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ST BERNARD HOSPITAL
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on document review and interview, it was determined that for 1 (Pt. #1) of 2 clinical records reviewed for one to one (1:1) supervision (monitoring patients at all times), the Hospital failed to ensure care in a safe setting was provided by not obtaining a physician's order for 1:1 supervision after it was initiated, as required.
Findings include:
1. The Hospital's policy titled, "One-to-One Supervision" (revised 12/19), was reviewed and included, "It is the policy of Nursing Services to institute one-to-one supervision of patient when ... suicidal ideation or behavior ...initiated by the RN (registered nurse) or doctor's order ... the attending physician will be notified and an order obtained within one hour ... An order for this intervention must be renewed daily by the attending physician ..."
2. The clinical record of Pt. #1 was reviewed on 7/20/21. Pt. #1 presented to the Hospital's ED (emergency department) for psych (psychiatric) evaluation on 6/3/21 at 11:30 PM and discharged on 6/7/21 at 10:00 PM . The clinical record included the following:
-Registered Nurse's note dated 6/4/21 at 11:32 PM, indicated that Pt. #1 was placed on one-to-one (1:1) constant supervision for elopement and suicide precautions due to (Pt. #1's) report of suicidal ideation, and report of aggressive behavior towards staff at group home. The clinical record lacked a physician's order after the initiation of 1:1 Supervision on 6/3/21, and renewal order for 6/4/21 through 6/7/21.
3. On 7/20/21, at approximately 12:45 PM, an interview was conducted with the Director of Nursing (DON-E #2). E #2 stated that (Pt. #1's) clinical record did not have an initial or renewal order for 1:1 supervision.
4. On 7/22/21, at approximately 8:50 AM, an interview was conducted via phone with an ED Registered Nurse (RN-E #5). E #5 stated that the RN is able to initiate 1:1 supervision if the patient has suicidal ideation and obtain an order from the Physician within an hour. E #5 stated that the order should be renewed daily.