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Based on observation, interview, record review, and policy review the facility failed to:
- Adequately assess and/or identify the patient's hallucinations and restlessness, which had the potential to lead to elopement (leaving the hospital before physician approval, or when not medically safe to do so), implement individualized interventions, and/or closely monitor one (#11) of four patients reviewed with a possible elopement risk. (Refer to A395)
- Follow their internal policy regarding elopement prevention and close observation (a level of supervision provided to patients with an increased risk for injury) for one (#11) of four patients reviewed with a possible elopement risk. (Refer to A395).
- Follow their internal policy regarding patient care planning for one of one patient (#11) reviewed on the medical/telemetry unit(med/tele) whereby patients with heart problems are monitored by a mechanical device). (Refer to A395 and A396).
- To conduct a timely, thorough, comprehensive investigation regarding the elopement of one (#11) of one patient, which resulted in the failure to implement corrective action to prevent any future elopements. (Refer to A395).

These failures had the potential to affect all inpatients. The facility census was 111, of which 19 patients were considered at risk for elopement.

The cumulative effect of these systemic practices had the potential to place all inpatients at risk for their health and safety, also known as immediate jeopardy (IJ) because staff failed to appropriately assess and/or identify all inpatients for the risk of elopement.

As of 02/26/14, at the time of survey exit, the facility had provided an immediate action plan sufficient to abate the IJ by implementing the following:
-Staff re-assessed Patient #11 for elopement risk, moved the patient to a room closer to the nurses' station, placed an alarm on the bed, placed the patient on close observation status and the patient's room door was to remain open.
-The physician reviewed Patient #11's medications. At least three medications, which could cause confusion or hallucinations, either individually or in combination with the others, were discontinued.
-Staff updated the patient's care plan to include a risk for injury related to elopement history.
-The facility revised multiple policies including risk assessment for elopement, patients leaving against medical advice and/or elopement, incident reporting/investigation and close observation.
-The facility implemented a new elopement risk assessment tool and log and a new observation flowsheet for patients at risk for elopement.
-On 02/25/14, after the survey team informed the facility of the IJ, the staff used their new assessment tool and re-assessed all patients identified as at risk for elopement and put into place interventions to protect the patients (a total of 19 patients.)
-The facility will educate all staff prior to their next patient assignment, regarding all new policies and processes. The education started the evening of 02/25/14 and will continue until all nursing staff is educated.

Based on observation, interview, record review, and policy review the facility failed to:
- Adequately assess and/or identify that the patient's hallucinations and restlessness had the potential to lead to elopement (leaving the hospital before physician approval, or when not medically safe to do so), implement individualized interventions, and/or closely monitor one (#11) of four patients reviewed with a possible elopement risk.
- Follow their internal policy regarding elopement prevention and close observation (a level of supervision provided to patients with an increased risk for injury) for one (#11) of four patients reviewed with a possible elopement risk.
- Follow their internal policy regarding patient care planning for one of one patient (#11) reviewed on the medical/telemetry (med/tele) unit whereby patients with heart problems are monitored via a mechanical device) unit.
- Follow their internal policy regarding a patient leaving the hospital against medical advice, when they failed to contact Patient #11's wife until approximately four hours after the patient eloped and had already arrived at his residence).
- To conduct a timely, thorough, comprehensive investigation regarding the elopement of one (#11) patient, which resulted in the failure to implement corrective action to prevent potential future elopements.

The above failures had the potential to affect all inpatients because staff failed to appropriately assess and/or identify all inpatients for the risk of elopement. The facility census was 111, of which 19 patients were considered at risk for elopement.

Findings included:

1. Record review of the facility's policy titled, "Close Observation," reviewed 11/22/11, showed the following direction:
- Indicators that a patient may need close observation include, confusion, impulsive behavior, restlessness or agitated behaviors, and the risk for elopement.
- If a patient exhibits one, or more, of the above behaviors, the professional nurse should consider utilizing the following interventions:
a. Bed assignment close to nursing station.
b. Assess the patient's medications for appropriate interventions.
c. See if a family member could stay with the patient.
d. Apply a bed alarm.
e. A physician's order is not required to provide close observation.
f. The Registered Nurse (RN) assigned to the patient will determine the need for close observation.

Record review of the facility's policy titled, "Against Medical Advice (AMA)," reviewed 02/09/11, showed the following:
- A voluntary patient is mentally alert and competent to make their own decisions.
- An involuntary patient is unable to comprehend safety measures, or is cognitively impaired.
- If either type patient leaves the hospital AMA, the emergency contact of the patient should be notified by nursing staff.

Record review of the facility's policy titled, "Incident Reporting," reviewed 10/19/10, showed the following:
- Investigations of incidents will lead to actions such as process improvement initiatives, education or coaching.
- The Director, Clinical Nurse Manager is responsible for completing the initial investigation.
- The Risk Manager will direct the investigation and follow-up.

2. Record review of Patient #11's Emergency Department (ED) nursing assessment dated 02/16/14, showed the following:
- The patient presented, at 11:08 AM, with painful abdominal spasms related to a urinary tract infection (UTI). A peripherally inserted central catheter (PICC) a type of intravenous line (IV- a needle placed into a vein that can be used for more long-term therapy) was inserted.
- The patient was a quadriplegic (generally defined as: inability to move entire body below the neck). (This patient could partially move his arms).
- The patient was admitted to the med/tele unit at 6:00 PM.

3. Record review of Patient #11's med/tele unit medications, from 8:00 AM on 02/18/14 through 8:00 AM on 02/20/14, showed the following:
- The patient received one dose of Norco 5/325 mg (a narcotic pain medication) at 8:01 PM on 02/18/14.
- The patient received 1 mg of Ativan IV (an anti-anxiety, which can cause drowsiness, delayed reactions and/or poor decision-making) at 8:24 AM, 3:29 PM, and at 10:51 PM on 02/18/14.
- The patient received 8 mg of Zanaflex (a muscle relaxant, which can cause drowsiness and hallucinations) at 10:22 AM on 02/18/14.
- The patient received 5 mg of Morphine IV (a narcotic pain medication, which can cause visual disturbances, agitation, drowsiness and restlessness) at 7:11 PM on 02/18/14.
- The patient received 5 mg of Ambien (a sleeping aid, which can cause drowsiness, dreams, and "sleep driving"-driving while not fully awake with subsequent amnesia of it afterward) at 12:04 AM and again at 9:19 PM on 02/19/14.
- The patient received 1 mg of Klonopin (an anti-convulsant, which can cause drowsiness, confusion, and behavioral disturbances) at 9:19 PM on 02/19/14.
- The patient received 25 mg of Seroquel (an anti-psychotic, which can cause dizziness and agitation) at 12:28 AM on 02/20/14.

4. Record review of nursing assessment documentation showed the patient was anxious at 8:00 AM, 12:03 PM, 4:02 PM, and at 7:50 PM on 02/19/14, and at 1:00 AM on 02/20/14.

5. Record review of nursing narrative documentation showed the following:
- The patient had been having hallucinations at midnight on 02/19/14.
- Staff dressed the patient and transferred him into his electric wheelchair (w/c) at 1:00 AM on 02/20/14. The patient asked if he could wander the halls, and go to the waiting room because he felt he had been in his room too long. The patient was directed to the waiting room.
- At 1:30 AM, on 02/20/14, the patient was discovered missing.
- At 2:00 AM on 02/20/14 (two hours after having hallucinations), staff determined the patient had left the unit and the hospital (eloped).
- The charge nurse, house supervisor, hospital security and police were notified (time not documented). Staff failed to notify the patient's wife at that time.
- The patient returned to the hospital, via ambulance, for continued medical care a few hours later (at about 6:50 AM), and remained an inpatient as of 02/26/14.

6. Record review of the facility's policy titled, "Care Planning and Clinical Paths," dated 01/22/08, showed the following:
- To establish a guideline for development of an individualized plan of care;
- The RN is responsible for initiation and ongoing documentation on the patient's plan of care.
- On admission the RN will initiate either an individualized plan of care or a clinical path (individualized goals/interventions and expected outcomes which drive patient care for a specific medical diagnosis through all phases of the patient's hospitalization) based on patient condition and diagnosis.
- The RN is responsible for reviewing the plan of care each shift and making modifications as needed.

7. Record review of Patient #11's plan of care on 02/25/14, revised as of 02/25/14, showed one problem for this patient since admission, Risk for infection. The facility staff failed to identify the patient's actual elopement, or risk for elopement, on the plan of care, with interventions to prevent potential further confusion and/or elopement.

8. During interviews on 02/24/14 at 3:04 PM and on 02/25/14 at approximately 9:40 AM, Staff G, med/tele Clinical Nurse Manager stated the following:
- It was the nurse's responsibility to develop/update the patient's plan of care based upon orders, changes in condition, and/or history every shift.
- The nurse had the opportunity, per the computer software, to add confusion/delirium, anxiety, risk for injury, and pain to the plan of care all with associated interventions.
- The nurse could tailor the plan of care to the patient by entering specific interventions individualized to the patient.
- Staff G could not explain why the nurses had not updated the plan of care appropriately, over a nine-day period.
- She received a phone call on 02/20/14 at approximately 4:00 AM (two and one-half hours after the patient eloped) from the nursing supervisor telling her that Patient #11 had eloped from the facility (at about 1:30 AM) and had driven himself home (about five miles away).
- The patient had been seeing things earlier that day, that weren't there, (hallucinations) in his room.
- Staff G stated that staff dressed Patient #11 (in a T-shirt and sweatpants) and put him in his electric wheelchair because he was feeling "cooped up." Staff G stated staff took him to the unit waiting room, and left him, at approximately 1:00 AM.
- The patient still had his IV in his left forearm, and his cardiac monitor in place when he arrived home.
- As of 02/24/13, at the time of this interview, Staff G was not aware if the patient had a coat on when he eloped (temperature approximately 20-30 degrees Fahrenheit at the time of elopement), which doorway the patient eloped from, who the day shift nurses were the day he eloped, and she had not spoken with the patient, the patient's wife, the patient's physician, or many other staff members with knowledge of the elopement.

The facility had no method to identify flight/elopement risk.

9. During an interview on 02/24/14 at 3:43 PM, Staff H, RN, (assigned to the patient for day shift on 02/19/14) stated that she was aware that some of the patient's medications had been making him feel "off" during her day shift on 02/19/14. Staff H stated that the patient's wife reported the patient had been having hallucinations and heard voices telling him "to go." Staff H reported this finding to the oncoming nurse.

10. During an interview on 02/24/14 at 3:48 PM, Staff I, Graduate Nurse (being mentored by Staff H, assigned to care for patient
#11), stated that the patient had some minor visions during the day shift on 02/19/14.

11. During an interview on 02/24/14 at 3:55 PM, Patient #11 stated the following:
- UTI's typically caused him to have painful tremors/spasms.
- He believed the medications he had been prescribed since admission were causing him to have hallucinations, and hear voices.
- He had been seeing things in his room such as human reflections in the dry erase board on the wall across from his bed, and in the glass section above his bed. He also thought he saw smoke coming from under the bathroom door, where he thought multiple people were smoking marijuana.
- He asked staff, twice, to come into his room and verify these visions.
- Patient #11 asked if he could be moved to another room, to feel safer, but was told there were no empty, available rooms.
- Staff dressed him and placed him in his electric w/c. (The remote start/key to his disability van was attached via Velcro to his w/c).
- Once in his w/c, he rounded the nurses' station one time, and went to the waiting room.
- After a few minutes in the waiting room, he began to hear voices telling him he was not safe and he needed to get out of there.
- He saw the elevator, entered it and went down to the first floor, down the hall, out the ED door and got into his van.
- He then saw, what he thought to be intruders, in his van. One behind the driver's seat, and one crouched on the floorboard of the passenger's side (still having hallucinations).
- He eventually drove to his home, approximately five miles from the hospital, without remembering how he got there. Patient #11 now believed he was lucky to get home without crashing, injuring himself and/or others.
- When he got home he saw approximately 100 people lying on his sofa, floor and all over the place, like after a party. When the lights came on, they were gone.
- His wife was on the phone with the police, as they were notifying her of his elopement (the facility staff had not called yet).

12. During an interview on 02/24/14 at 9:33 PM, Staff J, RN (assisted with hygiene and turning of the patient one time on 02/19/14, at about 9:00 to 10:00 PM ) , stated the following:
- The patient had been having hallucinations on 02/19/14.
- If a patient was confused or unsafe, the nurse could institute close observation per her judgment. Patient #11 had been in Room 29 (approximately 44 feet away from the nurses' station) since admission (not moved closer to nurses' station related to the confusion/hallucinations per policy).
- No one from risk management or administration had questioned her about this event for an investigation.

13. During an interview on 02/25/14 at 8:35 AM, Staff K, RN (assigned to the patient on 02/19/14, night shift) stated the following:
- Patient #11 had been seeing reflections in the light over his bed.
- The hospitalist was notified and an order for Seroquel was received and given.
- The patient couldn't sleep and wanted to get up to his w/c at about 12:30 PM. Staff K saw no reason he could not. So, the patient got up and wandered around the unit and to the waiting room.
- At about 1:00 AM, Staff DD, Certified Nurse Assistant (CNA), asked Staff K if she had seen the patient. She had not.
- Staff began looking for the patient.
- The hospitalist and nursing supervisor were notified.
- The nursing supervisor notified the police, security, and the patient's wife (after the patient had already arrived home).
- Patient #11 was not safe to drive related to the medications he had been taking.
- The ambulance service retrieved the patient and brought him back to the hospital. The patient remained in the same room, on the same medications, without close observation, after an actual elopement.
- Staff K did not request close observation for the patient because he was alert and oriented at the time she last assessed him (both original and re-admission).
- The facility currently had no method to identify flight/elopement risk.
- No one from risk management or administration had questioned her about this event for an investigation.
- Staff K had not received any education or read any policy revision since the patient's elopement.

14. During an interview on 02/25/14 at 9:15 AM, Staff L, Physician, stated the following:
- Patient #11 was confused per assessment on 02/19/14 at approximately 1:00 PM (the patient was confusing dates and times).
- The patient received quite a few medications for his spasms.
- The patient should not have been driving.
- Staff L re-assessed the patient at about 1:30 PM on 02/20/14 and diagnosed him as delirious (fluctuating, rapid onset severe confusion and disorientation), and made multiple medication changes.
- No orders were given for close observation when the patient returned to the hospital because the nurses are more available during the day hours, and the nurses would call if they felt the patient needed it.

15. During an interview on 02/25/14 at 10:28 AM, Staff DD, CNA (assigned to the patient on 02/19/14, night shift) stated the following:
- Patient #11 had been seeing "paranormal activity" in his room.
- Other staff got the patient dressed and up into his w/c.
- The patient was in the unit hallway and asked Staff DD where the waiting room was, Staff DD told him.
- About 30 minutes later, Staff DD asked Staff K if she knew where the patient was, but she didn't.
- Staff DD looked for the patient, but did not find him.
- Staff DD had not received any education or read any policy revision since the patient's elopement.
- No one from risk management or administration had questioned her about this event for an investigation.

16. During an interview on 02/25/14 at 11:20 AM, Staff EE, CNA, stated the following:
- The patient was "claustrophobic" (fear of feeling closed in), and was seeing images toward the end of the day shift on 02/19/14.
- She checked for smoke under the bathroom doorway for the patient once (that he thought he saw).
- Staff EE stated that if she had been assigned this patient, while he was acting this way, she would not have left him alone in his electric w/c.

17. Record review of the facility's security Incident Report dated 02/20/14, showed the following:
- Staff FF, Security received a phone call at 2:40 AM from a nurse on the med/tele unit advising them Patient #11 was missing.
- Staff FF asked Staff T, Admitting Clerk (sitting at a desk near the ED exit), if she had seen a male patient in a w/c leave the hospital. She had.
- Staff FF reviewed video of the ED doors and confirmed Patient #11 had left via his van at 2:21 AM.

18. During an interview on 02/25/14 at 11:40 AM, Staff B, Risk Manager, stated the following:
- On 02/20/14, Staff G notified her of Patient #11's elopement (at the beginning of her day-not sure exactly what time).
- Staff B counted on Staff G's investigation and did not feel there had been a failure in policy or care provided to Patient #11.
- Staff B did not do a separate investigation, or add to Staff G's investigation.
- Staff B failed to interview the patient, Staff H, Staff I, Staff L, Staff T, Staff DD, Staff EE, or Staff FF.
- Staff B confirmed there had been no action plan put into place to prevent future occurrences as of this interview, five days after the occurrence.

19. Observation of the security video on 02/25/14 at 2:40 PM, showed the following:
- Patient #11 came out the ED doorway, in his electric w/c, at 2:19 AM on 02/20/14.
- Patient #11 started his van with his remote, lowered the ramp and entered the van.
- Patient #11 sat in his van for six minutes (at 2:55 AM) before he pulled out of his parking space and drove away.

20. During an interview on 02/25/14 at 8:00 PM, Staff T, Admitting Clerk, stated the following:
- She was sitting at the desk near security when she looked up and saw a man in a w/c go by and go out the ED doors (about 2:30 am).
- The man had street clothes on so she did not know the man was a patient.
- Later, security asked her if she had seen someone of this description.
- No one from risk management or administration had questioned her about this event for an investigation, until this date.

21. During an interview on 02/26/14 at 9:05 AM, Staff G, med/tele Clinical Nurse Manager, stated that she typically did a more thorough investigation, but Staff K, the RN responsible for the patient on 02/19/14 was a float nurse. This gave her less control. Staff G always liked to have a good understanding of the facts before she contacted the family or emergency parties.

Based on interview, record review, and policy review the facility staff failed to follow the facility policy for the patient's plan of care for four patients (#11, #2, #3, and #7) of 11 patient plans of care reviewed. This failure had the potential to deny all patients admitted to the facility plan of care interventions needed to meet their individual needs. The facility census was 111.

Findings included:

1. Record review of the facility's policy titled, "Care Planning and Clinical Paths," dated 01/22/08, showed the following:
- To establish a guideline for development of an individualized plan of care;
- The Registered Nurse (RN) is responsible for initiation and ongoing documentation on the patient's plan of care.
- On admission the RN will initiate either an individualized plan of care (IPC) or a clinical path (individualized goals/interventions and expected outcomes which drive patient care for a specific medical diagnosis through all phases of the patient's hospitalization) based on patient condition and diagnosis.
- The RN is responsible for reviewing the plan of care each shift and making modifications as needed.

2. Record review of the facility's computerized charting system/electronic medical record (EMR) showed a listing of "Select Diagnosis", that contained a list of 91 nursing diagnoses. This list located in the "Care Plan" section of the patient's EMR allowed the nurse to choose the clinical path for the patient's plan of care.

3. Record review of Patient #11's Emergency Department record dated 02/16/14, showed the patient was admitted to the Medical/Telemetry (med/tele) unit, on that date, with a diagnosis of a urinary tract infection (UTI). The patient had a history of quadriplegia (generally defined as: inability to move entire body below the neck), and a UTI caused the patient to have painful abdominal spasms. (This patient could partially move his arms).

4. Record review of Patient #11's medications, after admitted, showed he received several that could cause drowsiness, confusion, dreams, hallucinations, etc.

5. Record review of nursing narrative documentation showed the following:
- The patient had been having hallucinations at midnight on 02/19/14.
- Staff dressed the patient and transferred him into his electric wheelchair (w/c) at 1:00 AM on 02/20/14.
- At 1:30 AM, on 02/20/14, the patient was discovered missing.
- At 2:00 AM on 02/20/14 (two hours after having hallucinations), staff determined the patient had left the unit and the hospital (eloped).
- The patient returned to the hospital, via ambulance, for continued medical care a few hours later (at about 6:50 AM), and remained an inpatient as of 02/26/14.

6. Record review of Patient #11's IPC on 02/25/14, revised as of 02/25/14, showed one problem for this patient since admission, risk for infection. The facility staff failed to identify the patient's actual elopement, or risk for elopement, on the plan of care, with interventions to prevent potential further confusion or elopement. Facility staff also failed to identify the patient's painful spasms, confusion/delirium, or hallucinations.

7. During an interview on 02/25/14 at approximately 9:40 AM, Staff G, med/tele Clinical Nurse Manager stated the following:
- It was the nurse's responsibility to develop/update the patient's IPC based upon orders, changes in condition, and/or history every shift.
- The nurse had the opportunity, per the computer software, to add confusion/delirium, anxiety, risk for injury, and pain to the IPC, all with associated interventions.
- The nurse could tailor the IPC to the patient's needs by entering specific interventions individualized to the patient.
- Staff G could not explain why the nurses had not updated the IPC appropriately, over a nine-day period.

8. Record review of Patient #2's History and Physical (H & P) dated 02/22/14, showed the patient was admitted on 02/21/14 with dehydration, "near syncope" (fainting or passing out) with lightheadedness, chronic kidney disease and persistent atrial fibrillation (abnormal heart rhythm). The patient had reported a increase in dizziness, lightheadedness, nausea and weakness. Admission vital signs showed a blood pressure that ranged from 89/47 to 103/76, normal blood pressure is 120/80. Low blood pressure can cause lightheadedness and dizziness.

9. Record review of Patient #2's IPC showed no plan of care for the medical management of the patient's dehydration, chronic kidney disease or near syncope with lightheadedness.

10. During an interview on 02/24/14 at 3:25 PM, Staff D, RN, Charge Nurse, reviewed the patient's IPC and stated that he would have expected the IPC to address the patient's dehydration and fall risk associated with the patient's episode of near syncope.

11. Record review of Patient #3's H & P dated 02/18/14, showed the patient was admitted on 02/17/14 for left lower extremity cellulitis (a skin infection usually caused by bacteria accompanied by severe inflammation) hypokalemia (low levels of potassium in the blood) and hypertension (high blood pressure). The patient had erythema (redness), swelling and pain in the lower left leg upon admission. The patient's admission vital signs showed a blood pressure of 152/68 and a potassium level of 2.8 (normal potassium blood level is 3.5-5.2). The physicians plan stated to continue patient's home medications (which included a blood pressure medication) and to monitor her blood pressure.

12. Record review of Patient #3's IPC showed no plan of care for the medical management of her hypokalemia, hypertension or pain.

13. During an interview on 02/24/14 at 3:45 PM, Staff F, RN, (nurse assigned to the patient), reviewed Patient #3's IPC and stated that she would expect to see the patient's hypokalemia, hypertension and her leg pain addressed on the IPC and modified accordingly to the patient's progress throughout her hospitalization.

14. Record review of Patient #7's H & P dated 02/23/14 showed the patient was admitted on 02/22/14 with dizziness, pre-syncope, urinary tract infection and hypertension. The patient also had a diagnosis of type 2 diabetes (a metabolic disorder characterized by high blood sugar where there is a lack of the production of insulin to help regulate blood sugar levels in the blood).

15. Record review of Patient #7's IPC showed no plan of care for the medical management of the patient's dizziness, pre-syncope, hypertension or diabetes.

16. During an interview on 02/25/14 at 1:40 PM, Staff Z, RN, (nurse assigned to the patient), reviewed Patient #7's IPC and stated that there should have been more problems identified and addressed. She stated that the patient's admission assessment showed documentation that the patient was weak and had muscle weakness indicating the potential for risk of injury related to fall risk and that this was not addressed on the IPC.






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