HospitalInspections.org

Based on review of hospital policies/procedures, medical records, and interviews, it was determined that the hospital failed to require that a registered nurse supervise and evaluate the nursing care of each patient as evidenced by:

1. failure to implement and evaluate the monitoring of 1 of 1 patient who was on a strict line of sight observation orders (patient #1); and

2. failure to complete nursing assessments of 1 of 1 patients (patient #1).

Findings include:

1. Review of Facility Policy and Procedure titled "Levels of Observations" dated August 15,2007 revealed: "...All patients will be closely observed in compliance with physician orders and prescribed protocols...The RN may not decrease the level of observation (i.e. change from 1:1 to Line of Sight without a physician's order by the attending MD/designee...Line of Sight Observation (LOS)...Refer to the 'Practice Guidelines for Level of Observation'... Staff will maintain constant visual observation through direct observation...Practice Guidelines for Levels of Observation...Guidelines for LOS...Patient extremely confused and at risk of inadvertent self-harm..medically unstable...status post suicide attempt but not meeting 1:1 guidelines...acute suicide ideation...assault risk but not meeting 1:1 guidelines...constant elopement risk...."

Patient #1 had an unwitnessed fall on 07/11/11 at 1355. RN # 8's Nurse's Notes on 07/11/11 at 1405 revealed: "...Pt found down on floor in dayroom stated,'I hit my head,' pt assisted back into w/c, ice applied to discoloration on forehead, dr and daughter notified....."

MD #1 Order written on 07/06/11 at 2320 for "...strict line of sight for safety...."

MD #1 Order written on 07/07/11 at 1100 am for "...strict line of sight for safety...."

Medical Record Review revealed there was no MD order to change patient to a lower level of observation. Employee # 3 confirmed on 09/23/11 at 1350 there was no new orders for level of observations.

Employee # 3 during an interview conducted on 09/23/11 at 1350 did not know why the fall on 07/11/11 would have been unwitnessed if the patient was ordered to be on strict line of sight for safety.

Review of assignment sheets for date range of 07/07/11 to 07/21/11 revealed there was no specific employee assigned to patient #1 for line of sight. Employee # 3 confirmed during an interview conducted on 09/23/11 at 1350 that the assignment sheets did not specify patients who were on line of sight.

2. MD #2's Progress Notes on 07/11/11 at 0940 revealed "pt c/o some pain in L (left) hand...She fell on her L hand yesterday...mild bruising and swelling noted on dorsal aspect of L hand....pain to L hand....check X-rays...ice to left hand...."

MD#2's order on 07/11/11 at 0935 revealed: "...Order for X-ray Left hand and wrist for pain in left hand...."

MD # 4's Psychiatric Progress Note on 07/11/11 at 10 am revealed "...Pt has significant swelling and bruising and pain left hand, acc (sic) (according) to pt she fell yesterday (no hip Fx), Dr (#2) evaluated and ordered X-ray hand to rule out fracture...."

There was no documentation in the medical record of patient fall or patient incident by Nursing which involved an injury to the left hand. The medical record review did not reveal any documentation by nursing of an assessment of patient # 1's left hand until 07/11/11 at 1040 after MD # 2 and MD #4 progress notes mention the left hand injury.

Employee # 3 confirmed on 09/23/11 at 1350 there was no documentation in the medical record concerning how the injury to the left hand occurred. Employee # 3 also confirmed on 09/23/11 at 1350 there was no documentation in the medical record of the left hand injury and assessment until the Nurse's Note 07/11/11 at 1040.