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Based on review of clinical records, hospital documentation, hospital policies and procedures and interviews for one of ten patients reviewed for restraint usage, Patient #2, the hospital failed to ensure that safety was maintained while awaiting provision of a one to one (1:1) sitter resulting in a fall with injury. The findings include:
Patient #2 was admitted to the hospital on 08/18/15 with diagnoses that included acute encephalopathy secondary to seizure, chronic encephalopathy with poor short term memory, recurrent seizures, and chronic Methadone use.
Review of the clinical record identified that during the night and early morning of 08/18/15 through 08/19/15 the patient became agitated and restless, began screaming, and kicking, and was unable to follow directions. Ativan was administered intravenously without significant effect. While RN #3 was attempting to locate staff to provide 1:1 observation, Patient #2 sustained an unwitnessed fall. A post fall assessment documented by RN #3 on 08/19/15 at 3:13 AM identified that Patient #2 had rolled over the side rails and onto the floor at 1:00 AM, sustaining a nasal fracture. Bilateral soft restraints were applied at 1:35 AM due to ongoing high fall risk behaviors as well as interference with multiple medical devices. A 1:1 sitter was provided at 3:00 AM. The restraints were discontinued at 8:45 AM.
Interview with RN #3 on 08/20/15 at 2:30 PM identified that Patient #2 was identified as a high fall risk and had been agitated, restless, and resistant to care most of the evening and night, however, he/she had not been attempting to climb out of bed. Interventions included reorientation, repositioning, bed alarm, locked bed in low position, medications and three, quarter side rails elevated. RN #3 had assisted the Clinical Care Associate, Unlicensed (CCAU) in providing care and repositioning and exited the patient room to arrange 1:1 services. The CCAU left the room to provide care to another patient. Within approximately one minute, RN #3 heard the bed alarm and found the patient on the floor. RN #3 further identified that he/she did not feel that the patient was at risk of climbing out of bed and, therefore, did not require the immediate placement of a 1:1.