Analyse what may have caused this situation to occur

Analyse what may have caused this situation to occur

You are a first year RN and this is your third week in the Emergency Department you have been assigned to care for four patients that have been admitted to the emergency department for treatment. Three of the four patients are comfortable with stable vital signs and all are awaiting various diagnostic test results. The fourth patient is a 42 year old male Ben Willow (accompanied by his wife) presenting with persistent headaches that have been so intense he has not been able to sleep for the past two days.

The patient was seen by the medical officer and is awaiting an MRI scan. He is on full neurological observations hourly. It is time to undertake the next set of hourly neurological observations you enter the darkened cubicle and before you say anything the patient’s wife tells you that she does not want her husband disturbed because he has finally gone to sleep. You consult the observation chart and see that the previous two sets of observations were within normal range. You decide not to wake the patient and note on the emergency chart that you were requested not to wake the patient by his wife.

It is now time for your meal break and you hand over to the coordinator who says she will keep an eye on the four patients. You return from you break to find Ben’s cubicles curtain pulled and you can see from the legs showing under the curtain that it is full of staff and you see the wife crying outside of the curtain. The coordinator approaches you and explains that Ben is unconscious and the medical officer wants to know why the last set of neurological observations have not been filled in?