HospitalInspections.org

Based on interview and record review, the facility failed to ensure that nursing care in the form of a sitter was assigned in accordance with the patient's needs as defined by physician orders for a sitter for 1 of 10 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. The patient was admitted to the facility on 2/09/14. A physician ordered a sitter on 2/13/14 at 3:19 PM. Regarding the basis for assigning a sitter, there was no specific mention in the medical record by the physician of a justification for it through the point of discharge. However, the Discharge Summary, dictated on 3/23/13 at 3:09 PM read, "....he was not stable enough on the gait; so apparently, he was at high risk for falls, so he had a sitter in the room all the time...."

A nurse's note of 2/13/14 at 5:15 PM read, "Pt (patient) sitter at the bedside...." A nurse's note of 2/13/14 at 8 PM read, "Pt very restless and combative-hitting, kicking and spitting. Code Gray was called." A nurse's note of 2/14/14 at 10:51 PM read, "Sitter at bedside." A nurse's note of 2/16/14 at 8 AM read, "Pt has sitter at bedside...."

A nurse's note of 2/17/14 at 7:04 PM read, "Pt was combative and uncooperative much of the day.... Continued to be combative and uncooperative.." Per interview of the Director of Critical 3/31/14 at 3:10 PM, this was a day shift (7 AM-7 PM) nurse.

The Director of Critical Care confirmed in an interview on 3/31/14 at 3:10 PM that there was no sitter available on the 7 PM-7 AM shift (2/17/14 into 2/18/14); therefore, the patient was moved at the beginning of this shift to room 315, which was very close to the nurse's station. She stated that there was no cancellation of the sitter order. Placement by the nurse's station is considered as an option to provide increased patient visibility over placement in a room which is away from the nurse's station. However, during an interview of the Risk Manager on 2/01/14 at 12:44 PM, she agreed that placement by a nurse's station (without a sitter) cannot ensure the same non-stop visibility as possible with a sitter.

A fall risk assessment of 2/17/14 at 8 PM read, "Is patient following fall prevention directions: N (no).... Pt is confused and consistently asking or attempting to get OOB (out of bed). Presently place in soft wrist restraints to prevent self injury. High risk for falls: Y." It then listed various fall prevention approaches which excluded mention of a sitter. It also read, "Plan to initiate sitter for pt." This last note indicated that the nurse perceived a need for a sitter. As indicated above, no sitter was available during this shift

During the above interview of the Risk Manager on 3/31/14 at 2:55 PM, she stated that the patient had a fall in the evening of 2/17/14.

A nurse's note of 2/18/14 at 12:10 AM read, "Pt. fell climbing OOB (out of bed). Dr.... made aware of laceration to right eyebrow and that steri strips were applied. He asked was the patient complaining of any pain. I 'said no'. He then said to observe him throughout the night. No orders at this time."

An interview was conducted with the Director of Critical Care on 4/01/14 at 2:40 PM concurrent with an interview of the Risk Manager. She stated that staff learned of the fall when an alarm sounded and that staff could not get there quick enough. She confirmed that there was no evidence that a nursing assessment was performed prior to removal from a sitter. She stated that the patient needed someone to be with him during the evening shift of 2/17/14 to help keep him in bed.

Thus, a physician had ordered the use of a sitter on 2/13/14. A physician had associated this measure with fall prevention. This order was not canceled as of 2/17/14. The patient was deemed at a high risk of falls at the beginning of the evening shift on 2/17/14. The facility removed the patient from sitter coverage on the shift commencing at 7 PM, due to staffing concerns. A nursing assessment was not performed with respect to this sitter removal. This left the patient who had a high risk of falls and the behavior of constantly attempting to get out of bed with a room assignment which afforded reduced observation by staff. The patient subsequently experienced a fall with injury.

During an interview of the Risk Manager on 4/01/14 at 5:45 PM, she confirmed the findings.