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Based on observation, interview, record review, and policy review the facility failed to appropriately assess/reassess the potential of elopement for one patient (#3) as the patient was allowed to go outside the building to smoke while unattended. The facility also failed to follow their internal policy regarding nursing care plans for one patient (#3) of one current patient. These failures had the potential to place all elopement precaution patients that were allowed to go outside to smoke (while unattended) at risk for elopement. The facility census was three.

Findings included:

1. Record review of the facility's policy titled, "Patient Admission Assessment," revised 09/13 showed the following:
- Assess patient regarding presenting complaint(s) and physical status on admission for baseline data. Include any medical/surgical history.
- Assess environmental factors, which may affect patient's need for care both during hospitalization and after discharge.
- Assess patient's self-care capabilities.
- Assess patient's/families learning needs regarding knowledge of the disease process, self-care, diet, medications, life-style changes, treatment measures and any limitations resulting from the disease or its treatment.

Record review of the facility's policy titled, "Assessment/Reassessment Time Frames," revised 09/13, showed the following:
- The time frames for reassessments (including minimum required documentation of such) is every shift and immediately prior to transfer and as needed for Medical/Surgical patients.
- Document evaluation of patient status and effectiveness of interventions in reassessment summary.
- Use ongoing assessment/reassessment data to revise Nursing Care Plan.
- Identify problems, needs, or concerns.
- Evaluate the interventions as stated in the plan and document.

Record review of the facility's policy titled, "Use of Tobacco Products," revised 12/13, showed the following:
- Patients and visitors will be informed of the tobacco free policy through signage, and written information in the admission packet.
- Patients will be offered tobacco cessation information in the form of verbal communication and preprinted brochures. Patients may also use medicated nicotine patches if ordered by their physicians or participate in scheduled smoking cessation classes.
- Individuals observed violating this policy will be verbally informed of the facility policy and will be given an informational preprinted card. Continued noncompliance will be reported to the Chief Executive Officer (CEO) or the administrator on call.

2. Record review of current Patient #3's Nurses' Note documentation of admission assessment dated 10/28/14 showed Patient #3 was admitted on 10/28/14 at 12:50 PM for abdominal pain. The assessment showed he was alert and oriented to person, time, place and situation. He was able to ambulate without assistance. He was a smoker and was given smoking cessation information.

Record review of Patient #3's Elopement Risk Assessment Form dated 10/28/14 showed the following:
Potential Risk Factors:
- Does the patient have a diagnosis of dementia, Organic Brain Syndrome (decreased mental function due to a medical disease), Alzheimer's, delusions, hallucinations, anxiety disorder, depression, bipolar (also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks) or schizophrenia (chronic, severe, and disabling brain disorder where the affected person may hear voices other people do not hear and may believe other people are reading their minds, controlling their thoughts or plotting to harm them). Yes
- Does the patient ambulate independently, with or without the use of an assistive device (including a wheel chair)? Yes
- Is the patient over 60 years old and receiving hypnotics (medications used to induce sleep, also called sedatives), anxiolytics (medications used to treat anxiety disorders), pain medication or other medications that affect cognitive function? Yes
Patients that are at risk for elopement should have the following implemented:
- Apply RED slipper socks to patient.
- Set the patient bed alarm.
- Close fire doors at the West end of the hall at 9:00 PM.
- Close fire doors to the outpatient therapy area at 9:00 PM.
- Close the door to the Medical/Surgical lobby at 9:00 PM.
- Make staff aware of the Elopement Risk through patient report.
- Initiate the Elopement Care Plan.

During an interview on 10/28/14 at 2:45 PM, Staff C, RN, Charge Nurse, stated that Patient #3 had just been admitted earlier that day and that he "fit the criteria" for the "red socks" per the patient elopement assessment. She stated that he was alert and oriented but that he met three of the five possible criteria on the risk assessment for elopement precautions. She stated he was over 60 years old and on pain medications, ambulatory and said that he had a history of depression. Staff C stated that she would not put the bed alarm on due to his orientation status and the fact that he was able to get up by himself.

3. Record review of the facility's policy titled, "Nursing Care Plan," revised 11/13 showed the following:
- The RN is responsible for initiating a guide for the patient's plan of care from admission to discharge according to the adopted Nursing Standards of Practice.
- The plan is updated and revised periodically based on evaluation of patient progress/achievement of goals.
- The RN is responsible for the coordination and implementation of the patient's plan of care.

4. Record review of Patient #3's Patient Care Plan, dated 10/28/14, initiated by Staff C, RN, showed the following:
- Pain;
- Fall Risk;
- Tobacco Use;
1. Patient will achieve complete tobacco cessation.
2. Patient will decrease tobacco use.
- Potential for injury related to Wandering/Elopement.
1. Patient will remain safe and within the hospital confines during hospitalization.
a. Orient patient to room and unit.
b. Complete Elopement Risk Assessment.
c. Apply red slippers per Wandering Patient/Elopement policy if indicated by assessment.
d. Utilize bed alarm when family not present in room.
e. Instruct family to notify staff when leaving patient.
f. Close unit doors at end of hallway.
g. Increase monitoring of patient.

Nursing staff failed to follow the nursing care plan for Patient #3. He did not remain within the hospital confines as he was allowed to go outside to smoke unattended and he did not have a bed alarm in place.

5. Record review of Patient #3's Informed Consent to Refuse form dated 10/28/14 showed the following:
- Smoking Cessation indicated as reason for the refusal form;
- The patient was offered smoking cessation.
- Due to the responsibilities that facility staff must fulfill within the hospital, you will be unattended while smoking outside of the building.
- Standing after extended periods of inactivity can cause dizziness or light headedness which might be amplified by your condition.
- Smoking could further exacerbate these symptoms.
- Because you will be outside of the building and unattended while smoking, a fall might not be immediately discovered and this could result in injuries being magnified.
- I understand that, if I refuse the offered services, I am doing so against medical advice.
- I understand that my refusal may result in a worsening of my condition and could pose a threat to my life, health and medical safety.
- I hereby release the attending physician, the hospital and employees from all responsibilities for any ill effects which may result from my refusal.
- Patient signature in agreement of above information dated 10/28/14 at 2:30 PM.
- Staff C, RN and Staff D, LPN both signed as witnesses.

During an interview on 10/28/14 at 3:55 PM, Staff C, RN, stated that patients were allowed to go outside to smoke even if they were on elopement precautions. "Sometimes we do not have the staff to take the patients out." She stated that Patient #3 had already gone out to smoke, unattended, prior to getting his intravenous (within the vein, IV) line hooked up.

During an interview on 10/28/14 at 4:40 PM, Staff D, LPN, stated that there was a new assessment form, criteria, that patient's must meet in order for them to be placed on elopement precautions. She stated that if she had a patient that met the criteria and was a smoker and had signed the "smoking form" she would allow that patient to go outside to smoke but she would stay with them if she was able. She stated that she had allowed patients on elopement precautions to go outside unattended to smoke.

During an interview on 10/28/14 at 4:50 PM Staff E, RN, stated that if she had a patient on elopement precautions that had signed the smoking cessation refusal form she would allow them to go out and smoke unattended and would give them a time limit of five to ten minutes and then she would be back to get them. She stated she would watch the camera at the nurses' station that showed the exit frequently. She stated she would not be able to go with them as she had other patients to care for.

During an interview on 10/29/14 at 8:30 AM Staff F, LPN, stated that they just don't have the staff to go out with patients who smoke even if they are on elopement precautions. She stated that luckily patients didn't usually go out to smoke at nighttime. She stated that Patient #3 "wasn't really" an elopement risk that the assessment sheet was not very good or accurate that too many patients were being identified as elopement risks but truly were not. She stated if a patient were to request to go out at night she would ask family to go with them.

Observation and concurrent interview on 10/29/14 at 1:00 PM showed Patient #3 inside his room in a patient gown and red slipper socks. Patient #3 stated that he wanted to go outside to smoke. He stated that he had gone out the day before by himself to smoke.

During an interview on 10/29/14 at 2:20 PM Staff K, Chief Nursing Officer (CNO) and Staff A, Quality/Risk Director both stated that patients on elopement precautions who had signed the smoking cessation refusal form were allowed to go outside unattended to smoke. Both Staff K and A stated that the new assessment "tool" needed "tweaking" and that the refusal form contradicted the elopement precautions to ensure patient safety and that those patients identified as elopement risks could possibly elope while outside unattended.

During an interview on 10/29/14 at 3:35 PM Staff B, CEO, stated that he was aware that some patient's sign a refusal form for smoking cessation and by doing so they could continue to go outside to smoke as this was their right but it had not occurred to him that the patient's were going outside to smoke when they also had been identified as an elopement risk and that this was contradictive to each other.