HospitalInspections.org

Based on document review and interview, it was determined that for 4 of 5 (Pts. # 11, 12, 13 & 14) records reviewed in the Intensive Treatment Unit (ITU), the Hospital failed to ensure a physician's order was obtained to board patients from another unit into ITU.

Findings include:

1. The Hospital policy titled, "Bed Utilization and Boarding Policy" required, "Actions Steps: 1. Charge Nurse Identifies patients who would be appropriate for boarding, based upon presenting patient needs. As early in the shift as possible, contact the physician, review the appropriateness of boarding the patient and then obtain and record an order."

2. The clinical record for Pt. #11 was reviewed on 6/23/15. Pt. #11 was a 54 year old male admitted to 2 North, on 6/18/15 with a diagnosis of major depression. Admission orders included suicide and assault precaution with every 15 minute safety observation. Pt. #11 did not have orders to be boarded on the ITU unit.

3. The clinical record for Pt. #12 was reviewed on 6/23/15. Pt. #12 was a 55 year old male admitted to 2 North on 6/16/15 with a diagnosis of schizoaffective disorder. Admission orders included assault precaution with every 15 minute safety observation. Pt. #12 did not have orders to be boarded on the ITU unit.

4. The clinical record for Pt. #13 was reviewed on 6/23/15. Pt. #13 was a 28 year old male admitted to 2 North on 6/19/15 with a diagnosis of Schizoaffective disorder. Admission orders included suicide precaution with every 15 minute safety observation. Pt. #13 did not have orders to be boarded on the ITU unit.

5. The clinical record for Pt. #14 was reviewed on 6/23/15. Pt. #14 was a 34 year old male admitted to 2 North on 6/21/15 with a diagnosis of bipolar disorder. Admission orders included suicide and assault precaution with every 15 minute safety observation. Pt. #14 did not have orders to be boarded on the ITU unit.

6. The above findings were discussed with the Night Supervisor during an interview on 6/23/15 at approximately 5:40 AM, who stated that the ITU was currently being used as a boarding unit for five, 2 North patients, due to 2 North having several blocked rooms (rooms with two beds currently used only for one patient based on diagnosis). The night supervisor stated that a physician order is required to board patients in another unit, and the patients boarding in ITU should not have occurred until the orders were obtained.