HospitalInspections.org

Based on review of medical records and interview with staff a registered nurse did not evaluate and ensure that all orders issued by a physician for the patient of concern were implemented.

Findings:

a. In review of the patient (38 y/o male) medical record in reviewing the physicians orders on September 23, 2016 at 1:00pm there was a physicians order to place the patient on a 1:1 safety precautions to monitor left arm immobilizes. In the review of the Behavioral Health Daily Observation there is no documented evidence of the the patient being on a 1:1 monitor on the September 23-25, 2016. It was not until September 26, 2016 after the physician placed a second order for the patient to be placed on a 1:1 when staff started to document the patient being on a 1:1.
In the nursing assessment notes on September 23-25, 2016 there was no documentation of the patient being on a 1:1 with nursing staff.

b. In an interview with the patient psychiatrists at 10:20am on December 8, 2016 in the administration conference the physician confirmed the patient should have been on a 1:1 as of Sept. 23, 2016.

c. In an interview with staffs # 4-8, mental health technicians at 2:30pm, 2:45pm, 3:00pm , 3:10pm and 8:15pm all staff interviewed said they did not remember standing a 1:1 with the patient of concern until after both of his hands were in soft splints. This was on September 26, 2016.

There is no evidence the patient was receiving 1:1 safety observation between September 23-September 25 as ordered by physician.