HospitalInspections.org

Based on video review, observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. This was evidence by:
1) Failing to complete 15 minute observations by the MHTs and 2 hour observations by the RN on 22 (#6, #7, #9-#21, #23-#26, #28, #29, #31) psychiatric patients of 27 psychiatric patients with 15 minute observations ordered after a patient had eloped and died;
2) Failing to document 15 minute observations by the MHTs on 2 (#1, #2) of 5 (#1-#5) patient records reviewed for completeness;
3) Failing to document 2 hour observations by the Registered Nurse on 1 (#2) of 5 (#1-#5) patient records reviewed for completeness, and
4) Failing to follow hospital policy for elopement protocol for 1 (#2) of 3 (#1-#3) patient records reviewed for following policy.
(See findings under Tag A0144)


1) Failing to complete 15 minute observations by the MHTs and 2 hour observations by the RN on 22 (#6, #7, #9-#21, #23-#26, #28, #29, #31) psychiatric patients of 27 psychiatric patients with 15 minute observations ordered after a patient had eloped and died;

On 06/20/2023 at 11:25 a.m. a review of the hospital policy titled Level of Observation, Last revised 03/01/2023 revealed in part:
Observation Levels:
Every 15 minutes- the staff will visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities.
Every 15 Minute Observation:
- Physically walks to find each patient on q 15 minute observations.
- Documents patient's location and reports identified risk to RN when indicated.
- Documents the location on the close observation form and documents the activity when indicated, e.g., water offered, and etc.
- Initials the form every 15 minutes.
- Notifies the Charge Nurse immediately of any patient who cannot be observed or located.

Review of Patient #2's medical record revealed he had been admitted to the hospital with diagnosis including dementia.

On 06/20/2023 at 12:15 p.m. a review of video footage from 06/17/2023 shows Patient #2 exiting the secure psychiatric unit at 6:10:11 p.m. after an employee enters the unit through the secured door. Patient #2 is then seen exiting the hospital at 6:10:56 p.m. Review of Patient #2's observation sheet revealed he had been documented as having been observed by a staff member every 15 minutes from 6:00 p.m. until 6:45 p.m.

On 06/18/2023 around 7:30 p.m. Patient #2 was found deceased.

Review of census sheets revealed there were 27 patients currently ordered to be on 15 minute observations on 06/20/2023.

On 06/20/2023 at 12:25 p.m. a review of the secured psychiatric unit cameras facing both patient hallways on 06/20/2023 at 2:37 a.m. revealed staff completing every 15 minute checks on the patients with one patient in a recliner in front of the nurses station. Observation also reveal 4 other patients exiting and re-entering their rooms at various times. Further observation revealed staff did not make 15 minute checks again until 4:36 a.m. (1 hour and 59 minutes) on 12 patients located on the north hall of 27 patients total. Staff did not initiate 15 minute checks on 15 patients on the south hall out of 27 total patients until 4:53 a.m. (2 hours and 16 minutes).

In an interview on 06/20/2023 at 12:30 p.m. S1Adm verified staff had about a 2 plus hour gap where they failed to round on approximately 22 patients, (#6, #7, #9-#21, #23-#26, #28, #29, #31) who were in their rooms. S1Adm also verified which patients were not rounded on for the every 15 minute observation.

In an interview on 06/20/2023 at 12:50 p.m. S2DON verified all 27 patients on the unit during the time of the video observation were on every 15 minute observations.

An Immediate jeopardy situation was identified on 06/20/2023 at 3:40 p.m. and reported to S1Adm. The Immediate Jeopardy was the result of the staff failing to notice Patient #2 had eloped for 50 minutes because a staff member was not making her 15 minute observations as ordered. This resulted in Patient #2 being found deceased. Current staff failed to complete 15 minute observations on 22 (#6, #7, #9-#21, #23-#26, #28, #29, #31) of 27 current patients. This placed all 22 patients (#6, #7, #9-#21, #23-#26, #28, #29, #31) at risk for serious injury, serious harm, serious impairment or death.

On 06/21/2023 at 1:18 p.m. S1Adm presented the plan for lifting the immediacy of the IJ situation and the plan included the following.
All staff working the night shift on 06/19/2023 received a documented final warning on 06/20/2023.
All staff must complete online hospital specific education prior to their next shift.
The administrator of designee will monitor rounding by reviewing video footage at least 3 x week with at least 2 hours of footage reviewed on that date. Footage from nights and weekends will comprise 50% of the required video. Any non-compliance will result in final warning and then termination.
The Administrator or designee will also perform observation status rounds on the unit at least 3 x weekly. During rounds the administrator or designee will ensure that observation sheets are current and documented appropriately. The sample will be chosen randomly but will encompass at least one third of the required rounds. Any non-compliance will be addressed with a final warning and then termination of the employee if further action is necessary.
The plan will be implemented by 06/21/2023 to remove the likely hood of serious harm to all patients currently in the facility as well as future admits.

On 06/21/2023 at 1:18 p.m. the IJ was lifted.

Based on observation, record review and interviews the hospital failed to ensure patients received care in a safe setting as evidenced by:
1) Failing to complete 15 minute observations by the MHTs and 2 hour observations by the RN on 22 (#6, #7, #9-#21, #23-#26, #28, #29, #31) psychiatric patients of 27 psychiatric Patients with 15 minute observations ordered;
2) Failing to document 15 minute observations by the MHTs on 2 (#1, #2) of 5 (#1-#5) patient records reviewed for completeness;
3) Failing to document 2 hour observations by the Registered Nurse on 1 (#2) of 5 (#1-#5) patient records reviewed for completeness, and
4) Failing to follow hospital policy for elopement protocol for 1 (#2) of 3 (#1-#3) reviewed for following policy.
Findings:


1) Failing to complete 15 minute observations by the MHTs and 2 hour observations by the RN on 22 (#6, #7, #9-#21, #23-#26, #28, #29, #31) psychiatric patients of 27 psychiatric Patients with 15 minute observations ordered.

On 06/20/2023 at 11:25 a.m. a review of the hospital policy titled Level of Observation, Last revised 03/01/2023 revealed in part:
Observation Levels:
Every 15 minutes- the staff will visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities.

Every 15 Minute Observation:
- Physically walks to find each patient on q 15 minute observations.
- Documents patient's location and reports identified risk to RN when indicated.
- Documents the location on the close observation form and documents the activity when indicated, e.g., water offered, and etc.
- Initials the form every 15 minutes.
- Notifies the Charge Nurse immediately of any patient who cannot be observed or located.

Review of Patient #2's medical record revealed he had been admitted to the hospital with diagnosis including dementia.

On 06/20/2023 at 12:15 p.m. a review of video footage from 06/17/2023 shows Patient #2 exiting the secure psychiatric unit at 6:10:11 p.m. after an employee enters the unit through the secured door. Patient #2 is then seen exiting the hospital at 6:10:56 p.m. Review of Patient #2's observation sheet revealed he had been documented as having been observed by a staff member every 15 minutes from 6:00 p.m. until 6:45 p.m.
On 06/18/2023 around 7:30 p.m. Patient #2 was found deceased.

Review of census sheets revealed there were 27 patients currently ordered to be on 15 minute observations on 06/20/2023.

On 06/20/2023 at 12:25 p.m. a review of the secured psychiatric unit cameras facing both patient hallways on 06/20/2023 at 2:37 a.m. revealed staff completing every 15 minute checks on the patients with one patient in a recliner in front of the nurses station. Observation also reveal 4 other patients exiting and re-entering their rooms at various times. Further observation revealed staff did not make 15 minute checks again until 4:36 a.m. (1 hour and 59 minutes) on 12 patients located on the north hall of 27 patients total. Staff did not initiate 15 minute checks on 15 patients on the south hall out of 27 total patients until 4:53 a.m. (2 hours and 16 minutes).

In an interview on 06/20/2023 at 12:30 p.m. S1Adm verified staff had about a 2 plus hour gap where they failed to round on approximately 22 patients, (#6, #7, #9-#21, #23-#26, #28, #29, #31) who were in their rooms. S1Adm also verified which patients were not rounded on for the 1every 15 minute observation.

In an interview on 06/20/2023 at 12:50 p.m. S2DON verified all 27 patients on the unit during the time of the video observation were on every 15 minute observations.

2) Failing to document 15 minute observations by the MHTs on 2 (#1, #2) of 5 (#1-#5) patient records reviewed for completeness.
At 9:35 a.m. and observation of Patient #1's observation sheet revealed he was a new admit with Q 15 min checks. Further review revealed the first check was completed at 8:15 a.m. and the 8:30, 8:45, 9:00, 9:15, 9:30 a.m. checks were blank.

In an interview on 06/20/2023 at 9:35 a.m. S4MHT verified she had not yet documented the q15 minute checks for Patient #1 between 8:30 a.m. and 9:30 a.m.

In an interview on 06/20/2023 at 10:00 a.m. S3RN reviewed Patient #1's Observation Check Sheet and verified the missing times and stated the q15 minute checks should be documented every 15 minutes and not be an hour behind.

3) Failing to document 2 hour observations by the Registered Nurse on 1 (#2) of 5 (#1-#5) patient records reviewed for completness.

A review of the Patient #2's MHT Observation sheets revealed:
On 06/02/2023 15 min observations revealed S8RN completed the 2 hour check at 6:00 p.m. and none were completed the remainder of the day through 6:45 a.m. on 06/03/2023.

On 06/03/2023 15 min observations revealed S8RN failed to document every 2 hour RN observations from 7:00 p.m. through 6:45 a.m.

On 06/12/2023 Q15 min observation revealed S8RN failed to document every 2 hour RN observations from 7:00 p.m. through 6:45 a.m.

On 06/15/2023 Q 15 min observation revealed S8RN failed to document every 2 hour RN observations from 7:00 a.m. through 6:45 p.m.

In an interview on 06/21/2023 at 2:45 p.m. S14VOOp verified the missing documentation.

In an interview on 06/21/2023 at 4:45 p.m. S14VPOp verified all missing documentation was by S8RN.

4) Failing to follow hospital policy for elopement protocol for 1 (#2) of 3 (#1-#3) reviewed for following policy.

A review of the hospital policy entitled Elopements last revised 07/01/2022 revealed in part:
8. Should an elopement occur, the following actions shall be taken:
- If a patient cannot be quickly located, the staff member will activate the emergency code system by announcing twice "Code Pink" and location of the emergency over the paging system.
- Assign staff to search building and grounds. Staff are to pursue the patient at a distance. Staff are not to pursue the patient off hospital grounds and under unsafe conditions such as into traffic, over fences, etc. or if the patient verbalizes or motions to assault staff if he/ she is pursued. Contact 911 immediately.

A review of the self-report revealed S8RN called the following at the following times on 06/17/2023;
S2DON, notified at 8:17 p.m.
S1Adm, notified at 8:24 p.m.
S16Police, notified at 8:23 p.m.
S17Sp, notified at 8:30 p.m.
S18MD, notified at 9:00 p.m.

In an interview on 06/21/2023 at 10:00 a.m. S8RN states she was working the night shift starting at 7:00 p.m. on 06/17/2023. S8RN stated at around 7:00 p.m. the MHTs were starting vital signs and S9MHT told her she had not seen Patient #2. S8RN told S9MHT that Patient #2 wanders be sure to check the other patient rooms. S9MHT came back and said she still had not seen Patient #2. S8RN stated she directed all the MHTs to check every room and door to check for Patient #2. She asked S11MHT to check the outside perimeter while the entire inside building was checked. S8RN stated they could not locate Patient #2 and S2DON was called. S8RN stated they probably looked for 30-40 minutes prior to calling S2DON.
During this telephone interview this surveyor reviewed the Elopement Policy with S8RN who verified: No Code Pink was called, nor did they immediately call 911. Per the hospital policy.
Also, during the interview S8RN verified the above times the S2DON, S1Adm, S16Police, S17Sp and S18Md were notified.

Based on record review and interview, the hospital failed to ensure that the nursing staff developed, and kept a current, and individualized nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs. This deficient practice is evidenced by the failure to update the care plans of 1 (#2) of 5 (#1-#5) patient reviewed for completed and updated care plans.
Findings:

A review of Patient #2's medical record with S14VPOp who verified the findings, revealed:
He was admitted on 06/02/2023 at 5:15 p.m. with a diagnosis of dementia with behavior disorder. Under PEC then it expired and patient's wife signed Non- Contested admission.
Initial Psych evaluation completed on 06/03/2023 at 8:29 p.m. face to face. Mental status blunted. Oriented to person and situation, homicidal- passive- aggression towards wife, prognosis guarded.
On 06/04/2023 at 9:15 a.m. Patient #2 had an unwitnessed fall in the hallway of the secured unit. He was transferred to the emergency room for lacerations to his face and evaluation.

On 06/11/2023 at 8:05 p.m. Patient #2 wandered into another patient's room, stood over the other patient resulting in the other patient hitting Patient #2 multiple times in the face. Patient #2 suffered lacerations near his right eye and forehead. Patient #2 was transferred to the emergency room where he received sutures. Patient #2 had a CT of his maxillofacial and head without contrast. Patient #2 was diagnosed with a closed fracture of nasal bone and bilateral periorbital contusions.

Review of Patient #2's care plan failed to reveal any modifications after either incident.

In an interview on 06/21/2023 at 2:10 p.m. S14VPOp verified Patient #2's care plan was not modified and individualize after the above incidents occurred.

Based on record review and interviews the hospital failed to ensure a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs for 31 (#1-#31) of 31 (#1-#31) patients on the unit.

Findings:

A review of the hospital policy titled Staffing Plan last revised 09/01/2022 revealed in part:
A registered nurse plans, assigns, supervises and evaluates the nursing care of each patient daily.

In an interview on 06/21/2023 at 12:29 p.m. S12MH stated the MHTs complete the MHT daily schedule. She reviewed the MHT schedule for 06/21/2023 and verified S13MHT had completed the MHT daily schedule.

In an interview on 06/21/2023 at 12:32 p.m. S13MHT reviewed the MHT schedule for 06/21/2023 and stated she created the assignments for the day shift MHT schedule for 06/21/2023.

In an interview on 06/21/2023 at 12:48 p.m. S2DON verified the hospital policy is for the RN to complete patient care assignments.