No 1:1 sitter for fall risk patient

amoLucia · Jan 24, 2015

Like a PP, I have never worked in any facility that would have a supply of sitters avail for 1:1 assignments. That seems to be a real luxury that exists primarily in hospital settings. To my knowledge, it is all but unheard of or nonexistent in most LTC. And to play devil's advocate, our pts in LTC/rehab settings are just as likely to fall (or other crazy behavior) just as much as yours are in the hospital setting. And to top it off, we have LESS staff and MORE pts to provide for.

There have been more episodes too numerous to count when I've had a confused pt in a whch making rounds with me. I would just have to drag the whch with me room to room and park them at the doorway. It would be me or the CNA - we each would do a couple rooms then we'd switch to take the pt. A med pass at 6am is NOT FUN, nor were last rounds FUN for the CNA either. Talk to any LTC staff member.

We don't have any physical restraints, and to use anything chemical requires that the pt must first have been trialed with less restrictive approaches. So all our pts HAVE TO first been walked (if poss), talked to, fed, toileted, have towels to fold, magazines to rip (er, to read), and other diversions. We have to try to put them to bed intermittently, etc. Then, MAYBE, some miniscule PRN can be administered. And then you know, they will sleep away the whole dayshift!

I never knew that 1:1 was used as widely as it seems to be until I read it here on AN.

I always let the supervisor know (or I did some relief pt-sitting myself when I was super). Not that it would change anything. As for charting, all I could document was that 'pt under close supervision by staff' and any of my interventions.

And all PP are correct that nurses will be sacrificed by the powers that be should an incident occur. Maybe some documentation to your Risk Management Dept might alert them to the situation, but I doubt that it would have any effect. (And then I'd be concerned that that someone might become a 'whistleblower'.

Not good for anyone - staff or pts.

MunoRN, RN · Jan 24, 2015

Identifying that a patient is a high fall risk and therefore should have a 1:1 sitter is often done by the nursing staff, although MD's sometimes make the same observation which they document with an "order", from a liability standpoint it doesn't really make a difference who identified the high-fall risk and requested a sitter.

Unfortunately there isn't any legal ground to encourage hospitals to staff for sitter requests. The main question in a court is going to be: do 1:1 sitters reduce fall risks? And while I'm skeptical of the evidence, the current evidence says that no, sitters don't reduce falls. So unless that changes, there is not likely to be any repercussions for hospitals that don't follow requests for sitters, either by physicians or by nurses, in terms of liability.

SpyderWebb · Jan 28, 2015

It happens frequently in the small ICU that I work in. All of the suicide attempts, no matter how stable, end up on our hands. The docs assume that we can watch them more closely. There are three types of orders for these patients. 1:1, line of sight and close observation. None of these are possible unless a nurse only has one patient or an incredibly stable, self sufficient walkie talkie for their second. Those two scenarios almost never ever happen.

Until policies and procedures are put into place by the big company that purchased this small hospital, I have done the following and my direct supervisor is aware of my actions.

I am not a trouble maker and have constantly proven myself to be oriented towards being part of solutions. I take patient advocacy very seriously.

I immediately notify the house supervisor of the order and my inability to carry it out due to my patient assignment and acuity.

I notify my director of the same.

I notify the physician as well.

I then document these calls in a narrative note.

Lastly, an incident report.

Hopefully, things will get safer before someone hurts themselves because of inappropriate admissions to ICU and unsafe staffing.

My colleagues have begun to follow suit.

toomuchbaloney · Jan 28, 2015

I agree with SpyderWebb.

The MD orders it, I cannot safely delegate that so I inform up my chain of command to advise of inability to safely provide the ordered level of care and I document it narratively.

The onus is then upon the management of the facility to discover the resources to meet the needs of the patient as ordered by the provider...OR...to get the provider to write a new and less demanding level of supervision.

One night I had a very challenging assignment with a confused and agitated patient who required constant supervision. I notified the House Supervisor of the inability to dedicate one staff member to his room and the House Super solved the problem by sitting with the patient herself, having on staff clergy and MSW sit with the patient, etc until a more reasonable arrangement could be discovered the next day.

The point is, once I adequately identified that it was not possible to carry out the order as written with the current level of staffing in the specific unit, the problem became the responsibility of the health professional who had control of staffing...which was not me. No incident report was necessary because, ultimately, the fellow received the level of supervision that was requested. All while I just did my nursing thing with my compliment of patients.

nurseprnRN, BSN, RN · Jan 28, 2015

You don't just say, "No 1:1 sitter available." You will then set yourself up for being asked why the patient was supposed to be on 1:1, what your thoughts are on safety as a prime responsibility of the registered nurse, why you didn't pursue this more, and what did you think when you found the patient on the floor (or out the window on the ground three stories below...)... and so forth.

So. What you have to do, and document meticulously, is,

"7:30 pm. 1:1 sitter necessary for patient safety due to (describe behaviors), prescribed by Dr. X. (and BTW, you do not need to have a physician rx for a 1:1 if you, the RN, deem it necessary for safety. Yes, you can get it yourself. No, you don't need an MD rx. Yes, you can. You can look it up.) No sitter available according to Beth Jones, staffing office. Patient moved to hall for direct observation. Call to Mary Jones RN supervisor to obtain sitter from registry."

"9:00pm. Ms. Jones RN, supervisor, advises no sitter available. Call to DON Sue Smith RN to request sitter from registry. Family notified (Bob Lee, 555-1212, son) that sitter needed and not available."

"9:30pm. Ms. Smith advises no sitter available. Informed by RN that patient has not slept and cannot rest in hallway with lights and activity. Call to Dr. X to advise of events since 7:30pm. No change in medical plan of care. Call to Karen Wainwright, adminstrator on call, to inform of events and request sitter."

"11:15pm. Report given to SuzieQ RN about events since 7:30pm. Callback from Ms. Wainwright pending."

THEN you can leave and go home. In the morning, you write this all up and send it return receipt requested in the mail, not in email, to your corporate risk manager. Keep a copy for yourself and send another to your nursing malpractice insurance carrier.

allnurses Guide · Jan 28, 2015

There are repercussions if the failure to implement an order results in a tragedy.

In this situation The hospital was cited by the state and fined $75,000.00.

The nurses were not held responsible because they filled out an "Assignment Despite Objection" (ADO) form each shift stating "In our professional judgment the patient needs a sitter. We will care for the patient the best we can under the circumstances, however and adverse effect on patient care is the responsibility of the hospital."

This was given to the manager on days and the shift supervisor on nights. For several days before the fall this went on.

These nurses reported to management verbally and in writing whenever their staffing was not as it should be. They keep a copy. Unfortunately this time the patient got out of bed, fell, and sustained a skull fracture.

Nurses had a CNA stay with the patient when the supervisor wouldn't order a sitter. Then the son sat with his father until he had to go the work.

Then the nurses had a volunteer sit with the patient for a few hours.

From page 5 of the state document is:

RN 2, the care provider for Patient A on the day of the fall (1/31/10) was interviewed on
2/12/10. According to RN 2, Patient A had fall precautions in place, including a tab alarm, which the patient removed, as well as a bed alarm.
RN 2 stated that following the patients' fall, she had asked the supervisor why a sitter was not used for Patient A.
According to RN 2 the supervisor told her there were a hundred other things to do before utilizing a sitter.
http://www.cdph.ca.gov/certlic/facilities/Documents/HospitalAdministrativePenalties-2567Forms-LNC/2567PomeradoHospital-LQQ711-SanDiegoCounty.pdf

Pomerado Hospital (PDF)

15615 Pomerado Road, Poway, 92064, San Diego County - The hospital failed to ensure the health and safety of a patient when it did not follow its policies and procedures for fall prevention. This is the third administrative penalty issued to the hospital. The penalty is $75,000.

caliotter3 · Jan 28, 2015

We used to set the person up in a geri chair/recliner at the nurses station.

wanderlust99 · Jan 29, 2015

I would notify the charge nurse. And ensure the charge nurse notifies the supervisor. Chart both interactions.

You also need to notify the physician that you can't follow through w/the order. Document the notification and the MD response. It covers you. The hospital, not so much. It is the nursing supervisor's responsibility to staff appropriately.

Also I assume a bed alarm was in place, what about a posey vest? Move the patient to a room close to the nursing station.

macfar28 · Feb 1, 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.

I have been told this is illegal, at least in my state. A 1:2 or 1:3 is in violation of the order. Also, our policy states 1:1 means within arms reach at all times so we cannot use a recliner by the nurses station.

As previously suggested, if it comes down to the RN sitting and his/her assignment being redistributed, we do it.

We also do not page the doc to change the order because should a serious injury occur, you can bet it will be asked, "why was the order written but then changed?" We had a patient hang herself who was taken off a 1:1 due to lack of staffing. Never again.

calivianya, BSN, RN · Feb 12, 2015

We only use sitters for suicide precautions, not fall risk patients.

If a patient is one of those super confused, doesn't know where he is, ripping everything off, sundowning patient, we just use restraints. I am concerned about falls, but I am a little more concerned about the patient ripping his central line out of his IJ and getting an air embolism and dying, or ripping out his art line and bleeding so profusely he needs a blood transfusion. My patients have enough equipment attached to them that it's usually pretty easy to justify restraints to keep them from half-killing themselves due to confusion. The fact that tying them to the bed makes it a little more difficult for them to get out of the bed is just an added bonus.

RNKX · Feb 12, 2015

Only time I have used and will ever use a restraint is if they are an immediate threat/danger to others or themselves. JC is not a fan of the use of restraints especially if the patient is redirectable with a sitter.

calivianya, BSN, RN · Feb 13, 2015

Only time I have used and will ever use a restraint is if they are an immediate threat/danger to others or themselves. JC is not a fan of the use of restraints especially if the patient is redirectable with a sitter.

I think we probably have about half of our patients in restraints at any given time, so we probably have 15 restrained patients on my unit alone. Unfortunately, my job is not willing to pay for 15 extra sitters when we can just restrain these people instead, and honestly, I feel like a sitter would not be enough to keep most of them from endangering themselves. The people that are determine to get OUT!, and to pull everything OUT! can be pretty strong. I worked as a sitter a lot in nursing school, and if someone is really strong, it can be almost impossible to stop him/her from pulling out the staples in his incision, the central line, etc.