HospitalInspections.org

Based on review of facility documents and medical records, and interviews with staff, the Governing Body failed to function effectively and ensure the hospital consistently operated in a manner that protected the health and safety of its patients. Findings include:
The Governing Body failed to ensure that the facility operated in a manner that ensured continued compliance with the federal regulations that promote and protect patients ' health and safety as evidenced by the hospital's history of noncompliance over the past 12 months.
A review of survey results from February 2018 revealed that the facility failed to ensure that patients consistently received physician ordered respiratory treatments. A review of survey results from November 2018 revealed that the facility failed to ensure that patients were free from abuse and failed to conduct timely and comprehensive investigations when allegations of abuse were alleged by patients.

As a result of the surveys in February and November, 2018, mentioned above, the facility responded with a plan to correct the deficient practices. During each follow up survey, it was determined that the facility implemented their plan of correction and had achieved compliance but the period of compliance did not last more than a few months.

In February, 2019, it was determined that the hospital did not have a plan in place to supervise wandering cognitively impaired patients and as a result, a patient, MR 1, eloped from the facility at night and walked by herself through town to another hospital. MR1 would have walked 1.3 miles taking approximately 23 minutes to arrive in 49 degree weather wearing only hospital scrubs and crocs.

Based on a review of the facility's compliance history, it was determined that the facility's chief executive officer did not provide the supervision and oversight necessary to ensure staff consistently provided the necessary care and treatment needed by the patients.

Findings include:

Based on a review of the Department of Health deficiency reports for the past 12 months from February 2018 to February 2019, revealed that the facility had been cited for its non compliance in these areas: failure to follow physicians' orders for respiratory treatments; failure to conduct timely and comprehensive investigations of alleged patient abuse; and failure to ensure that cognitively impaired patients received adequate supervision to keep them safe. In each of these situations, the facility had developed and implemented a plan of correction however, the facility failed to maintain compliance thus placing patients at risk for harm.

Based on the facility's failure to ensure cognitively impaired ambulatory patients were provided with consistent and appropriate supervision (MR 1), it was determined that cognitively impaired ambulatory patients (MR 1, MR 2, and MR 3)were at risk for harm. Findings include:
Medical record review on 2/15/19 revealed that MR 1 was transferred by ambulance to the emergency department on 9/20/19, due to the patient's refusal to take medications and attempts to harm staff and other patients at the facility that MR 1 lived. Nursing documentation indicated that following admission to the hospital on 9/20/18, MR 1 began to wander in and out of the room and the unit. Based on a review of documentation in the medical record, the hospital failed to have a system in place which protected the wandering patient and implemented a plan of care that met the patient ' s needs. This failure placed MR1, and other cognitively impaired patients (MR 2 and MR 3), at risk for harm if they left their room, unit, or building without staff ' s knowledge or assistance.

Based on the review of medical records and facility documents, and staff interviews, it was determined that the facility failed to ensure each patient received the supervision necessary based on their assessed needs. This failure placed a cognitively impaired ambulatory patient (MR 1) and other patients with similar diagnoses (MR 2 and MR 3), at risk for harm. Findings include:
According to the medical record, on 9/20/18, MR1 was transferred to the facility from another healthcare facility ' s locked dementia unit. MR 1 had a diagnosis of acute encephalopathy and vascular dementia with behavioral disturbances and a history of bipolar and schizoaffective disorder. On 9/20/18, at 4:44 pm, MR 1 was brought to the emergency room due to the refusal to take medications and attempts to harm other patients and staff. Assessment in the emergency room by the physician on 9/20/18 signed at 11:01 pm, revealed that MR 1 was " adamantly agitated pacing in the room intermittently " and " restless ". Nursing documentation indicated that both a sitter and a bed alarm were utilized while the patient was in the emergency department due to the patient ' s behaviors at the other facility. Documentation also revealed that case management was involved and recommended hospitalization for placement.
The admitting physician note written on 9/20/18 at 7:31 pm indicated that MR 1 was going to be admitted to the hospital to get the patient back on medications which would help with the problematic behaviors. Nursing documentation revealed that on 9/22/18 at 8:39 pm, the patient tried to leave the floor without the assistance or knowledge of the staff. Additional nursing documentation from 9/22/18 through 10/12/18, revealed that the patient attempted to and/or successfully left the unit unattended without staff ' s knowledge, on seven (7) occasions. According to documentation in the medical record and interview with staff (EMP 2 and EMP 3), the facility failed to develop a plan to keep MR 1 safe. Further interview confirmed that interventions to stop MR 1 from wandering off the unit unattended were not consistently documented and/or implemented.
Medical record review for MR 2 on 2/15/19, indicated that the patient was admitted on 1/22/19. The patient had diagnoses which included: behavioral disturbances, encephalopathy, heroin abuse, ambulatory dysfunction-falling at home, and medication non-compliance. According to interview with EMP 4 on 2/15/19, MR 2 was to have a constant sitter because the patient was so weak and unsteady. Nursing documentation indicated that the patient ambulated around the room and to the restroom but was considered a high fall risk. Due to agitated and combative behaviors, MR 2 was restrained per doctors' order and the restraints were to be discontinued when the behaviors improved. The patient was assessed as cognitively impaired with delirium and visual hallucinations according to notes written in a psych consult and that some of MR 2's behaviors and delirium were associated with self-medicating with multiple medications including psychiatric medications.
Based on MR 2's condition and past history, the patient was assessed as an elopement risk but according to staff, EMP 4, on 2/15/19, " she is too weak to get out ". Staff indicated that they were concerned that when MR 2's condition improves, the patient may try to elope from the unit. Staff failed to develop an individualized care plan that addressed the need to provide supervision to MR 2 so that patient would not leave the facility without staff or staff's knowledge of the patient's whereabouts.
Medical record review for MR 3 on 2/15/19, revealed the patient was admitted in 1/19 due to the patient's need for psychiatric assessment and treatment. The patient was admitted from home which was facilitated by the spouse who was aware and concerned about the decisions that the patient was making. The patient was ambulatory and the delirium that was present at home continued upon admission to the facility. Due to the patient's impaired cognition, staff felt that MR 3 may be an elopement risk. Staff failed to develop an individualized plan of care for MR 3 to ensure that the patient did not elope from the facility and potentially suffer harm.

Based on the facility's failure to develop and implement a plan of supervision to ensure the safety of cognitively impaired patients, placed the patients at risk for serious injury, harm, and death. Three patients were identified as being in jeopardy due to their impaired cognition and ambulatory status, MR 1, MR2, and MR 3.
Findings include:
Medical record review on 2/15/19 revealed that MR 1 was brought to the hospital's emergency department on 9/20/18, from another healthcare facility where the patient lived on a locked dementia unit. According to documentation from the hospital emergency room record on 9/20/18, MR 1 had been refusing medications and was exhibiting behaviors some of which could have harmed others. In addition, the record stated that MR1 had been pounding on the walls daily and yelling to be let out of the locked unit.
Medical record review revealed that MR1 was assessed by the physician in the emergency room at 9:01 pm. The assessment revealed a history of schizoaffective disorder and dementia. In addition, the physician documented the "ED diagnosis" was Acute metabolic encephalopathy. The physician wrote that the patient required inpatient admission due to the diagnoses and that the patient could not be treated safely as an outpatient.
Medical record review revealed that MR 1 was admitted to the hospital on 9/20/18 and a consult with a psychiatrist the following day, 9/21/18, at 8:51 am, revealed an additional diagnosis of vascular dementia with behavioral disturbance and a note that indicated that MR 1's decision making capacity was compromised with no recollection of behaviors at the the prior facility. Nursing documentation indicated that the use of a sitter would continue since the patient, MR 1, had been a danger to others at the facility the patient lived prior to admission.
Medical record review revealed that two (2) days following admission, on 9/22/18, MR 1 became combative and threw the dinner tray and then slipped on the liquid that had spilled on the floor from the food tray. Later that same day, nursing notes indicated that MR 1 was noted to be impulsive and attempted to leave the unit. On 9/23/18, it was documented in the nursing notes at 11:01 pm, that MR 1 said, "I want to go home." The following day, 9/24/18, on 12:42 am, nursing notes indicated that alarms were being used and the sitter would be used only as needed. At 7:45 pm that evening, nursing notes indicated the patient was turning off the chair alarm and wondering in the room. On 9/25/18, at 5:55 am, nursing documentation indicated that staff were "occasionally finding patient attempting and successfully turning off safety alarm. " Although staff documented MR 1 was confused to the situation, they reminded the patient to ring the call bell if assistance was needed. On 9/26/18, at 5:34 am, nursing notes indicated that the patient was an elopement and safety risk and further documentation over the next four (4) days, revealed MR 1 continued to ambulate in the room and in the hall refusing to use the bed alarm. On 9/30/18, a note written by the physician at 6:15 pm, indicated that MR 1 left " the floor without permission for a walk " and " just wanted to get out of the room a bit. I think it may help to have planned walks off the floor with a staff member ". The physician wrote an order for the patient to be taken off the floor by a staff member for walks. Review of MR 1 ' s record on 2/15/19, indicated there was no evidence that this order was followed. Nursing documentation on 9/30/18 at 6:45 pm, revealed that MR 1 left the floor earlier that day without staff ' s knowledge and was found in the emergency room. As of 10/1/18, nursing staff began to document that MR 1 was on elopement precautions. Interview with staff EMP 2 and EMP 3 on 2/15/19, revealed the facility had not defined " elopement precautions " and there was no policy or protocol for staff to follow if they had a patient like MR 1 who attempted to elope. Based on a review of the medical record documentation for MR 1 and this interview, there was no evidence that the interventions used to supervise MR 1 to ensure safety were being evaluated and changed if needed when the episodes of attempted elopement continued. Nursing documentation from 10/2/18 through 10/11/18, indicated that MR 1 remained an elopement risk and attempted to or successfully elope on six (6) occasions and on two (2) of those elopements, MR1 was found in the emergency room or in radiology.
Nursing documentation written on 10/13/18 at 2:53 am revealed that MR 1 was seen by security at 10:00 pm on 10/12/18, standing alone outside on the emergency room ramp, wearing a pair of staff ' s scrubs. When security approached MR 1, security inquired if the patient was an employee. MR 1 said yes. Because security did not see an armband on the patient, security called the emergency room to see if any of their patients were missing. When the emergency room said no, security spoke again to MR 1 telling the patient to have a good evening. Two hours later, security was notified that a patient, MR 1, was missing. Nursing documentation indicated that staff had gone into MR 1 ' s room at 9:30 pm to check on the patient but when staff returned for their two (2) hour check at 11:30 pm, MR 1 was missing. Nursing notified security of the missing patient and security realized that the individual they observed earlier on the emergency room ramp, was most likely MR 1. Calls were made to local hospitals to notify them of the missing patient. Another hospital responded indicating that the patient was on their property. This hospital is 1.3 miles away and the evening of the elopement, the air temperature was 49 degrees. Nursing documentation written on 10/13/18 at 5:36 am, indicated that when MR 1 was returned to the hospital around 2:00 am, nursing management indicated that the " patient should be changed into a hospital gown. Pt now has a 1:1 sitter in the room " .
On 2/15/19, interview with facility staff (EMP 2 and EMP 4), confirmed that: the facility failed to develop a plan to keep a known wanderer safe; have evidence that included the interventions that were used to prevent elopement and if they were effective; failed to demonstrate follow-up and reevaluation of the interventions if they were not effective; failed to utilize established tools the hospital had created including the complex care meeting which brought together multiple disciplines to discuss complex cases and make recommendations; and failed to define elopement precautions and create a policy and procedure, so staff knew what to do if they had a patient who was at risk for elopement.
A review of facility documentation and interview with EMP 1, revealed that the hospital staff met on 10/25/18 to discuss the circumstances around the incident of 10/12/18. Staff presented their findings of the incident to the hospital ' s Patient Safety Committee on 11/19/18. A taskforce began to meet to further develop and implement interventions on January 1, 2019, 82 days after the elopement. At the time of this survey, 2/15/19, four (4) months after MR 1 eloped, the hospital had not implemented a policy and plan designed to protect patients like MR 1 who were at risk for serious harm, injury, or death.
Medical record review on 2/15/19, revealed that MR 2 and MR 3 were both assessed as potential elopement risks. Both patients were ambulatory and cogently impaired. Staff felt that although the patients had not attempted to elope from the facility, their inability to make sound decisions and the psychiatric diagnoses that they were suffering from, put the two (2) patients at risk for harm should they leave the facility themselves.