HospitalInspections.org

Based on review of records and interview, the hospital failed to ensure that 1 of 1 patient (Patient #1) received care in a safe setting. Patient #1 received treatment that included cognitive re-training in the hospital's inpatient rehabilitation unit for a traumatic brain injury and left the hospital by himself on 06/29/11. Patient #1 did not return to the hospital until 06/30/11 when he was brought back by the security personnel. This incident could have caused Patient #1 increased injuries and a set-back to his physical and mental progress that was made during his rehabilitation.

Findings included:

The "History and Physical" of Patient #1, age 31, included that Patient #1 was admitted to the hospital on 05/16/11 after being involved in an "auto versus pedestrian" motor vehicle accident. He had frontal contusions, a traumatic brain injury, and a fracture of the lumbar transverse process. On 05/17/11 Patient #1 had a left sided decompressive craniectomy and evacuation of a hematoma. Treatment included neurological monitoring.

The 06/03/11 "History and Physical" indicated Patient #1 was admitted to the rehabilitation unit for a "comprehensive intradisciplinary rehabilitation program" that included medication administration, wound care, discharge planning, therapy for mobility and transfers, occupational therapy for self care, swallowing, and cognitive treatment. Patient #1 was "unable to follow safety precautions due to his injury...family will be staying with him 24 hrs/day to assist...not terribly agitated, and seems...well with just redirection...protective helmet for patient ..."

On 06/29/11 at 08:21 AM, the physician noted Patient #1 was still confused and trying to go out per the nurse. Patient #1's sister said he was much more calm and not agitated any more. Tentative discharge was for 07/01/11. The family's questions were answered and Patient #1's cognitive impairment was discussed in addition to his poor safety awareness and need for 24 hour supervision 7 days a week at the time of discharge. Patient #1 had met his rehab inpatient goals.

On 06/29/11 at 08:34 AM, Patient #1's speech therapy progress note indicated that he continued to show steady small gains with functional communication skills in speech therapy. He showed "more consistent participation with structured and unstructured tasks with decreased need for redirection...some improvement with general effectiveness with communication exchange with contextual familiar topics however continues to require...cues for redirection of fluent empty utterances with conversational exchange...decreased insight into deficits and attempts at self-correction require cues from listener..." Patient #1 was to continue 24 hour supervision after discharge.

On 06/29/11 at 08:40 AM, the nurse's notes indicated Patient #1 was agitated and wanted to leave the unit. Lorazepam was administered and he was gently guided back to his room.

On 06/29/11 at 08:00 PM, Registered Nurse #12 noted Patient #1's assessment was completed and he denied the need for pain medication. At 08:30 PM, Patient #1 got out of his enclosed bed and "...walked up and down in his room and hallway for a while refusing to take medication to calm him down." Registered Nurse #12's 09:00 PM notes indicated that Patient #1 "...tried to leave the floor but was repeatedly accompanied back to his room but this time...walked out of the floor despite attempts to keep him from leaving the floor ...security was called and Dr...notified..." At 12:00 Midnight, Patient #1 was "...still not back in room."

The physician's 06/30/11 11:20 AM progress notes revealed, "fortunately was found by police and brought back."

During a telephone interview on 07/01/11 at approximately 12:15 PM, Registered Nurse #12 was asked if she cared for Patient #1 at the time he left the hospital on 06/29/11. Registered Nurse #12 said that she was Patient #1's primary nurse on 06/29/11 from 7:00 PM to 7:00 AM. When she came on the shift she had questioned why Patient #1 was no longer on a 1 to 1 with a sitter. She was told he was thought to be getting better. During her shift, Patient #1 got out of his enclosed bed and walked towards the door. He also walked up and down in his room. He went into the hall and walked towards the exit, the alarm went off, and he went back to his room. Patient #1 had attempted to leave the unit three times, but was coaxed back to his room. After the third time, Patient #1 again came out of his room and kept walking, and didn't come back. When Patient #1 went through the door the fourth time, the alarm went off. Registered Nurse #12 said that security arrived and did not see Patient #1, and nobody had followed Patient #1.

The hospital's "Patients' Rights and Responsibilities" administration policy of June 2009, revised March 2011, noted, "Patients have the right to...be cared for with respect and kindness...privacy, and to be cared for in a safe way in a safe place..."

Based on review of records and interviews, the hospital failed to provide adequate numbers of personnel to meet the safety needs of 1 of 1 patient (Patient #1) who received treatment that included cognitive re-training in the hospital's inpatient rehabilitation unit for a traumatic brain injury and left the hospital by himself on 06/29/11. Personnel was not available to follow Patient #1 and Patient #1 did not return to the hospital until 06/30/11 when he was brought back by the security personnel. This incident could have caused Patient #1 increased injuries and a set-back to the physical and mental progress that was made during his inpatient rehabilitation hospitalization.

Findings included:

The "History and Physical" of Patient #1, age 31, included that Patient #1 was admitted to the hospital on 05/16/11 after being involved in an "auto versus pedestrian" motor vehicle accident. He had frontal contusions, a traumatic brain injury, and a fracture of the lumbar transverse process. On 05/17/11 Patient #1 had a left sided decompressive craniectomy and evacuation of a hematoma. Treatment included neurological monitoring.

The 06/03/11 "History and Physical" indicated Patient #1 was admitted to the rehabilitation unit for a "comprehensive intradisciplinary rehabilitation program" that included medication administration, wound care, discharge planning, therapy for mobility and transfers, occupational therapy for self care, swallowing, and cognitive treatment. Patient #1 was "unable to follow safety precautions due to his injury...family will be staying with him 24 hrs/day to assist...not terribly agitated, and seems...well with just redirection...protective helmet for patient ..."

On 06/29/11 at 08:21 AM, the physician noted Patient #1 was still confused and trying to go out per the nurse. Patient #1's sister said he was much more calm and not agitated any more. Tentative discharge was for 07/01/11. The family's questions were answered and Patient #1's cognitive impairment was discussed in addition to his poor safety awareness and need for 24 hour supervision 7 days a week at the time of discharge. Patient #1 had met his rehab inpatient goals.

On 06/29/11 at 08:34 AM, Patient #1's speech therapy progress note indicated that he continued to show steady small gains with functional communication skills in speech therapy. He showed "more consistent participation with structured and unstructured tasks with decreased need for redirection...some improvement with general effectiveness with communication exchange with contextual familiar topics however continues to require...cues for redirection of fluent empty utterances with conversational exchange...decreased insight into deficits and attempts at self-correction require cues from listener..." Patient #1 was to continue 24 hour supervision after discharge.

On 06/29/11 at 08:40 AM, the nurse's notes indicated Patient #1 was agitated and wanted to leave the unit. Lorazepam was administered and he was gently guided back to his room.

On 06/29/11 at 08:00 PM, Registered Nurse #12 noted Patient #1's assessment was completed and he denied the need for pain medication. At 08:30 PM, Patient #1 got out of his enclosed bed and "...walked up and down in his room and hallway for a while refusing to take medication to calm him down." Registered Nurse #12's 09:00 PM notes indicated that Patient #1 "...tried to leave the floor but was repeatedly accompanied back to his room but this time...walked out of the floor despite attempts to keep him from leaving the floor ...security was called and Dr...notified..." At 12:00 Midnight, Patient #1 was "...still not back in room."

The physician's 06/30/11 11:20 AM progress notes revealed, "fortunately was found by police and brought back."

On 07/01/11 at approximately 12:30 PM, a review of the staffing information for 06/29/11 7:00 PM to 11:00 PM was conducted with the Unit Manager, Registered Nurse #2. The staffing grid was applied to the 06/29/11 16 patient census. Three nurses and two patient care assistants were available for the 16 patients. This was one less patient care assistant than should have been in attendance at the approximate time Patient #1 left the hospital. Registered Nurse #2 agreed that staffing was less than the hospital's staffing requirement for the unit and patient census of 16 during the time Patient #1 left the hospital.

During a telephone interview on 07/01/11 at approximately 12:15 PM, Registered Nurse #12 was asked if she cared for Patient #1 at the time he left the hospital on 06/29/11. Registered Nurse #12 said that she was Patient #1's primary nurse on 06/29/11 from 7:00 PM to 7:00 AM. When she came on the shift she had questioned why Patient #1 was no longer on a 1 to 1 with a sitter. She was told he was thought to be getting better. During her shift, Patient #1 got out of his enclosed bed and walked towards the door. He also walked up and down in his room. He went into the hall and walked towards the exit, the alarm went off, and he went back to his room. Patient #1 had attempted to leave the unit three times, but was coaxed back to his room. After the third time, Patient #1 again came out of his room and kept walking, and didn't come back. When Patient #1 went through the door the fourth time, the alarm went off. Registered Nurse #12 said that security arrived after security was called, and did not see Patient #1, and nobody had followed Patient #1. Registered Nurse #12 said that she had to go back to care for her patients and nobody was able to follow Patient #1.

The "Staffing Plan" procedure #19-29 written June 2011 noted, "Nurse staffing requirements are based on the needs of each patient care unit and shift and on evidence relating to patient care needs...assignments are based on the staff competency and patient acuity...additional considerations include...patient and family needs...safety...charge nurse or designee shall continuously monitor all assignments and take corrective action when indicated...call-ins or unfilled shifts will be supplemented with part-time, float pool staff, management staff, requesting an additional day of work from off duty employees, or voluntary overtime staff..."

The hospital's "Patients' Rights and Responsibilities" administration policy of June 2009, revised March 2011, noted, "Patients have the right to...be cared for with respect and kindness...privacy, and to be cared for in a safe way in a safe place..."