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Based on record reviews, observations, interviews, and policy and procedures, the hospital failed to ensure that patients, admitted to the Intensive care Unit (ICU) under Physician Emergency Certificate (PEC) and Coroner's Emergency Certificate (CEC) due to being a danger to self, received care in a safe setting for 1 of 1 patient observed by not providing direct visual observation as required under PEC and CEC (#1) and 9 additional patients admitted to ICU under PEC and CEC from 06/12/12 to present (#2, #4, #5, #6, #7, R1, R2, R3, R4) from a total of 7 sampled patients and 4 random patients.

The ICU patient rooms were not safe for suicidal patient without direct visual observation due to: a) long bed cords, b) long cardiac monitor cords, c) long intravenous pump electrical cords, d) pulse oximetry cords that extended from the monitor to the patient, e) intravenous tubing that could be used to hang or strangulate one's self and, f) large plastic garbage liners in two receptacles that could be used for suffocation.
Findings:

Patient #1
Review of Patient #1's medical record revealed he was a 41 year old male admitted to the ED (emergency department) on 08/05/12 at 9:34am with diagnoses of Alcoholism with Psychosis, Human Immunodeficiency Virus (HIV), Hypoxia, Seizure Disorder, and Acute Subdural Hematoma (was ruled out). Review of Patient #1's PEC signed on 08/05/12 at 3:15pm revealed he was hallucinating with delusional demanding personality, alcoholic, HIV positive, suicidal, dangerous to self, and gravely disabled. Review of his medical record revealed he was transferred to ICU on 08/05/12 at 6:54pm. Review of Patient #1's CEC signed on 08/07/12 at 5:10pm revealed he was dangerous to self and gravely disabled.

Observation of ICU room "a" on 08/09/12 at 5:20am revealed Patient #1 lying in bed with the curtain pulled across the front of the glass door that blocked the view of Patient #1 from Registered Nurse (RN) S5 seated at the computer in the nursing station across from room "a".

Observation on 08/09/12 at 5:32am revealed RN S5 walked away from ICU room "a" to speak with ICU Charge RN S4 down the hall from room "a" with no staff present with direct visibility of Patient #1 in room "a".

Observation on 08/09/12 at 5:43am revealed RN S5 (assigned to the care of Patient #1 in room "a") entered room "b" with no staff was present to provide direct observation of Patient #1.

Continuous observation on 08/09/12 at 5:57am revealed a lab staff member exited room "a" and pulled the curtain upon exiting which prevented visibility of Patient #1 from the nursing station.

Observation of room "a" revealed a) long bed cords, b) long cardiac monitor cords, c) long intravenous pump electrical cords, d) pulse oximetry cords that extended from the monitor to the patient, e) intravenous tubing that could be used to hang or strangulate one's self and, f) large plastic garbage liners in two receptacles that could be used for suffocation.

In a face-to-face interview on 08/09/12 at 5:20am, RN S5 confirmed that she could not visualize Patient #1 while she was seated at the computer in the nursing station and indicated that they usually have a sitter assigned to patients who were suicidal and placed in ICU.

In a face-to-face interview on 08/09/12 at 9:20am, Director of ICU S8 indicated that patients under PEC and CEC were required to have a sitter for direct observation at all times according to hospital policy, and the curtains to the room were not to be closed

In a face-to-face interview on 08/09/12 at 9:40am, Director of ICU S8 indicated that Patient #1 had never had a sitter assigned to directly observe him at all times since he was admitted on 08/05/12.

In a face-to-face interview on 08/09/12 at 9:55am, Chief Nursing Officer (CNO) S2 confirmed that the presence of long electrical cords, long monitor and intravenous pump cords, intravenous tubing, and plastic garbage liners could present a means for suicidal patients to harm themselves.

Review of the hospital policy titled "Patient Rights and Responsibilities", policy number OMC.PTREL.001, issued 06/11, and presented by Risk Manager S6 as the current policy for patient rights, revealed, in part, "...13. The patient has a right to personal safety (free from mental, physical, sexual and verbal abuse, or humiliation, neglect and exploitation)...". Review of the entire policy revealed no documented evidence that patients' right to care in a safe setting was addressed.

Review of the handout titled "Suicide Precautions (Mental Health)", presented by CNO S2 as a source available for use by staff from "Mosby's Skills" revealed, in part, "...8. While maintaining the patient's privacy and dignity, the staff will search the patient for contraband, such as medications, belts, ... plastic bags... Staff will remove the items and secure them out of the patient's possession..."

Review of the handout titled "Clinical Practice Guideline: Center", revealed, in part, "...Assessment/Interventions/Clinical Reasoning/Decision-Making: ... E. Identify risks to safety. F. Implement appropriate interventions as follows and document: ...5. Remove any stimuli/object(s) from environment that may precipitate potentially destructive behavior/self-harm (... sharp objects, cords)..."

Patient #2
Review of Patient #2's medical record revealed he was a 26 year old male admitted on 07/30/12 at 8:05am to ICU with diagnoses of Suicide Attempt by Overdose, new onset Seizure, Depression, Altered Mental Status, and Morbid Obesity. Review of his PEC signed 07/30/12 at 2:50am revealed he was a danger to self and gravely disabled. Review of the CEC signed 07/31/12 at 4:37pm revealed he was a danger to self and others.

Review of patient #2 observation records revealed there was no documented evidence that Patient #2 was under direct visual observation from 7:00am on 07/31/12 until 7:00am on 08/01/12, or from 9:15pm on 08/04/12 through his discharge to an inpatient psychiatric facility on 08/07/12.

Patient #4
Review of Patient #4's medical record revealed he was a 24 year old male admitted to ICU on 08/04/12 at 4:15am with diagnoses of Unresponsiveness, Drug Overdose, Acute Respiratory Failure, and Depression. Review of his PEC signed on 08/04/12 at 1:30pm revealed he was suicidal and dangerous to himself.

Review of patient #4 observation records revealed there was no documented evidence that Patient #4 was under direct visual observation from 7:00am to 7:00pm on 08/04/12. Further review revealed Patient #4's PEC was discontinued by Psychiatrist S19 on 08/05/12 at 11:57am, and he was discharged home on 08/05/12 at 1:13pm.

Patient #5
Review of Patient #5's medical record revealed he was an 18 year old male admitted to ICU on 07/30/12 at 1:09pm with diagnoses of Suicide Threat or attempt, Antidepressant Overdose, and Depression. Review of his PEC signed on 07/30/12 at 2:30pm revealed he was suicidal and a danger to himself. Review of his CEC signed on 07/31/12 at 4:55pm revealed he was a danger to himself.

Review of patient #5 observation record revealed no documented evidence that the patient was under direct visual observation as required by hospital policy from 2:30pm to 7:00pm on 07/30/12. Further review of Patient #5's medical record revealed he was discharged to an inpatient psychiatric facility on 08/01/12 at 4:31pm.

Patient #6
Review of Patient #6's medical record revealed she was a 66 year old female admitted to ICU on 07/21/12 at 7:37pm with diagnoses of Altered Mental Status, Seizures, and Hypertension. Review of her PEC signed on 07/21/12 at 4:40pm revealed she was suicidal and dangerous to herself.

Review of of Patient #6 observation record revealed no documented evidence that direct visual observation from 7:35 pm on 07/21/12 to 11:50 am on 07/23/12. Further review of her medical record revealed Patient #6's PEC was discontinued by Psychiatrist S19 on 07/23/12 at 11:51am, and she was discharged home on 07/23/12 at 2:53pm.

Patient #7
Review of Patient #7's medical record revealed she was a 62 year old female admitted to ICU on 07/28/12 at 3:58pm with diagnoses of Altered Mental Status and Suicide Attempt. Review of her PEC signed on 07/28/12 at 4:30pm revealed she was suicidal and a danger to herself. Review of her CEC signed on 07/31/12 at 10:40am revealed Patient #7 was a danger to herself.

Review of Patient #7 observation records revealed no documented evidence of direct visual observations as required by hospital policy from 4:00pm on 07/28/12 to 7:00pm on 07/29/12 or from 9:00pm on 08/04/12 to 1:25pm on 08/07/12. Further review revealed Patient #7 was transferred to an inpatient psychiatric facility on 08/07/12 at 1:27pm.

Patient R1
Review of Patient R1's medical record revealed he was a 55 year old male admitted to ICU on 07/29/12 at 9:15pm with diagnoses of Suicide attempt and a history of Schizophrenia. Review of his PEC signed on 07/29/12 at 8:45pm revealed he was a danger to himself. Review of his CEC signed on 07/31/12 at 4:15pm revealed he was a danger to himself.

Review of Patient R1 observation record revealed no evidence that patient was under direct visual observation as required by hospital policy from 7:00am to 8:30 pm on 07/31/12. Further review of Patient R1's medical record revealed he was discharged to an inpatient psychiatric facility on 07/31/12 at 8:30pm.

Patient R2
Review of Patient R2's medical record revealed he was a 45 year old male admitted to ICU on 07/29/12 at 8:15pm with a diagnosis of Suicide Attempt with an anticholinergic drug overdose. Review of his PEC signed on 07/29/12 at 5:40pm revealed he was suicidal and dangerous to himself.

Review of Patient R2 observation record revealed no evidence that patient was under direct visual observation as required by hospital policy from 7:00am to 3:30 pm on 07/31/12.Further review of his medical record revealed he was transferred to an inpatient psychiatric facility on 07/31/12 at 3:30pm.

Patient R3
Review of Patient R3's medical record revealed she was a 57 year old female admitted to ICU on 08/03/12 at 11:59am with diagnoses of Alcohol Dependence with withdrawal, Alcoholism/Alcohol Abuse, Hypertension, and Urinary Tract Infection. Review of her PEC signed 08/03/12 at 4:50pm revealed she was suicidal, violent, dangerous to herself, and gravely disabled. Review of her CEC signed on 08/06/12 at 2:25pm revealed she was dangerous to herself.

Review of Patient R3 observation record revealed no evidence that patient was under direct visual observation as required by hospital policy from 12:00pm on 08/03/12 to 7:00am on 08/04/12 or from 9:00pm on 08/04/12 to 7:00am on 08/05/12. Further review of Patient R3's medical record revealed she was discharged to an inpatient psychiatric facility on 08/08/12 at 4:00pm.

Patient R4
Review of Patient R4's medical record revealed she was a 32 year old female admitted to ICU on 06/12/12 at 6:09pm with a diagnosis of Drug Overdose. Further review revealed she eloped from ICU and was returned to the ED on 06/12/12 at 9:27pm. Review of Patient R4's PEC signed on 06/12/12 at 11:20pm revealed she was uncooperative and dangerous to herself. Review of Patient R4 observation record revealed she was not provided direct visual observation prior to elopement. Further review of her medical record revealed Patient R4's PEC was discontinued on 06/13/12 at 10:46am, and she was discharged home on 06/13/12 at 1:11pm.

Based on record reviews and interview the hospital failed to focus performance improvement activities on high-risk, high-volume or problem prone areas as evidenced by failure to develop and implement quality indicators to track, analyze, and trend ICU (intensive care unit) patients admitted under Physician Emergency Certificate (PEC) and/or Coroner's Emergency Certificate (CEC) who required continuous direct observation according to hospital policy. This resulted in not having continuous direct observation for 6 of 7 sampled patients and 4 random patients (#1, #2, #4, #5, #6, #7, R1, R2, R3, R4).

Findings:

Review of the ICU quality improvement data that was being collected, which was presented by Director of Quality S17, revealed no documented evidence that data was currently collected related to ICU patients under PEC/CEC requiring continuous direct observation.

Patient #1
Review of Patient #1's medical record revealed he was a 41 year old male admitted to the ED (emergency department) on 08/05/12 at 9:34am with diagnoses of Alcoholism with Psychosis, Human Immunodeficiency Virus (HIV), Hypoxia, Seizure Disorder, and Acute Subdural Hematoma (was ruled out). Review of Patient #1's PEC signed on 08/05/12 at 3:15pm revealed he was hallucinating with delusional demanding personality, alcoholic, HIV positive, suicidal, dangerous to self, and gravely disabled. Review of his medical record revealed he was transferred to ICU on 08/05/12 at 6:54pm. Review of Patient #1's CEC signed on 08/07/12 at 5:10pm revealed he was dangerous to self and gravely disabled.

In a face-to-face interview on 08/09/12 at 5:20am, RN S5 confirmed that she could not visualize Patient #1 while she was seated at the computer in the nursing station. She indicated that they usually have a sitter assigned to patients who were suicidal, but no sitter was scheduled for the present shift.

In a face-to-face interview on 08/09/12 at 9:20am, Director of ICU S8 indicated that patients under PEC and CEC were required to have a sitter for direct observation at all times according to hospital policy, and the curtains to the room were not to be closed.

In a face-to-face interview on 08/09/12 at 9:34am, RN S9 indicated she was scheduled as a sitter for Patient #1 after she arrived to work on 08/09/12.

In a face-to-face interview on 08/09/12 at 9:40am, Director of ICU S8 indicated that Patient #1 had never had a sitter assigned to directly observe him at all times since he was admitted on 08/05/12. She confirmed that RN S9 had not been scheduled to observe Patient #1 today, but S8 was assigned since the surveyor's entrance to ICU.

Patient #2
Review of Patient #2's medical record revealed he was a 26 year old male admitted on 07/30/12 at 8:05am to ICU with diagnoses of Suicide Attempt by Overdose, new onset Seizure, Depression, Altered Mental Status, and Morbid Obesity. Review of his PEC signed 07/30/12 at 2:50am revealed he was a danger to self and gravely disabled. Review of the CEC signed 07/31/12 at 4:37pm revealed he was a danger to self and others. Further review revealed Patient #2 was transferred to an inpatient psychiatric facility on 08/07/12.

Review of Patient #2's sitter observation records revealed no documented evidence that Patient #2 was under direct visual observation from 7:00am on 07/31/12 until 7:00am on 08/01/12 or from 9:15pm on 08/04/12 through his discharge to an inpatient psychiatric facility on 08/07/12.

Patient #4
Review of Patient #4's medical record revealed he was a 24 year old male admitted to ICU on 08/04/12 at 4:15am with diagnoses of Unresponsiveness, Drug Overdose, Acute Respiratory Failure, and Depression. Review of his PEC signed on 08/04/12 at 1:30pm revealed he was suicidal and dangerous to himself. Further review revealed Patient #4's PEC was discontinued by Psychiatrist S19 on 08/05/12 at 11:57am, and he was discharged home on 08/05/12 at 1:13pm.

Review of Patient #4's sitter observation records revealed no documented evidence that Patient #4 was under direct visual observation from 7:00am to 7:00pm on 08/04/12.

Patient #5
Review of Patient #5's medical record revealed he was an 18 year old male admitted to ICU on 07/30/12 at 1:09pm with diagnoses of Suicide Threat or attempt, Antidepressant Overdose, and Depression. Review of his PEC signed on 07/30/12 at 2:30pm revealed he was suicidal and a danger to himself. Review of his CEC signed on 07/31/12 at 4:55pm revealed he was a danger to himself.

Review of patient #5 observation record revealed no documented evidence that the patient was under direct visual observation as required by hospital policy from 2:30pm to 7:00pm on 07/30/12. Further review of Patient #5's medical record revealed he was discharged to an inpatient psychiatric facility on 08/01/12 at 4:31pm.

Patient #6
Review of Patient #6's medical record revealed she was a 66 year old female admitted to ICU on 07/21/12 at 7:37pm with diagnoses of Altered Mental Status, Seizures, and Hypertension. Review of her PEC signed on 07/21/12 at 4:40pm revealed she was suicidal and dangerous to herself.

Review of of Patient #6 observation record revealed no documented evidence that direct visual observation from 7:35 pm on 07/21/12 to 11:50 am on 07/23/12. Further review of her medical record revealed Patient #6's PEC was discontinued by Psychiatrist S19 on 07/23/12 at 11:51am, and she was discharged home on 07/23/12 at 2:53pm.

Patient #7
Review of Patient #7's medical record revealed she was a 62 year old female admitted to ICU on 07/28/12 at 3:58pm with diagnoses of Altered Mental Status and Suicide Attempt. Review of her PEC signed on 07/28/12 at 4:30pm revealed she was suicidal and a danger to herself. Review of her CEC signed on 07/31/12 at 10:40am revealed Patient #7 was a danger to herself.

Review of Patient #7 observation records revealed no documented evidence of direct visual observations as required by hospital policy from 4:00pm on 07/28/12 to 7:00pm on 07/29/12 or from 9:00pm on 08/04/12 to 1:25pm on 08/07/12. Further review revealed Patient #7 was transferred to an inpatient psychiatric facility on 08/07/12 at 1:27pm.

Patient R1
Review of Patient R1's medical record revealed he was a 55 year old male admitted to ICU on 07/29/12 at 9:15pm with diagnoses of Suicide attempt and a history of Schizophrenia. Review of his PEC signed on 07/29/12 at 8:45pm revealed he was a danger to himself. Review of his CEC signed on 07/31/12 at 4:15pm revealed he was a danger to himself.

Review of Patient R1 observation record revealed no evidence that patient was under direct visual observation as required by hospital policy from 7:00am to 8:30 pm on 07/31/12. Further review of Patient R1's medical record revealed he was discharged to an inpatient psychiatric facility on 07/31/12 at 8:30pm.

Patient R2
Review of Patient R2's medical record revealed he was a 45 year old male admitted to ICU on 07/29/12 at 8:15pm with a diagnosis of Suicide Attempt with an anticholinergic drug overdose. Review of his PEC signed on 07/29/12 at 5:40pm revealed he was suicidal and dangerous to himself.

Review of Patient R2 observation record revealed no evidence that patient was under direct visual observation as required by hospital policy from 7:00am to 3:30 pm on 07/31/12.Further review of his medical record revealed he was transferred to an inpatient psychiatric facility on 07/31/12 at 3:30pm.

Patient R3
Review of Patient R3's medical record revealed she was a 57 year old female admitted to ICU on 08/03/12 at 11:59am with diagnoses of Alcohol Dependence with withdrawal, Alcoholism/Alcohol Abuse, Hypertension, and Urinary Tract Infection. Review of her PEC signed 08/03/12 at 4:50pm revealed she was suicidal, violent, dangerous to herself, and gravely disabled. Review of her CEC signed on 08/06/12 at 2:25pm revealed she was dangerous to herself.

Review of Patient R3 observation record revealed no evidence that patient was under direct visual observation as required by hospital policy from 12:00pm on 08/03/12 to 7:00am on 08/04/12 or from 9:00pm on 08/04/12 to 7:00am on 08/05/12. Further review of Patient R3's medical record revealed she was discharged to an inpatient psychiatric facility on 08/08/12 at 4:00pm.

Patient R4
Review of Patient R4's medical record revealed she was a 32 year old female admitted to ICU on 06/12/12 at 6:09pm with a diagnosis of Drug Overdose. Further review revealed she eloped from ICU and was returned to the ED on 06/12/12 at 9:27pm. Review of Patient R4's PEC signed on 06/12/12 at 11:20pm revealed she was uncooperative and dangerous to herself. Review of Patient R4 observation record revealed she was not provided direct visual observation prior to elopement. Further review of her medical record revealed Patient R4's PEC was discontinued on 06/13/12 at 10:46am, and she was discharged home on 06/13/12 at 1:11pm.

In a face-to-face interview on 08/13/12 at 12:30pm, Risk Manager S6 indicated there no sitter was assigned to observe Patient R4 in ICU on 06/12/12.

In a face-to-face interview on 08/13/12 at 1:40pm, Director of Quality S17 confirmed that high risk, high volume, and problem-prone areas were used to develop quality indicators. She indicated the patients admitted to ICU under PEC/CEC and requiring continuous direct observation would be considered high risk and problem-prone. S17 indicated they had discussed adding to the ICU's quality indicators, since Patient R4 had eloped on 06/12/12 but had not taken any action as of the present time.

Review of the "Quality Improvement Plan" presented by Director of Quality S17 revealed, in part, "...Evaluate high volume, high risk, high cost, and problem prone processes in terms of the dimensions of performance outlined in the Quality Improvement Plan...".

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements for the Condition of Participation for Nursing Services as evidenced by:

1) Failing to ensure that the nursing service had adequate number of personnel to provide the nursing care to all patients as needed. This resulted in patients, admitted to ICU under Physician Emergency Certificate (PEC) and/or Coroner's Emergency Certificate (CEC) requiring continuous direct observation according to hospital policy, not having continuous direct observation for 6 of 7 sampled patients and 4 random patients (#1, #2, #4, #5, #6, #7, R1, R2, R3, R4) (see findings in tag A0392).

2) Failing to ensure that a registered nurse (RN) supervised and evaluated the nursing care for each patient by:

a) The RN failed to ensure that each patient, admitted to ICU under PEC and/or CEC due to being suicidal or a danger to self, was under direct observation by a staff member at all times as required by hospital policy for 6 of 7 sampled patients and 4 random patients (#1, #2, #4, #5, #6, #7, R1, R2, R3, R4). This resulted in Patient R4 eloping from ICU while she was not under constant direct observation on 06/12/12.

b) The RN failed to assess suicidal patients each shift for the presence of suicidal thoughts as required by hospital policy for 6 of 7 sampled patients who were PEC'd due to being a danger to self (#2, #3, #4, #5, #6, #7) (see findings in tag A0395).

3) Failing to ensure that a RN assigned the nursing care of each patient according to the patient's needs and the specialized qualifications and competence of the nursing staff. The RN assigned the observation of ICU patients, who were under PEC and/or CEC to sitters who had not received training and orientation and had not been assessed for competency for 6 of 6 staff members' files reviewed for competency as a sitter (S11, S12, S13, S14, S15, S16) (see findings in tag A0397).

Based on observations, record reviews, and interviews, the hospital failed to ensure that the nursing service had adequate number of personnel to provide the nursing care to all patients as needed. This resulted in patients, admitted to ICU under Physician Emergency Certificate (PEC) and/or Coroner's Emergency Certificate (CEC) and requiring continuous direct observation according to hospital policy, not having continuous direct observation for 6 of 7 sampled patients and 4 random patients (#1, #2, #3, #4, #5, #6, #7, R1, R2, R3, R4).

Findings:

Review of the hospital policy titled "Providing Care for Psychiatric and Suicidal Patients Not in Psychiatry", policy number OHS.NURS.037, revised 07/12, and presented as the current policy by Risk Manager S6, revealed that all suicidal PEC/CEC patients required a staff member to observe the patient and to stay with the patient at all times to provide strict visual contact.

Review of Patient #1's medical record revealed he was a 41 year old male admitted to the ED (emergency department) on 08/05/12 at 9:34am with diagnoses of Alcoholism with Psychosis, Human Immunodeficiency Virus (HIV), Hypoxia, Seizure Disorder, and Acute Subdural Hematoma (was ruled out). Review of Patient #1's PEC signed on 08/05/12 at 3:15pm revealed he was hallucinating with delusional demanding personality, alcoholic, HIV positive, suicidal, dangerous to self, and gravely disabled. Review of his medical record revealed he was transferred to ICU on 08/05/12 at 6:54pm. Review of Patient #1's CEC signed on 08/07/12 at 5:10pm revealed he was dangerous to self and gravely disabled. This required direct visual observation of Patient # 1.

Observation of ICU room "a" on 08/09/12 at 5:20am revealed Patient #1 lying in bed with the curtain pulled across the front of the glass door that blocked the view of Patient #1 by Registered Nurse (RN) S5 who was seated at the computer in the nursing station across from room "a". Therefore restricting direct observation of Patient #1.

Observation on 08/09/12 at 5:43am revealed RN S5 (assigned to the care of Patient #1 in room "a") entered room "b". therefore no staff was present to provide direct observation of Patient #1.

Continuous observation on 08/09/12 at 5:57am revealed the lab staff member exited room "a" and pulled the curtain upon exiting which prevented visibility of Patient #1 from the nursing station.

Review of the medical records of Patients #1, #2, #3, #4, #5, #6, #7, R1, R2, R3, and R4 revealed they were admitted to ICU under PEC/CEC which according to hospital policy required the patient to be under continuous direct observation by staff. Further review revealed no documented evidence of continuous direct observation by a sitter/staff as required by hospital policy on 06/12/12, 07/21/12, 07/22/12, 07/23/12. 07/28/12, 07/29/12, 07/30/12, 07/31/12, 08/04/12, 08/05/12, 08/06/12, 08/07/12, 08/08/12, 08/09/12. Further review revealed the observation was performed by 1 sitter performing continuous direct observation of multiple ICU patients under PEC/CEC on 07/29/12, 07/30/12, 07/31/12, 08/01/12, 08/02/12, 08/03/12, 08/04/12, and 08/05/12.

See findings for Patients #1, #2, #3, #4, #5, #6, #7, R1, R2, R3, and R4 in tag A0395.

In a face-to-face interview on 08/09/12 at 9:20am, Director of ICU S8 indicated sometimes 1 sitter was scheduled to observe up to 3 PEC/CEC patients at a time. She further indicated that when no sitter was scheduled, the patient's assigned RN was responsible for the constant direct observation. S8 indicated when a RN was assigned more than 1 patient, the RN could not provide constant direct observation as required by hospital policy.

In a face-to-face interview on 08/09/12 at 9:55am, CNO S2 confirmed that patients under PEC and/or CEC were to be under continuous direct observation by a sitter per hospital policy. She further confirmed that the continuous direct observation of PEC and/or CEC patients in ICU was not consistently done as required by hospital policy.

In a face-to-face interview on 08/13/12 at 2:28pm, House Supervisor S18 indicated she was responsible to arrange for sitters for PEC/CEC patients in the hospital. S18 indicated once she had unsuccessfully exhausted all efforts to fill sitter positions, she would have to look at which patient was the highest risk for suicide or a danger to self to determine which patient would get a sitter. She further indicated there was no system in place to determine the acuity of patients related to the level of risk for patients who are suicidal or a danger to self such as elopement, or pt would attempt to use long cords in ICU for strangulation purposes.

Review of the hospital policy titled "Staffing and Scheduling", policy number PMC-NS: 6015-004, revised 10/07, and presented by Risk Manager S6 as the current policy, revealed, in part, "...In the critical care unit, a minimum of two (2) employees shall be available at all times... B. The recommended nurse/patient ration shall be 1:2 or 1:3. A nurse/patient ratio of 1:1 shall be maintained in situations in which acuity of the patient requires same... E. It is the policy of the unit that consistent and adequate nursing coverage be provided 24 hours a day, seven days a week...". Further review revealed the "ICU Staffing Pattern 2012" was attached to the policy that contained a grid showing the number of RNs required for a census from 1 to 20, notation of "1:1 patients are not included in this matrix. A judgement call between the Administrative Coordinator and ICU Charge RN will be made as to whether additional staff are needed R/T (related to) acuity. It may also be decided that some less critical patients can be consolidated to decrease the need for overstaffing/agency staff." No documented evidence of the tool that used by the Administrative Coordinator and the ICU Charge RN to determine acuity of ICU patients.

Review of the hospital policy titled "Staffing Guidelines", policy number OHS.NURS.020, issued 05/10, and presented by Risk Manager S6 as the current policy, revealed, in part, "...C. Each nursing unit will create staffing plans specific to the unit and patient population... Each unit utilized the Master Staffing Plan to develop the staffing grid and unit schedule. ... 2. Based on the approved budgeted numbers, every unit develops a staffing grid that serves as a guide when determining staffing needs. 3. When planning for staffing needs for the on-coming shift, the OC/Charge Nurse refers to the grid to determine the appropriate number of staff for the patient census. 4. The OC/Charge Nurse will also identify the nursing care needs of the patients currently on the unit. ... A. Mechanisms for Staffing adjustment ... a. The Unit Director/designee is responsible for the on-going first line evaluation and modification of staffing on each unit very shift, or every 4 hours. ... b. The Administrative Coordinator/House Supervisor/designee will evaluate staffing needs for the facility each shift or every 4 hours to ensure that sufficient numbers/skill mix of competent staff are available to meet defined patient care needs and/or unusual occurrences..."

Based on observations, record reviews, and interviews, the hospital failed to ensure that a registered nurse (RN) supervised and evaluated the nursing care for each patient.
1) The RN failed to ensure that each patient, admitted to ICU (intensive care unit) under Physician Emergency Certificated (PEC) and/or Coroner's Emergency Certificate (CEC) due to being suicidal or a danger to self, was under direct observation by a staff member at all times as required by hospital policy for 6 of 7 sampled patients and 4 random patients whose records were reviewed for direct observation (#1, #2, #4, #5, #6, #7, R1, R2, R3, R4). This resulted in Patient R4 eloping from ICU while she was not under constant direct observation on 06/12/12.
2) The RN failed to assess suicidal patients each shift for the presence of suicidal thoughts as required by hospital policy (that an assessment for the presence of suicidal thoughts be performed each shift) for 6 of 7 sampled patients who were PEC'd due to being a danger to him/herself (#2, #3, #4, #5, #6, #7).

Findings:

1)
Patient #1
Review of Patient #1's medical record revealed he was a 41 year old male admitted to the ED (emergency department) on 08/05/12 at 9:34am with diagnoses of Alcoholism with Psychosis, Human Immunodeficiency Virus (HIV), Hypoxia, Seizure Disorder, and Acute Subdural Hematoma (was ruled out). Review of Patient #1's PEC signed on 08/05/12 at 3:15pm revealed he was hallucinating with delusional demanding personality, alcoholic, HIV positive, suicidal, dangerous to self, and gravely disabled. Review of his medical record revealed he was transferred to ICU on 08/05/12 at 6:54pm. Review of Patient #1's CEC signed on 08/07/12 at 5:10pm revealed he was dangerous to self and gravely disabled.

Observation of ICU room "a" on 08/09/12 at 5:20am revealed Patient #1 lying in bed with the curtain pulled across the front of the glass door that blocked the view of Patient #1 from Registered Nurse (RN) S5 seated at the computer in the nursing station across from room "a".

Observation on 08/09/12 at 5:32am revealed RN S5 walked away from ICU room "a" to speak with ICU Charge RN S4 down the hall from room "a" with no staff present with direct visibility of Patient #1 in room "a".

Observation on 08/09/12 at 5:43am revealed RN S5 (assigned to the care of Patient #1 in room "a") entered room "b" with no staff was present to provide direct observation of Patient #1.

Continuous observation on 08/09/12 at 5:57am revealed a lab staff member exited room "a" and pulled the curtain upon exiting which prevented visibility of Patient #1 from the nursing station.

In a face-to-face interview on 08/09/12 at 5:20am, RN S5 confirmed that she could not visualize Patient #1 while she was seated at the computer in the nursing station. She indicated that they usually have a sitter assigned to patients who were suicidal, but no sitter was scheduled for the present shift.

In a face-to-face interview on 08/09/12 at 9:20am, Director of ICU S8 indicated that patients under PEC and CEC were required to have a sitter for direct observation at all times according to hospital policy, and the curtains to the room were not to be closed.

In a face-to-face interview on 08/09/12 at 9:34am, RN S9 indicated she was scheduled as a sitter for Patient #1 after she arrived to work on 08/09/12.

In a face-to-face interview on 08/09/12 at 9:40am, Director of ICU S8 indicated that Patient #1 had never had a sitter assigned to directly observe him at all times since he was admitted on 08/05/12. She confirmed that RN S9 had not been scheduled to observe Patient #1 today, but S8 was assigned since the surveyor's entrance to ICU.

Patient #2
Review of Patient #2's medical record revealed he was a 26 year old male admitted on 07/30/12 at 8:05am to ICU with diagnoses of Suicide Attempt by Overdose, new onset Seizure, Depression, Altered Mental Status, and Morbid Obesity. Review of his PEC signed 07/30/12 at 2:50am revealed he was a danger to self and gravely disabled. Review of the CEC signed 07/31/12 at 4:37pm revealed he was a danger to self and others.

Review of patient #2 observation records revealed there was no documented evidence that Patient #2 was under direct visual observation from 7:00am on 07/31/12 until 7:00am on 08/01/12, or from 9:15pm on 08/04/12 through his discharge to an inpatient psychiatric facility on 08/07/12.

Patient #4
Review of Patient #4's medical record revealed he was a 24 year old male admitted to ICU on 08/04/12 at 4:15am with diagnoses of Unresponsiveness, Drug Overdose, Acute Respiratory Failure, and Depression. Review of his PEC signed on 08/04/12 at 1:30pm revealed he was suicidal and dangerous to himself.

Review of patient #4 observation records revealed there was no documented evidence that Patient #4 was under direct visual observation from 7:00am to 7:00pm on 08/04/12. Further review revealed Patient #4's PEC was discontinued by Psychiatrist S19 on 08/05/12 at 11:57am, and he was discharged home on 08/05/12 at 1:13pm.

Patient #5
Review of Patient #5's medical record revealed he was an 18 year old male admitted to ICU on 07/30/12 at 1:09pm with diagnoses of Suicide Threat or attempt, Antidepressant Overdose, and Depression. Review of his PEC signed on 07/30/12 at 2:30pm revealed he was suicidal and a danger to himself. Review of his CEC signed on 07/31/12 at 4:55pm revealed he was a danger to himself.

Review of patient #5 observation record revealed no documented evidence that the patient was under direct visual observation as required by hospital policy from 2:30pm to 7:00pm on 07/30/12. Further review of Patient #5's medical record revealed he was discharged to an inpatient psychiatric facility on 08/01/12 at 4:31pm.

Patient #6
Review of Patient #6's medical record revealed she was a 66 year old female admitted to ICU on 07/21/12 at 7:37pm with diagnoses of Altered Mental Status, Seizures, and Hypertension. Review of her PEC signed on 07/21/12 at 4:40pm revealed she was suicidal and dangerous to herself.

Review of of Patient #6 observation record revealed no documented evidence that direct visual observation from 7:35 pm on 07/21/12 to 11:50 am on 07/23/12. Further review of her medical record revealed Patient #6's PEC was discontinued by Psychiatrist S19 on 07/23/12 at 11:51am, and she was discharged home on 07/23/12 at 2:53pm.

Patient #7
Review of Patient #7's medical record revealed she was a 62 year old female admitted to ICU on 07/28/12 at 3:58pm with diagnoses of Altered Mental Status and Suicide Attempt. Review of her PEC signed on 07/28/12 at 4:30pm revealed she was suicidal and a danger to herself. Review of her CEC signed on 07/31/12 at 10:40am revealed Patient #7 was a danger to herself.

Review of Patient #7 observation records revealed no documented evidence of direct visual observations as required by hospital policy from 4:00pm on 07/28/12 to 7:00pm on 07/29/12 or from 9:00pm on 08/04/12 to 1:25pm on 08/07/12. Further review revealed Patient #7 was transferred to an inpatient psychiatric facility on 08/07/12 at 1:27pm.

Patient R1
Review of Patient R1's medical record revealed he was a 55 year old male admitted to ICU on 07/29/12 at 9:15pm with diagnoses of Suicide attempt and a history of Schizophrenia. Review of his PEC signed on 07/29/12 at 8:45pm revealed he was a danger to himself. Review of his CEC signed on 07/31/12 at 4:15pm revealed he was a danger to himself.

Review of Patient R1 observation record revealed no evidence that patient was under direct visual observation as required by hospital policy from 7:00am to 8:30 pm on 07/31/12. Further review of Patient R1's medical record revealed he was discharged to an inpatient psychiatric facility on 07/31/12 at 8:30pm.

Patient R2
Review of Patient R2's medical record revealed he was a 45 year old male admitted to ICU on 07/29/12 at 8:15pm with a diagnosis of Suicide Attempt with an anticholinergic drug overdose. Review of his PEC signed on 07/29/12 at 5:40pm revealed he was suicidal and dangerous to himself.

Review of Patient R2 observation record revealed no evidence that patient was under direct visual observation as required by hospital policy from 7:00am to 3:30 pm on 07/31/12.Further review of his medical record revealed he was transferred to an inpatient psychiatric facility on 07/31/12 at 3:30pm.

Patient R3
Review of Patient R3's medical record revealed she was a 57 year old female admitted to ICU on 08/03/12 at 11:59am with diagnoses of Alcohol Dependence with withdrawal, Alcoholism/Alcohol Abuse, Hypertension, and Urinary Tract Infection. Review of her PEC signed 08/03/12 at 4:50pm revealed she was suicidal, violent, dangerous to herself, and gravely disabled. Review of her CEC signed on 08/06/12 at 2:25pm revealed she was dangerous to herself.

Review of Patient R3 observation record revealed no evidence that patient was under direct visual observation as required by hospital policy from 12:00pm on 08/03/12 to 7:00am on 08/04/12 or from 9:00pm on 08/04/12 to 7:00am on 08/05/12. Further review of Patient R3's medical record revealed she was discharged to an inpatient psychiatric facility on 08/08/12 at 4:00pm.

Patient R4
Review of Patient R4's medical record revealed she was a 32 year old female admitted to ICU on 06/12/12 at 6:09pm with a diagnosis of Drug Overdose. Further review revealed she eloped from ICU and was returned to the ED on 06/12/12 at 9:27pm. Review of Patient R4's PEC signed on 06/12/12 at 11:20pm revealed she was uncooperative and dangerous to herself.

Review of Patient R4 observation record revealed she was not provided direct visual observation prior to elopement. Further review of her medical record revealed Patient R4's PEC was discontinued on 06/13/12 at 10:46am, and she was discharged home on 06/13/12 at 1:11pm.

In a face-to-face interview on 08/13/12 at 12:30pm, Risk Manager S6 indicated that no sitter was assigned to observe Patient R4 in ICU on 06/12/12 at the time that she eloped.

In a face-to-face interview on 08/09/12 at 9:20am, Director of ICU S8 indicated sometimes 1 sitter was scheduled to observe up to 3 PEC/CEC patients at a time. She further indicated that when no sitter was scheduled, the patient's assigned RN was responsible for the constant direct observation. S8 indicated when a RN was assigned more than 1 patient, the RN could not provide constant direct observation as required by hospital policy.

In a face-to-face interview on 08/09/12 at 9:55am, CNO S2 confirmed that patients under PEC and/or CEC were to be under continuous direct observation by a sitter. She further confirmed that the continuous direct observation of PEC and/or CEC patients in ICU was not consistently done according to hospital policy.

In a telephone interview on 08/13/12 at 12:52pm, CNA S11 indicated that she did sit once in ICU with PEC/CEC patients on 07/31/12 from 1:00pm to 7:00pm. She further indicated that she had taken the CPI (crisis prevention intervention) class that morning prior to her assignment. S11 indicated there was no orientation or training class for sitters, and she was told that she was to sit and make sure that the patients were not in harm's way. She further indicated that when she went into 1 patient's room to help the nurse pull the patient in bed, another nurse watched her other patient. S11 indicated that she was given a report on the 2 patients she was assigned to observe, but she did not receive any paperwork that described the duties of the sitter.

In a face-to-face interview on 08/13/12 at 1:10pm, Director of ICU S8 indicated that the house supervisor was the individual who decided if a sitter was scheduled for ICU. She further indicated that the absence of a sitter with PEC/CEC patients was due to the lack of an available person to assign, and in this instance it would become her responsibility to "deal with it" when no sitter was available.

In a telephone interview on 08/13/12 at 1:45pm, RN S15 indicated she was a pediatric nurse and had never had CPI training. She further indicated that she had been assigned as a sitter with PEC/CEC patients a total of 5 times between ICU and the ED (emergency department). S15 indicated that she reviewed the form that included the duties of a sitter, one of which was the patient had to be observed at all times within eye contact. She further indicated that she had been assigned the observation of 4 patients at one time. S15 indicated that she had never been assessed for competency as a sitter.

In a face-to-face interview on 08/13/12 at 2:28pm, House Supervisor S18 indicated she was responsible to arrange for sitters for PEC/CEC patients in the hospital. She further indicated that she worked on Saturday, Sunday, and Monday. S18 indicated once she had unsuccessfully exhausted all efforts to fill sitter positions, she would have to look at which patient was the highest risk to determine which patient would get a sitter. She further indicated there was no system in place to determine the acuity of patients related to the level of risk. S18 indicated that sitters with PEC/CEC patients were required to have CPI certification. When asked if there was a system in place for her to know which staff were CPI trained, she indicated there was no system, and she would only know if the individual had attended a CPI class that she had taught.

In a face-to-face interview on 08/13/12 at 3:05pm, CNO S2 presented a job description for the position of sitter that revealed that CPI certification was a requirement. She indicated that the job description was awaiting approval by the governing body pending getting approval for the compensation for the position. S2 further indicated it was the expectation of the hospital that a sitter be trained in CPI.

Review of the hospital policy titled "Providing Care for Psychiatric and Suicidal Patients Not in Psychiatry", policy number OHS.NURS.037, revised 07/12, and presented as the current policy by Risk Manager S6, revealed, in part, "...E. Sitters or security Guard: 1. All suicidal PEC/CEC patients require staff to observe the patient. 2. Sitters are to stay with the patient at all times (strict visual contact)... 4. The sitter must review the following documents: a. Sitter Responsibilities b. Precautionary Measures: Guide to Risk Sitting Flowsheet c. Guide to Risk Sitting - Information for Sitter ...G. Documentation: ... 3. Sitters assigned to patients will document on the sitter assessment form..."

Review of the "Guide to Risk Sitting - Information for Sitter", presented by Risk Manager S6, revealed, in part, "A. All staff sitting with patients will be given a brief report on why they have been assigned to monitor the patient. B. Sitters will maintain visual contact (do not close door to room) with the patient at all times... C. Documentation of observation will be completed at a minimum of every 15 minutes on the Precautionary Measure Guide to Risk Sitting Flowsheet..."

A document titled "Sitter Responsibilities" was not presented by the hospital during the survey.

Review of the "Job Description" for Sitter, not yet approved and presented by CNO S2, revealed, in part, "...B. Other Qualifications: ... CPI Training...".

2)
Patient #2
Review of Patient #2's medical record revealed he was a 26 year old male admitted on 07/30/12 at 8:05am to ICU with diagnoses of Suicide Attempt by Overdose, new onset Seizure, Depression, Altered Mental Status, and Morbid Obesity. Review of his PEC signed 07/30/12 at 2:50am revealed he was a danger to self and gravely disabled. Review of the CEC signed 07/31/12 at 4:37pm revealed he was a danger to self and others. Further review revealed Patient #2 was transferred to an inpatient psychiatric facility on 08/07/12.

Review of Patient #2's ICU nursing documentation revealed no documented evidence that he was assessed for suicidal thoughts every shift as required by hospital policy as evidenced by no documentation for the 7:00pm shift of 07/30/12, the 7:00am and 7:00pm shifts on 07/31/12, the 7:00pm shift on 08/01/12, the 7:00pm shift on 08/02/12 and the &:00am and 7:00pm shifts on 08/03/12, 08/04/12, 08/05/12, 08/06/12, and 08/07/12.

Patient #3
Review of Patient #3's medical record revealed she was a 19 year old female admitted to ICU on 08/01/12 at 8:42pm with diagnoses of Altered Mental Status and Tachycardia. Review of Patient #3's PEC signed on 08/01/12 at 7:25pm revealed she was a danger to herself. Review of her CEC signed on 08/02/12 at 4:23pm revealed she admitted to suicidal thoughts, was dangerous to self, and gravely disabled. Further record review revealed Patient #3 was transferred to an inpatient psychiatric facility on 08/03/12 at 12:31pm.

Review of Patient #3's nursing documentation revealed no documented evidence of a suicide risk assessment every shift that included an assessment for the presence or absence of suicidal thoughts after the admission assessment on 08/01/12 through the time of discharge on 08/03/12.

Patient #4
Review of Patient #4's medical record revealed he was a 24 year old male admitted to ICU on 08/04/12 at 4:15am with diagnoses of Unresponsiveness, Drug Overdose, Acute Respiratory Failure, and Depression. Review of his PEC signed on 08/04/12 at 1:30pm revealed he was suicidal and dangerous to himself. Patient #4's PEC was discontinued by Psychiatrist S19 on 08/05/12 at 11:57am, and he was discharged home on 08/05/12 at 1:13pm.

Review of Patient #4's nursing documentation revealed no documented evidence of a suicide risk assessment every shift that included an assessment for the presence or absence of suicidal thoughts after the admission assessment on 08/04/12 at 12:00pm through the time of discharge on 08/05/12.

Patient #5
Review of Patient #5's medical record revealed he was an 18 year old male admitted to ICU on 07/30/12 at 1:09pm with diagnoses of Suicide Threat or attempt, Antidepressant Overdose, and Depression. Review of his PEC signed on 07/30/12 at 2:30pm revealed he was suicidal and a danger to himself. Review of his CEC signed on 07/31/12 at 4:55pm revealed he was a danger to himself. .

Review of Patient #5's nursing documentation revealed no documented evidence of a suicide risk assessment every shift that included an assessment for the presence or absence of suicidal thoughts after the admission assessment on 07/30/12 at 3:42pm through the time of discharge on 08/01/12.

Patient #6
Review of Patient #6's medical record revealed she was a 66 year old female admitted to ICU on 07/21/12 at 7:37pm with diagnoses of Altered Mental Status, Seizures, and Hypertension. Review of her PEC signed on 07/21/12 at 4:40pm revealed she was suicidal and dangerous to herself.

Review of Patient #6's nursing documentation revealed no documented evidence of a suicide risk assessment every shift that included an assessment for the presence or absence of suicidal thoughts after the admission assessment on 07/21/12 at 6:45pm through the time of discharge on 07/23/12.

Patient #7
Review of Patient #7's medical record revealed she was a 62 year old female admitted to ICU on 07/28/12 at 3:58pm with diagnoses of Altered Mental Status and Suicide Attempt. Review of her PEC signed on 07/28/12 at 4:30pm and the CEC signed on 07/31/12 at 10:40am revealed she was suicidal and a danger to herself. Further review revealed Patient #7 was transferred to an inpatient psychiatric facility on 08/07/12 at 1:27pm.

Review of Patient #7's nursing documentation revealed no documented evidence of a suicide risk assessment every shift that included an assessment for the presence or absence of suicidal thoughts for the 7:00pm shift on 07/28/12, the 7:00am and 7:00pm shifts on 07/29/12 and 07/30/12, the 7:00am shift on 07/31/12, the 7:00pm shift on 08/01/12, and the 7:00am and 7:00pm shifts on 08/02/12, 08/03/12, 08/04/12, 08/05/12, 08/06/12, and on 08/07/12 through the time of discharge.

In a face-to-face interview on 08/13/12 at 1:10pm, Director of ICU S8 indicated that suicide risk assessments should be performed by the RNs every 2 hours on PEC/CEC patients in ICU.

Review of the hospital policy titled "Providing Care for Psychiatric and Suicidal Patients Not in Psychiatry", policy number OHS.NURS.037, revised 07/12, and presented as the current policy by Risk Manager S6, revealed, in part, "...F. Assessment 1. Psychiatric patients should be assessed on admission for suicidal thoughts... 2. Suicidal patients should be re-evaluated each shift for present suicidal thoughts...".

Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed and kept current a nursing care plan for each patient.

1) The nursing staff failed to develop a patient-specific nursing care plan based on assessing the patient's nursing care needs and developing the appropriate nursing interventions to meet those needs for 7 of 7 sampled patients (#1, #2, #3, #4, #5, #6, #7).

2) The nursing staff failed to implement a patient's physician orders for notification of the physician for elevated respiratory rate and blood pressure according to parameters established by the physician for 1 of 1 patient reviewed with physician-ordered parameters for respiratory rate and blood pressure from a total sample of 7 patients (#7).
Findings:

1)
Patient #1
Review of Patient #1's medical record revealed he was a 41 year old male admitted to the ED (emergency department) on 08/05/12 at 9:34am with diagnoses of Alcoholism with Psychosis, Human Immunodeficiency Virus (HIV), Hypoxia, Seizure Disorder, and Acute Subdural Hematoma (was ruled out). Further review revealed he was also diagnosed with Pneumonia after obtaining a chest x-ray. Review of Patient #1's PEC signed on 08/05/12 at 3:15pm revealed he was hallucinating with delusional demanding personality, alcoholic, HIV positive, suicidal, dangerous to self, and gravely disabled. Review of his medical record revealed he was transferred to ICU on 08/05/12 at 6:54pm. Review of Patient #1's CEC signed on 08/07/12 at 5:10pm revealed he was dangerous to self and gravely disabled.

Review of Patient #1's "Multi-Disciplinary Problems" revealed a general plan of care was developed with the goal of "individualization/patient-specific goal" and a description of "The patient and/or their representative will achieve their patient-specific goals related to the plan of care." Further review revealed no documented evidence that patient-specific goals and interventions were developed for Patient #1. Further review revealed the problem of infection, risk/actual was identified for Patient #1 with the goal being "infection prevention/resolution/control" and the description of "Patient will demonstrate the desired outcomes." Attached to this problem was a list of interventions that included sleep/rest enhancement (with a choice of 19 interventions), airway/ventilation management (included a list of 12 interventions from which to choose), thermoregulation maintenance (with a choice of 10 interventions for warming and 11 interventions for cooling), personal hygiene promotion (with a choice of 7 interventions), and skin/mucous membrane protection (with a choice of 24 interventions). There was no documented evidence of that patient-specific measurable goals and interventions were developed for Patient #1. Further review revealed that patient education was planned for anxiety, dietary modifications, and seizure disorder, but there was no documented evidence that a patient-specific care plan was developed to address Patient #1's suicidal thoughts and seizure disorder.

Patient #2
Review of Patient #2's medical record revealed he was a 26 year old male admitted on 07/30/12 at 8:05am to ICU with diagnoses of Suicide Attempt by Overdose, new onset Seizure, Depression, Altered Mental Status, and Morbid Obesity. Review of his PEC signed 07/30/12 at 2:50am revealed he was a danger to self and gravely disabled. Review of the CEC signed 07/31/12 at 4:37pm revealed he was a danger to self and others. Further review revealed Patient #2 was transferred to an inpatient psychiatric facility on 08/07/12.

Review of Patient #2's nursing plan of care revealed the problem identified was "general plan of care" with the goal of "The patient and/or their representative will communicate an understanding of their plan of care." Further review revealed no documented evidence that patient-specific measurable goals and interventions were developed. Further review revealed no documented evidence that a nursing plan of care was developed for Patient #2's diagnoses of suicide attempt, depression, and the new onset of seizure disorder.

Patient #3
Review of Patient #3's medical record revealed she was a 19 year old female admitted to ICU on 08/01/12 at 8:42pm with diagnoses of Altered Mental Status and Tachycardia. Review of Patient #3's PEC signed on 08/01/12 at 7:25pm revealed she was a danger to herself. Review of her CEC signed on 08/02/12 at 4:23pm revealed she admitted to suicidal thoughts, was dangerous to self, and gravely disabled. Further record review revealed Patient #3 was transferred to an inpatient psychiatric facility on 08/03/12 at 12:31pm.

Review of Patient #3's nursing plan of care revealed the problem identified was "general plan of care" with the goal of "The patient and/or their representative will communicate an understanding of their plan of care." Further review revealed no documented evidence that patient-specific measurable goals and interventions were developed. Further review revealed no documented evidence that a nursing plan of care was developed for Patient #3's suicidal thoughts.

Patient #4
Review of Patient #4's medical record revealed he was a 24 year old male admitted to ICU on 08/04/12 at 4:15am with diagnoses of Unresponsiveness, Drug Overdose, Acute Respiratory Failure, and Depression. Review of his PEC signed on 08/04/12 at 1:30pm revealed he was suicidal and dangerous to himself. Further review revealed Patient #4's PEC was discontinued by Psychiatrist S19 on 08/05/12 at 11:57am, and he was discharged home on 08/05/12 at 1:13pm.

Review of Patient #4's nursing plan of care revealed the problem identified was "general plan of care" with the goal of "The patient and/or their representative will communicate an understanding of their plan of care." Further review revealed no documented evidence that patient-specific measurable goals and interventions were developed. Further review revealed no documented evidence that a nursing plan of care was developed for Patient #4's suicidal thoughts.

Patient #5
Review of Patient #5's medical record revealed he was an 18 year old male admitted to ICU on 07/30/12 at 1:09pm with diagnoses of Suicide Threat or attempt, Antidepressant Overdose, and Depression. Review of his PEC signed on 07/30/12 at 2:30pm revealed he was suicidal and a danger to himself. Review of his CEC signed on 07/31/12 at 4:55pm revealed he was a danger to himself. Further review of Patient #5's medical record revealed he was discharged to an inpatient psychiatric facility on 08/01/12 at 4:31pm.

Review of Patient #5's nursing plan of care revealed the problem identified was "general plan of care" with the goal of "The patient and/or their representative will achieve their patient-specific goals related to the plan of care." Further review revealed no documented evidence that patient-specific measurable goals and interventions were developed. Further review revealed a problem identified was "Suicide Risk" with a goal of "strength-based safety/wellness/recovery" and a description of "Patient will demonstrate the desired outcomes." There was no documented evidence of what outcomes were expected for Patient #5. Further review revealed an intervention of suicide attempt prevention/intervention was listed with a choice of 20 interventions from which to choose and an intervention of manage environment was listed with a choice of 11 interventions from which to choose.

Patient #6
Review of Patient #6's medical record revealed she was a 66 year old female admitted to ICU on 07/21/12 at 7:37pm with diagnoses of Altered Mental Status, Seizures, and Hypertension. Review of her PEC signed on 07/21/12 at 4:40pm revealed she was suicidal and dangerous to herself. Further review of her medical record revealed Patient #6's PEC was discontinued by Psychiatrist S19 on 07/23/12 at 11:51am, and she was discharged home on 07/23/12 at 2:53pm.

Review of Patient #6's "Multi-Disciplinary Problems" revealed a problem identified was anxiety with a goal of "reduction/resolution" and a description of "Patient will demonstrate the desired outcomes." Further review revealed an intervention was anxiety management with a list of 24 choices of interventions from which to choose. There was no documented evidence of patient-specific measurable goals and interventions developed for Patient #6's problem of anxiety. Further review revealed another problem was "general plan of care" with the goal of individualization/patient-specific goal and a description of "The patient and/or their representative will achieve their patient-specific goals related to the plan of care." There was no documented evidence of the patient-specific measurable goals and interventions developed by the nursing staff for this problem.

Patient #7
Review of Patient #7's medical record revealed she was a 62 year old female admitted to ICU on 07/28/12 at 3:58pm with diagnoses of Altered Mental Status and Suicide Attempt. Review of her PEC signed on 07/28/12 at 4:30pm revealed she was suicidal and a danger to herself. Review of her CEC signed on 07/31/12 at 10:40am revealed Patient #7 was a danger to herself. Further review revealed Patient #7 was transferred to an inpatient psychiatric facility on 08/07/12 at 1:27pm.

Review of Patient #7's "Multi-Disciplinary Problems" revealed a problem identified was general plan of care with the goal of individualization/patient-specific goal and the description of "The patient and/or their representative will achieve their patient-specific goals related to the plan of care. There was no documented evidence of patient-specific measurable goals and interventions identified for this problem. Further review revealed a problem identified was suicide risk with the goal of "strength-based safety/wellness/recovery" and a description of "Patient will demonstrate the desired outcomes." Further review revealed no documented evidence of what outcomes were expected for Patient #7. Further review revealed an intervention was suicide attempt prevention/intervention with a choice of 20 interventions listed and an intervention of manage environment with a choice of 11 interventions listed. There was no documented evidence of the specific interventions selected for Patient #7. Further review revealed another problem identified was "nausea/vomiting in pregnancy, includes hyperemesis" (no documented evidence that Patient #7 was pregnant) with the goal of prevent/manage potential problems. Further review revealed interventions included promote oral nutrition (with a choice of 24 interventions from which to choose), fluid management (with a choice of 11 interventions), metabolic/electrolyte imbalance management (with a choice of 13 interventions), nausea/vomiting management (with a choice of 15 interventions), bowel function promotion (with a choice of 14 interventions), and prevent/minimize intrauterine growth restriction (with a choice of 6 interventions). There was no documented evidence of the specific interventions selected for Patient #7.

In a face-to-face interview on 08/09/12 at 11:15am, Chief Nursing Officer S2 indicated the patient care plans that were reviewed did not have patient-specific goal that were measurable, and the interventions were not patient-specific.

2)
Patient #7
Review of Patient #7's medical record revealed she was a 62 year old female admitted to ICU on 07/28/12 at 3:58pm with diagnoses of Altered Mental Status and Suicide Attempt. Review of her PEC signed on 07/28/12 at 4:30pm revealed she was suicidal and a danger to herself. Review of her CEC signed on 07/31/12 at 10:40am revealed Patient #7 was a danger to herself. Further review revealed Patient #7 was transferred to an inpatient psychiatric facility on 08/07/12 at 1:27pm.

Review of Patient #7's "Clinical Orders" revealed an order dated 07/30/12 at 9:39am to notify the physician of a systolic blood pressure greater than or equal to 140 (millimeters of mercury), a diastolic blood pressure greater than or equal to 90, and respirations rate greater than or equal to 25.

Review of Patient #7's "All Flowsheet Data" revealed her blood pressure on 08/01/12 at 6:42pm was 174/102, at 6:46pm 179/93, and at 7:05pm 161/97. Review of the entire medical record revealed no documented evidence that the physician was notified of the blood pressures that were outside the parameters requiring physician notification. Further review revealed Patient #7's respiratory rate was 32 on 08/03/12 at 7:30am, and it was 31 on 08/03/12 at 10:00am. Review of the entire medical record revealed no documented evidence that the physician was notified of the respiratory rate that was outside the parameters requiring physician notification.

In a face-to-face interview on 08/13/12 at 11:45am, Clinical Informatics Supervisor S20 confirmed, after reviewing Patient #7's computerized medical record, there was no documented evidence that the RN notified the physician of the elevated blood pressures and respiratory rate.

Based on record reviews and interviews, the hospital failed to ensure that a registered nurse (RN) assigned the nursing care of each patient according to the patient's needs and the specialized qualifications and competence of the nursing staff. The RN assigned the observation of ICU (intensive care unit) patients, who were under Physician Emergency Certificate (PEC) and/or Coroner's Emergency Certificate (CEC) to sitters who had not received training and orientation and had not been assessed for competency for 6 of 6 staff members' files reviewed for competency as a sitter (S11, S12, S13, S14, S15, S16).

Findings:

Certified Nursing Assistant (CNA) S11
Review of CNA S11's personnel file revealed no documented evidence of training, orientation, and an assessment of competency as a sitter with ICU patients under PEC/CEC.

Review of the medical record of Patients #2 revealed CNA S11 observed him as a sitter on 07/30/12 from 3:00pm to 7:00pm.

In a face-to-face interview on 08/13/12 at 10:40am, RN Director of Education S21 confirmed there was no documented evidence that CNA S11 had received orientation and training and had been assessed for competency as a sitter prior to performing those duties.

In a telephone interview on 08/13/12 at 12:52pm, CNA S11 indicated that she did sit once in ICU with PEC/CEC patients on 07/31/12 from 1:00pm to 7:00pm. She further indicated that she had taken the CPI (crisis prevention intervention) class that morning prior to her assignment. S11 indicated there was no orientation or training class for sitters, and she was told that she was to sit and make sure that the patients were not in harm's way. S11 indicated that she was given a report on the 2 patients she was assigned to observe, but she did not receive any paperwork that described the duties of the sitter.

CNA S12
Review of CNA S12's personnel file revealed no documented evidence of CPI (crisis prevention intervention) training or orientation and training and an assessment of competency as a sitter for ICU patients under PEC/CEC.

In a face-to-face interview on 08/13/12 at 10:45am, RN Director of Education S21 confirmed there was no documented evidence that CNA S12 had received orientation and training and had been assessed for competency as a sitter prior to performing those duties. She further indicated that S12 had not attended CPI training.

Respiratory Therapist (RT) S13
Review of RT S13's personnel file revealed no documented evidence of orientation and training and an assessment of competency as a sitter for ICU patients under PEC/CEC.

Review of the medical records of Patients #2, #7, and R3 revealed S13 performed the observations on 08/04/12 from 7:00am to 7:00pm.

In a face-to-face interview on 08/13/12 at 10:45am, RN Director of Education S21 confirmed there was no documented evidence that RT S13 had received orientation and training and had been assessed for competency as a sitter prior to performing those duties.

Respiratory Therapist S14
Review of RT S14's personnel file revealed no documented evidence of orientation and training and an assessment of competency as a sitter for ICU patients under PEC/CEC.

In a telephone interview on 08/13/12 at 12:00pm, Respiratory Therapist S14 indicated that she did sit with PEC/CEC patients in ICU once, but she couldn't remember which day it was. She further indicated she was assigned the observation of 3 patients at one time. S14 indicated she was given a handout of duties at the start of her shift by the charge nurse. She further indicated she had no one to assess her competency as a sitter of PEC/CEC patients in the ICU.

Pediatric RN S15
Review of Pediatric RN S15's personnel file revealed no documented evidence of CPI training, orientation and training as a sitter for ICU PEC/CEC patients, and an assessment of competency to perform those duties.

In a face-to-face interview on 08/13/12 at 10:45am, RN Director of Education S21 confirmed there was no documented evidence that RN S15 had received orientation and training and had been assessed for competency as a sitter prior to performing those duties. She further indicated that S15 had not attended CPI training.

In a telephone interview on 08/13/12 at 1:45pm, RN S15 indicated she was a pediatric nurse and had never had CPI training. She further indicated that she had been assigned as a sitter with PEC/CEC patients a total of 5 times between ICU and the ED (emergency department). S15 indicated that she reviewed the form that included the duties of a sitter, one of which was the patient had to be observed at all times within eye contact. She further indicated that she had been assigned the observation of 4 patients at one time. S15 indicated that she had never been assessed for competency as a sitter.

Respiratory Therapist S16
Review of RT S16's personnel file revealed no documented evidence of orientation and training as a sitter for ICU PEC/CEC patients and an assessment of competency to perform those duties.

In a face-to-face interview on 08/13/12 at 10:45am, RN Director of Education S21 confirmed there was no documented evidence that RT S16 had received orientation and training and had been assessed for competency as a sitter prior to performing those duties.

In a face-to-face interview on 08/13/12 at 3:05pm, CNO S2 presented a job description for the position of sitter that revealed that CPI certification was a requirement. She indicated that the job description was awaiting approval by the governing body pending getting approval for the compensation for the position. S2 further indicated it was the expectation of the hospital that a sitter be trained in CPI.

Review of the hospital policy titled "Providing Care for Psychiatric and Suicidal Patients Not in Psychiatry", policy number OHS.NURS.037, revised 07/12, and presented as the current policy by Risk Manager S6, revealed, in part, "...E. Sitters or security Guard: 1. All suicidal PEC/CEC patients require staff to observe the patient. 2. Sitters are to stay with the patient at all times (strict visual contact)... 4. The sitter must review the following documents: a. Sitter Responsibilities b. Precautionary Measures: Guide to Risk Sitting Flowsheet c. Guide to Risk Sitting - Information for Sitter ...G. Documentation: ... 3. Sitters assigned to patients will document on the sitter assessment form..."

Review of the "Guide to Risk Sitting - Information for Sitter", presented by Risk Manager S6, revealed, in part, "A. All staff sitting with patients will be given a brief report on why they have been assigned to monitor the patient. B. Sitters will maintain visual contact (do not close door to room) with the patient at all times... C. Documentation of observation will be completed at a minimum of every 15 minutes on the Precautionary Measure Guide to Risk Sitting Flowsheet..."

A document titled "Sitter Responsibilities" was not presented by the hospital during the survey.

Review of the "Job Description" for Sitter, not yet approved and presented by CNO S2, revealed, in part, "...B. Other Qualifications: ... CPI Training...".