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Based on documentation review and interviews, it was determined that the Hospital failed to ensure that Pt #1 was provided with 1 to 1 observation for suicidal ideation as indicated in the Admission Nursing Plan of Care dated 1/13/2012 at 8:00 A.M.

Findings include:

Background information:

Pt #1 was admitted on [DATE] for treatment of suicidal ideation and chemical dependency. Pt #1 was placed on 1 to 1 observation for safety. Pt #1 was administered multiple medications for treatment of his/her withdrawal symptoms. Pt #1 was found unresponsive and without respirations on 1/14/2012 at about 11:15 A.M. Extensive resuscitation effort was unsuccessful and Pt #1 was pronounced dead at 12:01 P.M. on 1/14/2012.

The Patient Note dated 1/13/2012 at 8:34 A.M. indicated that Pt #1 was to have a 1 to1 sitter at the bedside for safety.

The Nursing Physical assessment dated [DATE] at 5:54 P.M. indicated that Pt #1 had a Clinical Social Worker referral and continued on 1 to 1 observation.

The Nursing Physical Assessment date 1/14/2012 at 8:00 A.M. indicated that Pt #1 continued to have a 1 to 1 sitter and was on suicide precautions and awaiting an inpatient admission to a psychiatric facility.

1) Nursing Assistant (NA) #1 was interviewed by telephone on 8/16/2012 at 1:15 P.M. NA #1 said that she was assigned to be the 1 to 1 sitter on 1/14/2012 at 7:00 A.M. NA #1 said that she was assigned to be a sitter/observer both for Pt #1 and his/her roommate. NA #1 said that she was positioned in a chair between Pt #1 and his/her roommate's bed for continuous visualization of both patients.

2) NA #1 said that she was told that Pt #1 was unsteady on his/her feet and on a Section 12 (allows for licensed, qualified medical staff to hold a person who is considered likely to do harm to himself or others) during report. NA #1 denied knowing that Pt #1 was assessed to be at risk for suicide.

3) NA #1 said that she was assisting Pt #1's roommate with morning care with the privacy curtain closed and had no visualization of Pt #1 for an unspecified period of time. NA #2 came into the room at around 11:15 A.M. NA #1 said that when NA #2 entered Pt #1's room she asked NA #1 if she smelled vomit. NA #1 said that Pt #1 had the sheets pulled up to jaw line and was assumed to be sleeping prior to NA #2's question about smelling vomit. NA #1 said that she and NA #2 went to assess Pt #1 and immediately noticed that Pt #1's color was poor and he/she was not breathing.

4) The Hospitals Sitter/ Observer Guidelines indicated that the sitter/observer will sit in the patient's room with an unobstructed view of the Patient. When the Sitter/Observer is assigned to monitor two patients in the same room the Sitter/Observer is positioned to maintain an unobstructed view of both patients. Additional staff must be provided if patient activity prevents the observer simultaneously monitoring patients

5) NA #1 said that she would never leave the room while watching a patient on a one to one observation assignment. NA #1 said she knew that her role as the Sitter/Observer is to keep the patient safe and never leave patients alone in their rooms. However, NA #1 did not verbalize an understanding of when additional staff are required when one patient requires care and prevents her from observering the other patient she was assinged to, nor did she seek addional help when Patient #1's roommate needed assistance with morning care.

6) Nursing Assistant (NA) #2 was interviewed on 7/30/12 at 11:00 A.M. NA #2 said that she remembered seeing Pt #1 pacing in his/her room early in the morning. NA #2 said that she went in to give NA #1 a break. NA #2 said that she smelled vomit when she walked into Pt #1's room and asked NA #1 if she smelled it. Both NA #1 and NA #2 approached Pt #1's bedside and removed the blankets from his cheek. NA #2 said that Pt #1 did not have blankets completely over his/her face, but right to the jaw line. NA #2 said that Pt #1 had a slight blue tint and she attempted to wake him. Pt #1 did not respond and NA #1 called a code 9 and initiated CPR. NA #2 said that she has been assigned to watch 2 patients at once on 1 to 1 observation. NA #2 said that she has not received much training on 1 to 1 observation, except she knows patients can't be left alone.

7) The Hospial Policy titled Sitter/Observer Guidelines did not clearly define the criteria for one to one observation in contrast to observation. The policy also did not specifiy that more than one patient could be assigned to a sitter for one to one observation. One to one observation should be exactly one patient to one sitter.