HospitalInspections.org

Based on review of facility documents, medical records (MR), and staff interview (EMP) it was determined the facility failed to ensure nursing staff documented a change in a patient's condition and continuous observations were maintained for one of one medical record reviewed (MR1).

Findings:

Review on March 7, 2022, of the facility policy, "Patient Care Process: Including Admission, Assessment/Reassessment And Patient Plan of Care [B-02], "last reviewed July 2021 revealed" ... I. Purpose: The patient care process provides the framework for the documentation of care provided to patients. Key components include: assessment, reassessment, nursing diagnosis, planning, intervention, and evaluation. Documentation of this process is accomplished on various hospital forms and through electronic devices, according to hospital policies, procedures and guidelines. Charting by exception is the method of documentation incorporated in nursing documentation of the physical head to toe assessment of the patient. ... III. Procedure ... 2. The RN performs a complete assessment every 24 hours, based on the time the patient is admitted or based on unit routine. ... 3. Only those assessments relating to specific changes or exceptions in the patient's condition are documented within that 24-hour time period. ... C. Reassessment: 1. Policies and General Instructions: a. A RN must perform an assessment a minimum of every 24 hours. b. Reassessments or partial reassessments are done more frequently at the RN's discretion based on; 1) patient diagnosis 2) significant changes in the patient's condition 3) transfer 4) to evaluate the effectiveness of healthcare interventions ..."

Review on March 7, 2022, of the facility policy, "Event Reporting - Patient Safety and Non-patient Incidents and Facility Events (#22)," last reviewed October 2021 revealed "...I. Purpose: This document explains how to report Patient Safety Events and Non-patient Incidents or Facility Events. Also included are guidelines to assist in reporting to external agencies, including special circumstances for suspected criminal activity. It is the purpose of this policy to facilitate prompt identification, documentation, analysis, and resolution of actual and potential safety risks, as further defined in section II (Definitions). ... III. Procedure ... 5. In addition to the Patient Safety Event Report, all patient safety events should be documented in the medical record. The medical record should include the following: Factual description of the event Immediate effect on the patient, if known Name of the physician, or designee notified and time Any immediate physician orders, if applicable The medical record should not include documentation that a Patient Safety Event Report was submitted. ..."

Review on March 7, 2022, of the facility document, "Virtual Continuous Observation (1:1s) Process," last reviewed August 2021 revealed "Background Network-wide, SLUHN averages about 40 continuous observations daily consuming about 120 PCAs or POAs to sit 1:1 with these patients. Roughly half of these are for safety, meaning they are not for suicidal or other BH reasons. An example of a safety 1:1 is a patient with forgetfulness who is also a fall risk. Literature shows remote virtual (video) observation is an excellent alternative to in-person observation for certain patients. In fact, it has demonstrated an increase in safety and quality. ... Process ... 1. Inclusion/Exclusion a. Inclusion - Current order for continuous observation b. Exclusion - Suicidal, locked BH unit, 4-point locked restraints, <14 years of age, elopement attempt this admission, deaf, violent behavior last 24 hours ... b. Process i. Establish Virtual Sitter iPad ii. During 1st hour, Virtual Sitter assumes primary continual observation responsibility and in person sitter remains present (relocate to doorway/hallway) iii. If Virtual Sitter is unable to manage patient, they will request assistance from in person sitter iv. If the patient requires in person sitter intervention >3 times in the first hour, continue in person sitter and re-trial in 24 hours ..."

Review on March 7, 2022, of the facility policy, "Continual Observation Policy [D-02]," last reviewed November 2021 revealed "I. Policy ... III. Education, Training & Competence ... B. Education, training, and competence focus on the following: ...6. Appropriate clinical documentation. ... IV. Continual Observation Procedure ... 3. Monitoring (Non-Suicidal or Suicidal) a. Patient behaviors will be monitored continuously by the assigned staff member during the Continual Observation. Note: Documentation of patient behaviors will be completed by the assigned staff member (as appropriate to role) or by the RN at frequent intervals, normally not to exceed 2 hours. ... 6. Documentation (Non-Suicidal or Suicidal) ... b. The appropriate staff documents the following in the patient's medical record: ... 7) Results of monitoring including patient behaviors (documentation normally not to exceed every 2 hours). ..."

Review on March 7, 2022, of MR1 revealed there was no nursing documentation of MR1's change in condition and death on February 21, 2022.

Interview on March 7, 2022, with EMP2, at approximately 1300, confirmed MR1 did not contain nursing documentation related to MR1's change in condition and death on February 21, 2022.

Continued review of MR1 revealed MR1 was ordered a continuous observation on February 17, 2022. There was no documentation MR1's continuous observation was maintained from 0700 to 1100 on February 17, 2022, and from 2100 on February 17, 2022, to 0700 on February 18, 2022 .

Interview on March 7, 2022, with EMP2, at approximately 1330, confirmed MR1 was ordered a continuous observation on February 17, 2022, and there was no documentation MR1's continuous observation was maintained from 0700 to 1100 on February 17, 2022, and from 2100 on February 17, 2022, to 0700 on February 18, 2022 .

Continued review of MR1 revealed MR1 was ordered a continuous virtual observation on February 20, 2022. There was no documentation MR1's continuous virtual observation was maintained from 0700 to 1100, 1100 to 1500, and 1700 to 2000 on February 20, 2022.

Interview on March 7, 2022, with EMP2, at approximately 1335, confirmed MR1 was ordered a continuous virtual observation on February 20, 2022, and there was no documentation MR1's continuous virtual observation was maintained from 0700 to 1100, 1100 to 1500, and 1700 to 2000.

Continued review of MR1 revealed MR1 was ordered a continuous virtual observation on February 21, 2022. There was no documentation MR1's continuous virtual observation was maintained from 0500 to 0830 on February 21, 2022.

Interview on March 7, 2022, with EMP2, at approximately 1340, confirmed MR1 was ordered a continuous virtual observation on February 21, 2022, and there was no documentation MR1's continuous virtual observation was maintained from 0500 to 0830.