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MORTON HOSPITAL
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on observation, record review and interviews the Hospital failed to have two patients (Patient #4 and #5) in a sample of ten Emergency Department (ED) patients, ordered for 1:1 care and individually observed as 1:1 (one staff member per one patient) despite being continuously observed by a Patient Safety Sitter on a video monitor.
Findings include
An ED note dated, 12/8/18, indicated Patient #4 was brought to the Hospital after he/she was found with a belt around his/her neck and stated he/she was going to kill himself/herself. Patient #4 was assessed as having a high risk for suicide.
Continuous Observation Request Forms and Patient Safety Sitter Patient Care Plans for Patient #4, dated from 12/8/18 to 12/10/18 and completed by nursing staff, indicated nursing implemented continuous observation for Patient #4; however, there was no physician or other licensed independent practitioner's provider order for specific type or level of observation (1:1 care need for Patient #4).
An ED note, dated 12/7/18, indicated Patient #5 was brought to the Hospital after making suicidal and homicidal threats. Patient #5 was assessed as a high suicidal and homicidal risk.
Continuous Observation Request Forms and Patient Safety Sitter Patient Care Plans for Patient #5, dated from 12/7/18 to 12/19/18 indicated that continuous observation was implemented by nursing staff; however, there was no physician or other licensed independent practitioner's provider order for specific type or level of observation (1:1 care need for Patient #5).
The Surveyor observed the Behavioral Health Area of the ED at 8:00 A.M. on 12/10/18 with the Director of Quality Improvement. The Surveyor observed Patient Safety Sitter #1 sitting at a desk observing seven behavioral patients (including Pt #4 and Pt #5) on a video monitor screen. The Surveyor observed Patient Safety Sitter #2 walking in the hallway checking on all patients in the behavioral health area of the ED.
The Surveyor interviewed the Director of Quality Improvement at 10:30 A.M. on 12/11/18. The Director of Quality provided the Surveyor with a Hospital document outlining an algorithm for the suicidal patient dated 11/27/18. The Director of Quality Improvement said the Hospital was in the process of making improvements to ensure orders for 1:1 care were documented and that high suicidal risk patients are fully viewed by 1:1 sitters.