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Based on interview and record the hospital failed to ensure patient ID# 1 had a documented physician order for a "Vail bed."

Findings include:

Interview 6/8/12 at 9 a.m. with the Director of Quality Services (ID# 50) revealed patient ID# 1 had a traumatic head injury from a motor vehicle accident in March 2012. The patient had frequent agitation, was a high fall risk and made constant attempts to get out of bed. The patient was placed in a Vail bed for the patient's safety on 6/1/12 around 7 p.m.. The hospital has determined that there are conflicting statements by facility staff and the patient ' s physician as to whether a Vail bed was ordered for patient ID# 1. Staff members (ID#'s 54, 55, 56) stated that they saw a physician order in the chart for a Vail bed, but now the order is missing from the chart. The physician (ID# 57) denied writing an order for a Vail bed and said he only discussed the use of a Vail bed.

Record review of nursing notes dated 6/1/12 at 7:45 p.m. stated " Rounding to check patient, In Vail bed enclosed for patient safety.

Record review of the medical record for patient ID# 1 dated 5/29/12 to 6/1/12 revealed no physician order for a Vail bed.

A progress note written by patient ID# 1's physician (ID# 57) dated 6/2/12 stated " Late entry for 6/1/12 evening. I was paged by nurses late last night stating that patient was found unresponsive and that 911 EMS was coding her. Shortly after received call from nurses that patient had expired. On arrival here to unit to patient ' s room to find her expired (unresponsive, pupils fixed and dilated and no vital signs). Patient was found in Vail bed but I had not given order for this nor had I given order to discontinue 1:1 sitter. It was discussed briefly with Mother in passing at Hermann Hospital and here with RN staff but ultimately it was decided to leave patient on 1:1. It was decided to leave patient on 1:1 and hold off on Vail bed until medications could be optimized and I could discuss it with the Mother more in depth. "

Record review of a policy titled " Restraints " dated 8/11 stated " Physician order: If the attending physician is not available, a registered nurse, or Physician Assistant may initiate restraint in advance of physician ' s order. "

Based on interview and record the hospital failed to ensure patient ID# 1 had a documented physician order to discontinue a 1:1 (one-to-one) sitter that had been previously ordered.

Findings include:

Interview 6/8/12 at 9 a.m. with the Director of Quality Services (ID# 50) revealed patient ID# 1 had a traumatic head injury from a motor vehicle accident in March 2012. The patient had frequent agitation, was a high fall risk and made constant attempts to get out of bed. The patient was placed in a Vail bed for the patient's safety on 6/1/12 around 7 p.m.. The hospital has determined that there are conflicting statements by facility staff and the patient ' s physician as to whether a Vail bed was ordered for patient ID# 1. Staff members (ID#'s 54, 55, 56) stated that they saw a physician order in the chart for a Vail bed, but now the order is missing from the chart. The patient subsequently coded and died while in the Vail bed. The physician (ID# 57) denied writing an order for a Vail bed and said he only discussed the use of a Vail bed. In addition, there was an order for a 1:1 sitter but the night the patient coded she did not have a one to one sitter. The previous Director of Nursing (ID# 56) stated that the physician (ID# 57) told her that it would be alright not to have a sitter since the patient had a Vail bed, but no physician order was written to cancel the sitter.

Record review of physician orders dated 5/31/12 at 2:20 p.m. revealed an order that stated
" 1:1 Supervision. "

Record review of the medical record for patient ID# 1 dated 5/29/12 to 6/1/12 revealed no physician order to discontinue the 1:1 Supervision of the patient.

A progress note written by patient ID# 1's physician (ID# 57) dated 6/2/12 stated " Late entry for 6/1/12 evening. I was paged by nurses late last night stating that patient was found unresponsive and that 911 EMS was coding her. Shortly after received call from nurses that patient had expired. On arrival here to unit to patient ' s room to find her expired (unresponsive, pupils fixed and dilated and no vital signs). Patient was found in Vail bed but I had not given order for this nor had I given order to discontinue 1:1 sitter. It was discussed briefly with Mother in passing at Hermann Hospital and here with RN staff but ultimately it was decided to leave patient on 1:1. It was decided to leave patient on 1:1 and hold off on Vail bed until medications could be optimized and I could discuss it with the Mother more in depth. "

Interview 6/8/12 at 12:20 p.m. with nurse ID# 58 revealed he was on duty the day of 6/1/12 working the
7 a.m. to 7 p.m. shift. The nurse stated he actually placed patient ID# 1 in the Vail bed around 6 p.m. that day. The nurse conferred with the Director of Nursing (ID 56) and the decision was made to discontinue the 1:1 sitter for the 7 p.m. to 7 a.m. shift since the patient now had a Vail bed. The nurse stated he did not call the physician for an order to discontinue the sitter.