HospitalInspections.org

Based on observation, interview, and record review, the facility failed to adequately assess/monitor 1 (#14) of 5 behavioral health patients reviewed in the Emergency Department, resulting in less than optimal outcomes. Findings include:

On 10/21/19 at 1430, record review revealed that patient #14 was a 72 year-old male admitted to the Emergency Department (ED) on 9/13/19 at 1932 for behavior changes, he stated three times that he wanted to kill his wife, and required psychiatric evaluation. The patient had a history of dementia and was not oriented to time or situation. Interview with ED Nurse Manager W, on 10/21/19 at 1620 revealed that the patient was placed in a room across from the Nurses' Station in Module A (Room A-11), and was placed on hourly nursing assessments/checks and continuous video/audio monitoring in the ED.

On 10/21/19 at 1630, continued medical record review with ED Nurse Manager W revealed that nursing documentation assessment/hourly checks continued through 9/14/19 1100 and vital signs at 1114. There was a gap from 1114 to 1422. On 10/21/19 at 1645, interview with Nurse T revealed that nursing assessments needed to be documented hourly per protocol. Nurse T further stated that she took care of patient #14 until around 1000 then went to Module B when it opened, and Nurse V took over the care of patient #14. Nurse T also stated that a sitter was not implemented because she could visually see the patient and his behavior had not warranted it at the time. On 10/21/19 at approximately 1700, it was noted in the electronic record that video surveillance was discontinued on the patient on 9/14/19 at 0800 and Nurse Manager W stated that was due to nursing judgement.

On 10/21 at 1715, interview with Nurse V revealed that she had not done a 1200/1215 nursing assessment of patient #14 because "I was discharging a patient." Nurse V did not document again on the patient until 1422 because "We were looking for the patient." Nurse V stated that she had walked the halls with the patient earlier and he was able to be redirected.

Interview with Clinical Nurse Lead X, on 10/22/19 at 1000, revealed that she had come in to work at 1200, the door alarm in Module B went off on 9/14/19 at approximately 1225, and patient #14 ran out the door into the woods. Nursing staff and Security staff ran after the patient, but he was fast and climbed over the fence into the woods.

Interview with Security Staff Y, Z, and AA, on 10/22/19 at approximately 1020, revealed that they had followed the patient (on foot and in a car) but the patient hid in the woods. Security staff stated that they called the local police department to help find patient #14. The patient was located by the police and brought back to the ED on 9/14/19 at approximately 1422. He was evaluated and placed on continuous one to one staff monitoring, with every fifteen minute documentation. The patient was later transferred to a psychiatric facility on 9/14/19 at 1773.

On 10/22/19 at approximately 1500, further interview with Nurse Manager W concerning staffing on 9/14/19 and nursing assessments, she stated, "We followed our hourly PHR policy." On 10/22/19 at 1800, review of the facility policy titled "Rounding with Intention (Hourly Rounding/Bedside Shift Report), dated 02/2017" documented, "6. PHR (Purposeful Hourly Rounding) must be conducted at least once every hour...7. The rounding associate must be physically present in the patient's room when performing PHR..." This had not been done.