HospitalInspections.org

Based on interview and record review, the facility failed to document safety sitter observations for 1 (P-1) of 10 patients reviewed, resulting in the potential for negative outcomes. Findings include:

Record review of "History and Physical exam" dated 05/10/24 revealed that P-1 was a 23-year-old female, admitted to the facility on 03/13/23, with a past medical history of hypertension, premenstrual dysphoric disorder, constipation, obesity, acquired thrombocytopenia, dyslipidemia and anorexia.

Review of medical record documents titled, "Seclusion/Restraint Report," dated 12/08/24 at 1748 revealed that P-1 was placed in restraints from 1748 until 1954 on 12/08/24, and resident care associate (RCA) Staff T was the designated patient safety sitter (1:1).

Record review revealed that RCA Staff T's documentation of her 1:1 observations of P-1 in the restraint and seclusion room on 12/08/24, were not in the medical record.

During record review and interview on 02/04/25 at 1244, Nurse Executive (Staff D) was questioned why RCA (Staff T's) 1:1 restraint documentation was not present in the electronic medical record (EMR). Staff D stated, "(Staff T) should have charted the 1:1 safety observation but it doesn't look like she did."

Review of facility's Standard Operating Procedure (SOP) #2.24, titled "Use of Restraint and Seclusion," effective 10/20/23, revealed under paragraph 20, "The condition of the patient who is restrained or secluded must be monitored by a physician, or hospital staff who have completed the training criteria as specified in the procedure, at least once every 15 minutes." Further review under, "The Direct Care staff will," revealed, "Complete required monitoring and document in the EMR (electronic medical record)."