HospitalInspections.org

Based on medical record review, document review, and staff interview, it was revealed the facility failed to ensure medical staff adhered to policies and procedures by discontinuing one (1) out of ten (10) patients for one-to-one (1:1) observation level, patient #1, due to staffing constraints and not clinical justification. This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

Review of the medical record for patient #1 revealed "Client Profile - Order Details,'' with the following entries: "3/06/23 at 11:14 p.m. states, "One to One monitoring. Patient is to be 1:1 Monitoring between 7:00 a.m. and 11:00 p.m. and Q15 [every fifteen] monitoring between 11:00 p.m. and 7:00 a.m." The order was resumed for "1:1 monitoring for behavior" on 03/07/23 at 8:37 a.m. Order on 3/13/23 at 7:23 a.m. states, "One to One Monitoring for behavior." Order on 3/13/23 at 7:33 p.m. states, "One to One monitoring. Patient is to be 1:1 Monitoring between 7am and 11pm and Q15 monitoring between 11pm and 7am." Order on 3/14/23 at 7:33 a.m. states, "One to One Monitoring." No rationale was provided for the order modifications. No update was in the patient's treatment plan for the modifications to the order.

Staffing was reviewed for 03/13/23 at 11:00 p.m. The staffing was per matrix with one (1) Registered Nurse (RN) and two (2) Behavioral Health Technicians (BHT)s for eighteen (18) patients. Staffing was reviewed for 03/06/23 at 11:00 p.m. The staffing was not per matrix with one (1) RN and only one (1) BHT for sixteen (16) patients.

The policy titled, "Precautions and Observation Levels," last revised 07/22, was reviewed. The policy states in part, "... Procedure: ... F. Precautions will be evaluated on a daily basis by the Physician/provider and the treatment team. Precautions involving restrictions will be renewed daily. If the patient's status changes the physician/provider will write an order to change the precautions ... Observation Levels ... d. One to One Observation (1:1) -When a Patient status is clinically deemed to present an imminent risk of danger to self or others the patient shall be placed on constant observation by a single designated staff who shall remain readily available and accessible to the patient at all times ..."

The policy was reviewed titled, "Patient Observation Rounds," last revised 10/22. The policy states in part, "Procedures: ... 2. Observation Levels ... Levels of Special Observation 1. One to one (1:1) ... Discontinuation Criteria a. Compliance with 1:1, b. No verbalization or assessment of imminent harm to self or others, c. No attempt to harm self or others for 24 [twenty-four] hours, d. Per Provider order with rationale ..."

The "Rules and Regulations of the Medical Staff of Highland Hospital," last effective 09/21, were reviewed. The Rules state in part, "... 6.0 Care and treatment of patients ... 6.2 Each Practitioner agrees to adhere to the design of the Hospital's Treatment programs and agrees to practice in accordance with a program model. Each practitioner will adhere to all written Hospital policies, procedures, protocols and guidelines, including without limitation, hospitals policies addressing multidisciplinary treatment plans for situations where such plans are appropriate ..."

The "Medical Staff Bylaws," last revised 10/22, were reviewed. The Bylaws state in part, "... Article III. Medical Staff Membership ... 3. 3 General Obligations of Medical Staff Membership ... 3. 3. 3 Abide by the Medical Staff Bylaws, Rules and Regulations and by all other policies procedures and rules of the facility and the governing board as they may exist now or in the future ..."

A telephone interview was conducted with RN #1 on 03/14/23 at 1:53 p.m. Regarding staffing, RN #1 states, "I've never called and gotten an order to discontinue a 1:1 for staffing. We seem to always have staffing problems this time of year, but they usually find people to come in and do the 1:1 if needed."

An interview was conducted with RN #2 on 03/14/23 at 3:00 p.m. Regarding staffing, RN #2 states, "I would not call a physician to discontinue a 1:1 for staffing. I have heard it has been done, but I refuse to do it myself."

A telephone interview was conducted with the RN supervisor on 03/14/23 at 4:13 p.m. Regarding staffing, and discontinuing the 1:1 on patient #1, the RN supervisor states, "I do triage the 1:1 to make sure we keep the doors open. We make sure to get the doctor on board. We discuss the situation with them. The doctor gave an order in the case of [patient #1] for a specific time frame, 11:00 p.m. through 7:00 a.m. I don't know anything about the order going back to around the clock the next day. There were no incidents with [patient #1] that I know of. We have to use critical thinking to utilize staff where we need them to keep all the patients safe and keep the doors open."

An interview was conducted with RN #3 on 03/14/23 at 4:22 p.m. Regarding patient #1, RN #3 states, "The 1:1 was discontinued before I got there to start at 11:00 p.m. There were no incidents. I would feel comfortable calling the doctor if the patient needed to go back on the 1:1 observation. We do have issues with staffing, but I make sure all the patients are safe. If I felt it was unsafe to discontinue [patient #1] 1:1, I wouldn't have done it. At no time did I feel [patient #1] was unsafe that night. I wouldn't put my patients in jeopardy."

A telephone interview was conducted with RN #4 on 03/15/23 at 9:10 a.m. Regarding patient #1, RN #4 states, "[Patient #1] was a 1:1 then [patient #1] was taken off. There were only two (2) of us on the floor that night. [RN supervisor] got the order to discontinue the 1:1. Normally [patient #1] sleeps through the night, so it's not a problem."

An interview was conducted with the Intake Director on 03/15/23 at 10:06 a.m. Regarding staffing, the intake Director states, "In the intake, if we have a potential patient, we discuss with the doctor if the patient will need a higher level of observation. If we do not have the staffing for that, we arrange for the patient to be transferred if they are here, diverted if they aren't."

A telephone interview was conducted with Physician #1 on 03/14/23 at 10:36 a.m. Regarding 1:1 staffing, Physician #1 states, "I do not usually get a call to reduce 1:1 at night. We do not always feel it's appropriate to stop the 1:1 while sleeping. Low staffing though, does not always allow for us to provide 1:1. We evaluate on a case by case basis. If we feel in any way the patient is at risk, we would not discontinue the 1:1."

A telephone interview was conducted with Physician #2 on 03/14/23 at 1:17 p.m. Regarding 1:1 observations, Physician #2 states, "If the staff would call me in the evening to change the 1:1, I would tell them to uphold the 1:1 until I see the patient the next day. I just tell them if the patient needs the 1:1 then they have to provide it. I would not remove the 1:1 from the patient I haven't seen. Typically, when we order a 1:1, it's all the time unless there's a specific reason like aggressiveness with peers while awake, then I guess you could discontinue it at night, but it would be on a case-by-case basis if the patient was safe or not."

A telephone interview was conducted with the Medical Director on 03/14/23 at 12:00 p.m. Regarding staffing for 1:1, the Medical Director states, "I am not aware of any time we have discontinued a 1:1 for staffing. We talk about how a patient on 1:1 can make staffing difficult, but we will not sacrifice the safety of the patients. In this hospital, we have not had an issue staffing the 1:1 that I am aware of. If they are 1:1 then they should remain 1:1 until evaluated by the daily practitioner. I don't really think it should be discontinued or taken up by another physician to change the specific orders."

An additional interview was conducted with Physician #2 on 03/15/23 at 9:40 a.m. Regarding patient #1, Physician #2 states, "[Patient #1] has aggressive behaviors during the day, it is usually a conflict with other peers and staff. [Patient #1] usually sleeps at night. After times of trying to take [patient #1] off of the 1:1, we have just left [patient #1] on. Typical behaviors that [patient #1] has are during the day. [Patient #1] doesn't self harm, [patient #1] is just aggressive towards staff and peers. I don't see why we couldn't discontinue the 1:1 while sleeping."

An additional telephone interview was conducted with Physician #1 on 03/15/23 at 1:27 p.m. Regarding patient #1, and discontinuation of the 1:1, Physician #1 states, "There has to be a clinical indication if you're going to try someone off 1:1. The best time to try, if you're doing a trial period, is to do that while they are sleeping or in their room in bed. They are less likely to have issues. This would be a start of trialing off the 1:1 to hopefully discharge. In this patient, most of the issues are with peers and it's difficult when there's direct interaction, not while [patient #1] sleeping. There's no issues overnight when this 1:1 was discontinued. I'm not sure why we don't have the same thing ordered every day. If there's no issues, it's certainly something to consider. It would be reasonable to make that an order every day to have 1:1 while awake and not while asleep. The order would have to be modified during the day though. There's not just a selection for it, you would have to actually type in specific rules. You could write it as a standing order every day. I would consider trying this and trying this patient off 1:1 every night while [patient #1] is sleeping. We tried this patient off the 1:1 about a month ago, but the patient had a relapse and we had to put [patient #1] back on 1:1. Normally this patient is a slow riser, [patient #1] sleeps in for a while in the morning. [Patient #1] is usually not awake first thing in the morning, most of the behaviors are as the day progresses."

An interview was conducted with the Nurse Manager on 03/15/23 at 9:46 a.m. Regarding staffing, the Nurse Manager states, "We re-evaluate the 1:1 every shift to ensure the best utilization of resources."

On 03/14/23 at approximately 2:30 p.m., the Chief Executive Officer explained they were proud of Nursing for appropriately utilizing resources to keep the doors open.