HospitalInspections.org

19826

Based on review of the clinical records, interviews and review of hospital policy and procedure for three of three patients (Patients #5, 6 and 7) that required constant observation for safety, the hospital failed to ensure that the patient was safe. The findings include:
1. Patient #5 arrived at the Emergency Department (ED) on 8/8/10 at 7:41 P.M., via Emergency medical System (EMS) ambulance with the complaint that he/she wanted to kill him/herself and others. Review of the clinical record, reflected that Patient #5 would not contract for safety, was at risk to hurt self and others and a constant attendant was placed at the doorway. Review of the constant attendant instructions, dated 8/8/10, identified that Patient #5 was a flight risk.
2. Patient #6 arrived at the ED on 8/8/10 at 1:53 P.M. via EMS ambulance with the complaint of being found unresponsive due to alcohol intake and low blood sugar. Review of the clinical record identified that starting on 8/8/10 at 7:25 P.M. Patient #6 began demonstrating signs and symptoms of alcohol withdrawal. In addition on 8/8/10 at 11:00 P.M. a constant attendant was assigned to monitor Patient #6 for his/her history of low blood sugar. Review of the constant attendant instructions, dated 8/8/10, identified that Patient #6 experienced low blood sugar episode.
3. Patient #7 arrived at the ED on 8/8/10 at 8:06 P.M. via EMS ambulance with the complaint of disorientation and developing hallucinations. Review of the clinical record reflected that on 8/8/10 at 11:00 P.M. was upset, yelling at staff and wanting to leave and a constant attendant was put in place. Review of the constant attendant instructions, dated 8/8/10, identified that Patient #7was a flight risk.

During a tour of the ED, on 8/9/10 from 9:40 A.M. to 11:35 A.M., constant attendant #1 was observed sitting in a chair in the hallway observing Patients #5, 6 and 7 in two rooms and upon interview constant attendant #1 could not describe why he/she was observing these patients. Interview with RN #2, on 8/9/10, identified that he/she was the nurse assigned to provide care to Patients #5, 6 and 7 and he/she did not give a report to constant attendant #1 regarding each patient ' s needs and/or specific observation that the constant attendant needs to complete for each patient. Review of the facility policy and procedure, titled Constant Attendant Guidelines, identified that the constant attendant assists the nurse in observing a patient, the nurse is responsible to give a report to the constant attendant regarding the patient ' s problem areas, status and specific observations the nurse is requesting and the nurse will conduct an ongoing assessment of the patient.

Based on review of the clinical record, review of facility policy and procedure, and interview for one of three patients (Patient #11) that required a nutritional consult, the facility failed to ensure that a comprehensive nutritional consult was completed. The findings include:
Patient #11 was admitted on 8/4/10 with diagnosis of alcohol intoxication. Review of the clinical record identified that a nutritional consultation was ordered on 8/5/10 at 12:00 Noon. Review of Patient #11 ' s chart and interview with the Nurse Manager of the unit, on 8/9/10 at 1:35 P.M., identified that a comprehensive nutritional consultation had not been completed. Interview with the Supervisor of Clinical Nutrition, on 8/9/10 at 1:45 P.M., identified that he/she had not completed a comprehensive nutritional assessment for Patient #11. Review of the hospital policy and procedure, titled Department of Clinical Nutrition Services, Patient Assessment, identified that for a patient with an altered nutritional status the Registered Dietitian completes a comprehensive nutritional assessment in order to create an individualized nutrition plan.


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