary had been covering additional units. According to the CN the patient in room 11A18 had also had 1:1 monitoring ordered but did not have a sitter. The CN stated that around 2:00 a.m. the patient in room 11A 18 came out of his/her room and nearly fell. The CN explained that he/she took the patient back to room 11A 18 and put the patient in bed and gave the patient a snack and some juice. The CN stated, "when I got back to the nurse's station, patient #1's nurse informed me that the patient was not in his/her room or bathroom." The CN further stated that he/she and the patient's nurse noticed that the patient's window was opened, looked out and saw something on the ground, went down and found the patient's body on the street. The CN stated that they had then notified the physician, Administrator on duty, Unit Manager, and Security Officer. The CN stated that earlier in the evening the patient had walked in the hall with the sitter and that the patient's gait had been steady. The CN explained that around 1:00 a.m. the patient had been sitting in a chair by the closet. The CN stated that sitters were required to fill out a monitoring form when they sat with patients.


The following corrective action was taken by the facility:

Lack of sitter/staff coverage - 09/06/11 - The Chief Nursing Officer (CNO)) held an emergency meeting with the Nursing Leadership Team (NLT), reviewed sitter policy and compliance to policy.

The Unit Directors immediately added staff (additional clerk on days and an additional NA on nights) to the medical-surgical units.

The CNO immediately authorized overtime for unlicensed staff to work as sitters.

The 11A Unit Director instructed his/her staff to notify him/her when or if there were any potential opportunity where the sitter needs were not met/filled.

09/07/11 - The Unit Director of Nurse Staffing reviewed sitter expectations with staffing specialists.

09/08/11 - The staffing specialist was informed to alert the unit Director/Health System Administrators four (4) hours prior to the shift if unable to fill sitter needs.

The Unit Director of Staffing Office is to provide education and training sessions for sitters regarding safety and compliance to sitter documentation logs.

The CNO authorized the increase in NA positions on the unit and the positions were to be posted on 09/09/11. The posting of open RN and LPN positions was to continue to be ongoing.

Monitoring and Documentation: "Nurse to Sitter Handoff "form and "Sitter Report Sheets" missing:

09/06/11 - The Unit Director of Staffing Office verifying sitter competencies, guidelines, and appropriate documentation in files.

09/06/11 through 09/08/11 - The 11A Unit Director held shift huddles for every shift to cover: 1. Documentation in real time; 2. Completion of rounding sheets; 3. Timely vital signs; and 4. NA (nursing assistant) documentation of assistance with daily living (bath and grooming for example), intake and outputs, and the Rounding Logs.

09/07/11 - The Nursing Executive Council (NEC) approved walking rounds; shift report at the bedside policy and expectations communicated. E-mailed to Nursing Leadership distribution list on 09/08/11.

The NEC reviewed and updated Daily Rounding for Excellence and Compliance Nursing Leader checklist. E-mailed to Nursing Leadership distribution list on 09/08/11.

09/08/11 - The NEC reviewed the two (2) hour Rounding Log for the four (4) Ps (potty, pain, position, and periphery/surroundings). E-mailed to Nursing Leadership distribution list 09/08/11.

09/08/11 - Process changed so that sitters now receive the 1:1 Sitter Observation Record from the staffing office when their assignment has been made, instead of from the CN on the unit.

The unit Director of Nursing Staffing will revise sitter log from every 30 minutes observation documentation to every 15 minutes observations.

Process changed so that sitters now receive the Nurse to Sitter Hand -Off Communication form from the staffing office where their assignments are made, instead of from the CN on the unit.

The communication expectations that the sitter will now leave the 1:1 Sitter Observation Record and the Nurse to Sitter Hand-Off Communication form with the CN on the units rather than returning the forms to the staffing office.

09/07/11 and 09/08/11 - The Unit Director held staff meetings and covered: 1. Documentation in real time in the electronic medical record at the bedside; 2. Staff accountability, including sitters; 3. Supporting and working as a team; 4. Ensuring completion of the Sitter Logs; and 5. Completion of two (2) hour Rounding Logs.

Based on review of medical records, policies and procedures, protocols, staff interviews, and the Maintenance Department's corrective action plan, the facility failed to have a system in place to ensure that all windows were maintained in a manner that prevented safety hazards for one of four sampled patients (#1).


During a tour of patient #1's room at 9:55 a.m. on 09/08/11, the Senior Vice President of Operations and Facility (SVPOOP) (interview #2) explained that the room had two (2) windows, one (1) operational and one (1) non-operational. The SVPOOP stated it was 37 inches from the floor to the bottom of the windows and that the operational window was 28 7/8 inches wide. The SVPOOP explained that the operational window had two (2) sets of screws on each side of the window and that each screw controlled an internal toggle bolt that locked into the wall in order to prevent the window from opening. The SVPOOP stated that the screws could only be turned by using an Allen wrench (thin L shaped tool). The SVPOOP further stated that it was 41 1/2 inches from the floor to the first set of screws (one on either side of the window) and 68 5/8 inches from the floor to the second set of screws. The SVPOOP explained that the window had a retractable arm that allowed the window to open outward no more than six (6) to eight (8) inches. The SVPOOP stated that the retractable arm was broken when he/she had examined the patient's room after the incident. The SVPOOP explained that the facility's maintenance staff did not perform maintenance on exterior windows and that none of the maintenance staff were allowed to open the operational windows. The SVPOOP stated that the tower had been renovated between 1992 and 1995 and Unit 11 A was renovated around 1994. The surveyors noted that the patient's bedside and bathroom nurse call bells were operational, the bathroom toilet paper dispenser had been pulled off the wall and was lying on the counter in the patient's room, the window was opened outward approximately six (6) to eight (8) inches, and that there was a full hand print visible on the window pane. The SVPOOP explained that all patient and non-patient windows had been checked by Tuesday night (09/06/11) and that two (2) 2 1/2 inch additional hex screws had been added to the bottom of each operational window. The SVPOOP stated that tamper proof screws had been ordered and installed on 09/07/11. The surveyors observed that the two (2) additional 2 1/2 inch hex screws had been installed in the patient's window and in the windows of rooms 11A 25, 11A 06, 10A 04, 10A 05,10A 06, 9A 01, and 9A 02.


During a telephone interview at 1:40 p.m. on 09/08/11 in the conference room, the RN/Administrator (interview #8) on duty at the time of the incident stated that around 2:30 a.m. he/she had been notified that there was a body on the street. The Administrator also stated that the police would not let him/her near the body. According to the Administrator, that when he/she entered the patient's room, the window was open, did not look as if it had been tampered with and that there was no furniture near the patient's window. The Administrator stated there had been a screw on the floor under the window. The Administrator reported that he/she had been at the facility for 40 years and had never seen any of the windows opened and had also never seen any of the maintenance staff open the windows.

During an interview at 1:50 p.m. on 09/08/11 in the conference room, the Director of Security (DOS - interview #7) stated he/she had checked the patient's room about four (4) hours after the incident occurred. The DOS further stated there were smudges on the window and that the window was about a quarter of the way open. The DOS explained that the retractable arm was broken and that he/she saw masking tape on the retractable arm. The DOS stated that the toilet paper dispenser had been torn off the wall and that he/she noticed screws under the window and on the table top. The DOS reported that he/she had worked at the facility for 19 years and had never seen any opened windows.

During an interview at 2:00 p.m. on 09/08/11 in the conference room, the Director of Maintenance (DOM - interview #6) explained that the maintenance staff were not allowed to open windows. The DOM stated that when the maintenance staff performed any duties that required ventilation they used an air scrubber that circulated air in the room. The DOM further stated that he/she worked at the facility for three (3) years and was told that the maintenance staff were not to unlock the windows. The DOM stated that there was no policy regarding window maintenance because the staff were not allowed to open the windows. The DOM explained that when staff identified a maintenance issue, the staff called the Customer Service Department to report the issue and the location. The DOM stated this information would then be entered into the system and the maintenance staff would get a work order, complete the work, sign the work order, and turn the signed work order in to the Customer Service Department. The DOM also stated the completion date would then be entered into the system and the system would lock and could not be changed.

Review of the "Maintenance Log" from 02/06/06 through 09/06/11 revealed prior to the patient's incident the only work surrounding the window had been to repair or rehang the window blinds. On 09/06/11 the log revealed new screws were put in the retractable arm and two (2) additional screws were added to the window frame.


The following corrective actions were taken by the facility:

Maintenance Department

09/06/11 - A meeting was held to detail the protocol for facility-wide inpatient room window assessment.

The facility's Management staff was deployed throughout the facility to assess all operable windows in inpatient rooms to include checking each window for locked and unlocked condition, unlocking the window, opening the window, checking the window restrictor arm, closing the window, ensuring that all factory locking points were locked, installing two (2) 2 1/2 inch hex screws to the bottom of the window frame, and documenting findings.

09/07/11 - Standard screws were replaced with tamper proof screws in all patient care and non-patient care areas on all operable windows.

Results of the operable window survey found that the facility had 566 operable windows, 21 (3.54%) of the windows were found unlocked upon inspection, one (1) retractor arm (in the patient's room) was found broken.