HospitalInspections.org

Based on staff interview and facility record review the facility failed to ensure that 1 of 5 sampled patients (#1,) who was baker acted to the facility, was supervised adequately to manage the risks of elopement from the facility.

The Findings Include:

During an interview conducted on 01/21/10 at 5:40 PM with the evening Receptionist, she stated that the day Receptionist was in her car when she was given a report on the patients. The evening Receptionist also stated that she assumed a patient in the Admissions Lobby wearing a hospital gown was the baker act patient being referred to during a "walking report" from the day Receptionist. The evening Receptionist also said initially she did not see a second patient, in the Admissions Lobby, who was dressed in street clothing when she entered the Admission Lobby area. The evening Receptionist further stated that after coming from the Copy Room, she encountered the patient (in street clothing) in the Lobby. The patient asked her to be let outdoors to smoke, and against her better judgment she opened the door for the patient to go out; she had not checked with the nurse regarding the patients in the Admission Lobby, and stated that she should have verified with the nurse or counselor as to whether the person in street clothes was a patient but did not. The evening Receptionist documented on the Incident Report that the incident occurred at 5:30 PM.

During the interview conducted with the manager of the Receptionist on 01/21/10 at 4:00 PM, the manager confirmed that she was notified of the incident at approximately 6:30 PM (1 hour later).

During the interview with the admissions RN, the RN stated that he had heard that " the Baker Act " had eloped (referring to patient #1), but was unable to state who had notified him or at what time he had been notified. The RN further stated that he went outdoors to look for the patient but did not see anyone.

During the interview conducted with the Intake Coordinator / counselor on 01/22/10 at 12:15 PM, the counselor stated that she was aware of the patient ' s (#1) presence and that he/she was baker acted to the facility. The counselor stated that the last time that she saw the patient was when she introduced herself to the patient in the Assessment Room (she was unable to state the exact time). The counselor further stated that she told the patient she would return to do an assessment, but the patient stated that he/she wanted to use the Bathroom. Upon returning to the Assessment Room, the counselor stated, the patient was gone. Although the counselor confirmed that it is the responsibility of all staff to supervise the patients in the admissions area, the counselor stated that when she is in the office or in the Assessment Room the patients in the Lobby would not be within her view, therefore it is left to the Receptionist to monitor and supervise the patients.

Review of the facility Smoke Break Policy disclosed it documents: " If a patient wishes to have a Cigarette, the Receptionist must first obtain clearance from admissions personnel. "

The facility's policy for monitoring the patients documents: The standard of care is q (every) 15 minute observation for each patient.

It is to be noted that for at least 1 hour after being allowed to go outside to smoke, admission staff was not aware of the patient ' s whereabouts. No evidence was provided or found to substantiate patient #1 was supervised by any staff or nursing personnel while he/she was in the Admission Lobby area or while he/she was outdoors smoking. Furthermore, no documentation was provided or found to substantiate the performance of 15 minute checks (monitoring) on the patient. Although the Receptionist stated that she was not aware the patient dressed in street clothes was the baker act patient, the RN and the Intake Coordinator / Counselor knew. Both the RN and the Intake Coordinator / Counselor knew the patient (#1) had been baker acted to the facility for psychiatric evaluation and should have ensured assessment and clinical supervision of patient #1.

Based on staff interviews and review of facility reports it was determined the facility failed to ensure actions are implemented to improve the quality of care, measure its success and ensure improvements are sustained.

The Findings Include:

Review of the Triage Log, dated 11/19/09, revealed patient #1 presented at the facility Admissions Lobby/Area at 4:35 PM; the patient was prioritized as level 3 (lowest priority); the Log is signed by the admissions RN.

Upon request of patient #1 ' s clinical record for review the surveyor was informed the patient was not admitted to the facility and therefore did not have a medical record. The findings of this investigation pertaining to patient #1 are based on a review of the facility ' s Triage Log and interviews conducted with facility staff.

During an interview conducted with the Director of Nursing (DON) on 01/21/10 at 1:40 PM, to ascertain why patient #1 did not have a clinical record, the DON stated that the patient came to the facility to be admitted but eloped from the facility. The patient was asked to have a seat in the Admissions Lobby and to await triage. At approximately 5:30 PM the day shift Receptionist who was leaving gave a " walking report " to the evening shift Receptionist in the Admissions Lobby, regarding the patients who were in the Lobby at the time. The day shift Receptionist reported that there is a Baker Act patient (referring to patient #1) who was brought to the facility by Ambulance, and is wearing a Hospital Gown. The DON said the other patient in the Lobby, who was dressed in " street clothes, " was pacing around the Admissions Area. The information was incorrect because the patient in street clothes was in fact, patient #1, who had been Baker Acted and brought into the facility by law enforcement. Due to misinformation the evening Receptionist was unaware patient #1, who had been Baker Acted was the patient in the street clothes. The DON stated that patient #1 asked the evening shift Receptionist to be let out of the facility to smoke. Not realizing this is the baker act patient, and without first notifying and obtaining permission from the admissions staff (a Registered Nurse (RN) and the Intake Coordinator / Mental Health Counselor), the Receptionist opened the Exit Door and allowed the patient to go out. The patient thereby eloped from the facility.

The DON stated, they know that "this should not be done", referring to how the Receptionists gave and received the report on the patients. The DON further stated that patients who are Baker Acted to the facility should not leave the premises, and that the evening Receptionist did not follow policy and protocol when she allowed the patient to go outside for a smoke, without first obtaining permission.

The DON was questioned as to whether the patient was triaged and assessed by the admissions RN. The DON stated, the RN never assessed or triaged the patient.

During an interview with the admissions RN on 01/21/10 at 2:30 PM, to determine whether he had performed a triage assessment of the patient, the RN stated that he could not recall and that he could not recall if the Receptionist had informed him that the patient had been baker acted ( brought to the facility for psychiatric evaluation based on the Baker Act Law).

During an interview conducted on 01/21/10 at 4:05 PM, with the Director of Admissions who manages the licensed nurses working in admission / triage area, the director stated that when a baker act patient presents to the facility the nurse should see the patient ( " eye ball " ) within 5 to 10 minutes; the nurse should complete the actual triage assessment within 15 minutes of " eye balling " the patient, and should document on and sign the Triage Log. Upon inquiry, the director stated, the facility did not have a written Triage Policy but that the staff is aware of the procedure.

During an interview conducted with the day Receptionist on 01/21/10 at 4:55 PM, the Receptionist stated she notified admissions staff there was a patient who had been baker acted to the facility to be seen. The Receptionist also stated that the evening Receptionist was told during report that the Baker Act patient (patient #1) was in the Assessment Room and that the other patient was awaiting a ride.

Review of the Facility Reports revealed a brief summary of the incident documented by the evening shift Receptionist. The Report Form is checked in the treatment intervention area; the Form documents the severity index of the elopement to have been major, and that the incident was reported to the police. The Form is dated 11/20/09.

On 01/21/10, upon request, there was no evidence provided by the facility indicating the performance of data collection and analysis of the occurrence, and the implementation of corrective actions / measures to manage the risks for recurrence. Nor was a documented triage assessment found or provided.

During an interview conducted with the DON on 01/21/10 at 1:40 PM, the DON stated that the Director of Admissions would have been the one to do a Root Cause Analysis; the "Smoke Break Policy" was changed as a result of the incident. The DON was unable to provide supportive documentation to substantiate the findings of an investigation; the identification of occurrence variables that contributed to the negative outcome; a root cause analysis, and staff education/training to prevent recurrence.

During an interview conducted on 01/21/10 at 4:05 PM, with the Director of Admissions, who manages the licensed nurses working in admission/ triage area, the director confirmed that no corrective actions were taken as a result of the incident, and stated that she was unable to provide documented evidence that supports the implementation of preventive measures as a result of collection and analysis of data related to the incident.

During an interview with the executive assistant on 01/21/10 at 4:00 PM, the assistant confirmed that the last quarterly Quality Assurance (QA) meeting was held on January 15th, 2010, and that the incident was not reported and or discussed by the Quality Assurance/Quality Improvement Committee.

As of the time of the abbreviated survey on 01/21/10, the facility failed to substantiate actions were implemented to improve the quality of care, measure its success and ensure improvements are sustained. No effective measures were implemented to manage or prevent risk factors that potentiate recurrence of patient elopement incidents.