HospitalInspections.org

Based on medical record (MR) review, document review, interview in three (3) of five (5) medical records reviewed, the Nursing staff failed to ensure patients placed on 1:1 observation were consistently monitored and the appropriate interventions documented as per facility policy.

These lapses in patient monitoring may have placed patients at risk for harm.

Findings include:

Review of the MR for Patient #12 identified: Patient was triaged on 3/21/21 at 8:30AM. His chief complaint was Suicidal Ideation and extreme agitation. The physician ordered a 1:1 for safety on 3/21/21 at 10:14 AM and renewed the 1:1 order (for an additional 24 hours) on 3/21/21 at 4:00 PM.

Review of the "Constant Observation and Every Fifteen Minute Observation" flow sheet, revealed there was no documented evidence of 1:1 monitoring from 9:00 AM to 4:00 PM on 3/21/21, and from 4:00 PM to 9:30 PM on 3/22/21, when the patient was transferred and admitted to an inpatient unit.


Review of the MR for Patient #8 identified that the physician ordered 1:1 observation for elopement on 3/21/2021 at 10:01 PM, for a period of 24 hours. Review of the patient's "Observation Flow Sheet" revealed there was no documented evidence in the patient's chart that 1:1 monitoring continued after 1:35 AM on 3/22/21, and there was no order by a physician to discontinue the 1:1 observation on 3/22/21. The patient was discharged from the ED on 3/22/21 at 7:33 AM.


Review of the MR for Patient #11 identified that the physician ordered 1:1 constant observation for elopement risk on 3/22/2021 at 1:04 AM. The order remained in effect from 1:04 AM to 11:00 PM. Review of the patient's "Observation Flow Sheets" revealed that there was no documented evidence of 1:1 monitoring in the patient's chart from 1:04 AM to 11:00 PM on 3/22/21.

The facility's policy and procedure titled "One to One, One to Two, Two to One, and Every 15 minutes Observation," last revised 7/8/2020, states: "1:1 level of observation is initiated for patients for whom clinical assessment indicates a high level immediate risk for impulsive and /or intentional behavior that may result in harm to self, staff, patients, or other individuals ... this pertains to patients who are: Suicidal and prone to self-harm ...at risk for planned and intentional elopement , grossly disorganized in thinking and behavior, emotionally unstable, corresponding to internal stimuli in a manner that can unpredictably result in above listed behavior. Patients who are placed in four-point restraints for above listed or other reasons ...the Patient Care Assistant (PCA) shall observe for and maintain a safe environment and document on the flow sheet every 15 minutes ...Patients on all forms of observation shall be observed per order specified with documentation on the Constant Observation and Every 15 Minute observation flow sheet ....The RN documents observations and behavior every two hours ...the PCA documents all other required observations.


Per interview of Staff A (Director of Quality Management) on 4/20/21 at 10:00AM, she acknowledged that the patients should have been consistently monitored as per facility policy.