No 1:1 sitter for fall risk patient

elkpark · Jan 22, 2015

Wow, that's setting the hospital up for huge liability. Everywhere I've worked, the organization has done whatever was necessary to provide a sitter when one is ordered by the physician, or maybe presented an alternative safety plan to the physician and convinced the physician to d/c the order. But simply not implementing the order because of staffing needs is not acceptable -- what other physician orders don't get implemented at your facility because it's inconvenient for the facility staff??

RNKX · Jan 22, 2015

Oh here's another: there was no RRT (rapid response) on night shift last night!

Here.I.Stand, BSN, RN · Jan 22, 2015

I agree, that's a huge risk. On my unit, when a pt becomes a risk to him/herself and there is no extra staff to do the 1:1, the first thing we do is pull our own CNA to sit with that pt. If that's not possible, our CN contacts the nursing supervisor and he/she pulls one from another floor. That's not even taking the medical plan into account; if our nursing judgment says a pt is unsafe to be left alone, we do whatever we need to to keep the pt safe.

If nothing else, the RN should do the 1:1 while the rest of his/her assignment is redistributed. Or else, CN and nursing supervisor pitch in to help w/ sitting and/or care of the other pts. Is that ideal or even reasonable? No. But neither is ignoring safety concerns.

I can't imagine a lack of staff would hold up as a defense in court either, should this pt fall and get a head or C-spine injury.

CTnewgrad826 · Jan 22, 2015

In the mean time of trying to find one bring the pt in their recliner into the hallway. A nurse or CNA who isn't busy at that time can sit with the pt and you can switch off so everyone can get their assignments done while finding an actual sitter.

lovetosleep · Jan 23, 2015

We run into this problem at my work pretty often, and I also wonder how to document. Often we are so short that there is no charge, no Cna on the floor, and we will have one 1:1 when there are 3 pts that need 1:1s.

We try to move all the 1:1 pts so they can share a room, but that only works when they are the same sex, or until one walks out of the room. I don't understand why we are so short all the time.

jadelpn, LPN, EMT-B · Jan 23, 2015

Wow. Cutting corners for the bottom line is apparent.

Get malpractice insurance if you do not already. If you have a union, bring it to them. Make sure that you are doing incident reports each and every time. I would go to your manager, and up the chain of command. Risk management would also be interested in this as well, I would think.

Because the bottom line is that if a patient that you are caring for is supposed to be a 1:1 and that order is not being followed, it is YOU that would be liable for that. And there's no more of a selective amnesia than when a manager says "I had NO idea!!" when it is brought to their attention time and time again.

A suggestion would be to have a pool of sitters who are PRN. There can be other staff who can be trained as sitters that could be called in or pulled if needed.

This is a messy situation, that is for sure. And to answer your question: the reason you are running short staffed is because to hire more staff requires money. And there's lots of things that a facility would like to spend money on, however, nurses and nurses with a support staff are not among the priorities. And if something occurs that will affect the money that comes into the facility (ie: a patient fall and a lawsuit, for instance) it will be every way to Sunday on how this is the nurse's fault.

In the meanwhile, if you are given an assignment that is a 1:1 and there is not one available, I would have to call the MD for an alternate order. 15 minute checks maybe? Then I would either get a recliner and put the patient in plain sight or if feasible, a wheelchair with no legs (and an order for a seatbelt) so that the patient can self-ambulate with same. Needless to say, there needs to be an alarm on the patient regardless.

This is really an awful example of money greed by the big wigs gone bad. I am curious if your charge is a newer nurse and if your manager has ever been a bedside nurse. However, with that being said, they can only do as they are told by the DON. Who I am sure has not been a nurse at bedside for years (if at all) and has no clue what goes on in your unit. Same story just about everywhere it seems.

Good luck with this and keep us posted!

applewhitern, BSN, RN · Jan 23, 2015

None of the hospitals I have worked at used a 1:1 sitter. The family would be required to either sit with them, or else find a private sitter themselves. Not saying that is right, but that is the way it has been in every job I held. If the MD made that order, administration should have let the doctor know that was not possible; it should not be left up to a staff nurse to handle. If the doctor is a money-maker for the hospital, then he needs to voice his concerns in their medical meetings. Administration won't care what you think, but if it comes from someone who makes them money, they will.

lindarn · Jan 23, 2015

How about writing a letter to the Senior Partner of the Law Firm who represents the hospital, and informing them of the situation? I am sure that they would be very interested in how the hospital is setting themselves up for a big lawsuit.

Of course, they will try their old favorite, "throw the nurse under the bus", that has usually worked out well for them, but not for the poor nurse, who was only doing the best under the worse staffing. And of course, the nurse has NO say in the staffing of the unit.

JMHO and my NY$0.02

Lindarn, RN, BSN, CCRN(ret)

Somewhere in the PACNW

TriciaJ, RN · Jan 24, 2015

I once worked for a real Ebenezer Scrooge of a manager. Anytime a doctor ordered 1:1, she would insist they change the order to restraints and haldol. I'm sure that wasn't even legal. Haldol is poorly effective for elderly confused people (and constitutes a chemical restraint) and I've never seen soft restraints hold anyone yet. I used to beg my coworkers to complete an inadequate staffing report, but they were too intimidated.

I tried to bring it up with the manager's manager, who was shocked until she found out whose idea it was. Then she was all for it. I like the suggestion of notifying the law firm that represented the hospital. Wish I'd thought of that at the time.

vintagemother, BSN, CNA, LVN, RN · Jan 24, 2015

I'm wondering why the MD ordered it if it's not possible.

If it were me, I'd either call him to get the order changed or I'd let my charge know his order so that I could document why the order wasn't followed.

That being said, our MD doesn't typically place orders we have no ability to implement.

jennyincze · Jan 24, 2015

I work on the neuro floor as a tech and I frequently have 10-14 patients a night. Virtually all our patients are fall risks, unless they are walkie-talkies with a very steady gait. We do whatever we can to keep all our patients safe, but due to inadequate staffing it is hard. We very frequently get stuck with baker act patients. Our whole floor has 3-5 a shift... Those are required to have a 1:1 sitter. Our MDs do not put orders in for 1:1 unless they are a harm to others/themselves, and that does not usually mean fall risks. We set bed alarms, keep doors open, hourly rounding, etc. That is all we can do unless central gives us more staff.