HospitalInspections.org

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Based on interview and record review it was determined the hospital failed to provide an adequate number of "1:1 sitters" to comply with hospital policy and written physician orders for 5 of 5 sampled behavioral health patients in the ICU unit, (Patients 1, 2, 3, 4 and 5). Findings include:


A complaint investigation survey was initiated on 10/17/11, including an unannounced on-site visit. Information was obtained from review of policies and procedures, review of hospital staffing and attendance records, interview with staff and witnesses's and from medical record review.

The review of policies and procedures included review of policies entitled "Patient Rights," Scope of Practice for Registered Nurse, LPN and CNA's," "Plan for the Provision of Nursing Care," "Staffing Plan Policy: Critical Care," "Verbal and Telephone Orders," "Restraint and Seclusion," "Patient CNA Sitter Policy," "Guidelines for Behavioral Health Patients in ICU," "Suicide Precautions for Acute Care Adult Patients" and "Suicide Precautions and Emergency Psychiatric Care for Acute Care Adult Patients, October 2011"

Review of the medical records of five patients admitted to the ICU unit for behavioral health services determined the hospital failed to fully implement physician orders and hospital policy "Suicide Precautions for Acute Care Adult Patients" for a Patients 1, 2, 3, 4 and 5.

Hospital policy "Suicide Precautions for Acute Care Adult Patients" was in effect prior to October 2011. Effective October, 2011 that policy had been superceded by a proposed policy "Suicide Precautions and Emergency Psychiatric Care for Acute Care Adult Patients, October 2011."

The original policy stated that "if a patient who is exhibiting suicidal behavior and/or ideation requires medical care beyond ED treatment they will be admitted to the ICU unit and may require a 1:1 sitter, per order of the attending physician." The policy further stated that "Patients in the ICU will remain there until 1:1 observation is deemed unnecessary by agreement of the mental health professional and the physician," and that "the patient will remain in ICU with a 1:1 sitter until medically ready for discharge."

Hospital records indicate that Patient 1, 2, 3, 4 and 5 had been admitted to the ICU unit for exhibiting suicidal behaviors and/or ideation. Record review determined that at the time of admission, Patients 1-5 had written physician orders for "1 to 1 sitter" and/or observation. Review of the hospital staffing and attendance records and interview with Employees 1, 2, 3, 7, 8 and 10 determined that those orders were not implemented on 7/29 and 7/30/11 as directed.

In interview on 10/18/11 at 9:45 am the Chief Nursing Offices (Employee 1) and Manager of Critical Care (Employee 3) indicated that a "1 to 1 sitter" had been provided to each patient until approximately 11:00 am on 7/29/11. At that time the management staff (Employees 1 and 3) implemented an alternative process to provide patient observation. That alternative process was outlined in a proposed hospital policy "Guideline for Behavioral Health Patients in ICU," and included the video monitoring of the patients, and the use of a single "floating" sitter.

According to the CNO (Employee 1) the alternative process had been implemented because the management staff had determined the hospital would not be able to provide the number of staff needed over the coming night and weekend shifts. In interview on 10/18/11, Employees 1, 3 and 8 stated the hospital did not have a sufficient number of qualified "sitters" available to provide 1 to 1 observation of five separate patients during the night shift of 7/29, and the day and night shifts of 7/30/11.

Although the hospital implemented an alternative process to provide visual monitoring of Patients 1 through 5, that alternative process was not in compliance with policy "Suicide Precautions for Acute Care Adult Patients," or with written physician orders. The attending physicians for Patients 1, 2, 3, 4 and 5 had not been notified of the alternative process, and had not approved the change in orders.

In interview on 10/17/11 at 2:15 pm the Chief Nursing Officer (Employee 1) acknowledged that hospital policy and written physician orders for "1 to 1 observation" of Patients 1, 2, 3, 4 and 5 had not been implemented on the night shift of 7/29/11 and the day and night shift of 7/30/11.

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