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Based on observations, interviews and clinical record reviews, it was determined the hospital failed to furnish supervised nursing services to meet the needs for one patient (#1) in the selected sample of three. The hospital's nursing services failed to ensure Patient #1's nursing needs were continually assessed and that needed changes to his/her care were promptly implemented in order to ensure Patient #1's nursing care needs were met.

Refer to: A 395 and A 396

Based on observations, interviews and clinical record reviews, it was determined the hospital failed to furnish supervised nursing services to meet the individualized care needs for one patient (#1) in the selected sample of three.

Findings include:

Interviews conducted with the hospital's Vice President (VP) and Chief Nursing Officer (CNO) on 06/22/11 at 3:40 PM, revealed the "Missing Patient Guidelines" policy dated 05/10 addressed the protocols for staff to follow if a patient was missing, but there were no protocols in place for staff regarding "wandering" or "confused" patients.

Review of Patient #1's clinical records revealed Patient #1's "significant other" called the patient's physician, Physician #1, to inform him that on the morning of 05/09/11, Patient #1 woke up and "was unable to walk, communicate, or even stand without assistance." Patient #1 was transferred to the hospital's Emergency Room (ER) by Emergency Medical Services (EMS) on 05/09/11 at 9:00 AM, per direction from Physician #1, to rule out a medication "overdose." Physician #1 admitted Patient #1 to the 5th floor as an "observation" patient on 05/09/11 at 10:55 AM with the admitting diagnosis of "Dilantin Toxicity." The Consulting Psychiatric Physician #2 documented the following in his 05/12/11 "Consultation" report, Patient #1 had "Dementia with probable intercurrent delirium, ?Alzheimer's." Record review revealed Patient #1 had problems with medication compliance and was previously hospitalized on 11/08/10 due to "Dilantin Toxicity." Review of Patient #1's "Nursing Notes" since admission on 05/09/11, revealed the following wandering incidents:

1. Patient #1 was discovered missing from his/her room on 05/13/11 at 2:15 AM, by nursing staff during their routine supervision checks. Security was immediately notified and the search for Patient #1 was initiated. On 05/13/11 at 2:21 AM, Security located Patient #1 standing outdoors in the hospital's parking lot (which was a smoking area). Patient #1 was missing for 6 minutes after nursing staff had discovered the patient was not in his/her room. The exact amount of time the patient was not on the 5th floor was not known due to no documentation of nursing supervision on Patient #1.

2. Patient #1 was returned to the 5th floor on 05/24/11 at 5:30 AM after staff from the 2nd floor called the 5th floor and reported the patient had wandered down to the 2nd floor surgery area. Staff from the 5th floor did not realize Patient #1 had left the floor. The exact amount of time the patient was not on the 5th floor was not known due to no documentation of nursing supervision on Patient #1.

3. Patient #1 got on the 5th floor elevator on 06/17/11 at 1:00 AM with a pharmacy technician and rode the elevator up to the 6th floor. The pharmacy technician noticed the person riding the elevator had a hospital identification band on his/her wrist. The 5th floor staff was made aware of the patient's "brief" elevator ride with a pharmacy technician to the 6th floor by staff from the 6th floor. Patient #1 was promptly returned to the 5th floor by staff. An interview was conducted by telephone on 06/24/11 at 6:55 AM with LPN #1. She revealed staff was not aware Patient #1 rode the elevator up to the 6th floor with a pharmacy technician, until staff from the 6th floor called and notified her of Patient #1's elevator ride incident. She stated the incident happened quickly and the patient was gone for a "brief" amount of time. She revealed the 5th floor's nursing staff was not even aware Patient #1 had left the 5th floor until the phone call which alerted them of the elevator incident.

4. Patient #1 could not be found on 06/17/11 at 5:27 AM, on the 5th floor during a supervision check by CNA #1. Security and the Nursing House Supervisor were made aware Patient #1 was missing. Patient #1 was found walking around barefooted on the 4th floor. A patient on the 4th floor reported to staff that a man/woman, who matched Patient #1's description, was seen urinating in a sink. Patient #1 was located on the 4th floor and returned to the 5th floor on 06/17/11 at 5:52 AM. The patient talked to LPN #1 and she documented the following, "PT states he/she got off the plane and he/she remembers he/she did urinate in the sink." The exact amount of time the patient was absent from the 5th floor was not known due to no documentation of nursing supervision checks on Patient #1. Interviews conducted with CNA #1 on 06/23/11 at 9:00 AM and LPN #1 on 06/24/11 at 6:55 AM, revealed Patient #1 was missing from the 5th floor for no more than 25-30 minutes.

Interviews with the Clinical Manager and RN #1 on 06/21/11 at 11:15 AM, revealed there was one (1) undocumented incident of Patient #1 missing without staff's knowledge. On 05/15/11 at approximately 4:00 PM, Patient #1 left the 5th floor with nursing staff's approval and knowledge to go outdoors and smoke with a friend. However, during the time the patient was outdoors smoking with his/her friend, the patient's friend also drove Patient #1 home to get more cigarettes. Patient #1 was off the 5th floor for approximately 20 to 25 minutes. However, some of the time the patient was off the 5th floor was with staff's knowledge of the patient's location (smoking) and some of the time was without staff's knowledge of the patient's location (home). Patient #1's friend returned Patient #1 to the hospital after the patient smoked and got more cigarettes at home. The exact amount of time the patient was absent from the 5th floor to smoke and then returned to the floor was not known. The 5th floor nursing staff had no documented evidence of the time the patient went outdoors to smoke and then returned to the floor. The Clinical Manager stated there was no type of sign out/in form used for patients when they went outdoors to smoke and then returned.

An interview with Physician #1 on 06/21/11 at 12:00 PM, revealed he was made aware of Patient #1's wandering incidents in the hospital by the 5th floor nursing staff. Physician #1 stated he was aware that Patient #1 was confused at times. He confirmed he wrote an order on 05/23/11 for Patient #1 to go "downstairs to smoke only with a responsible caregiver or friend." He stated the hospital was a non-smoking facility and he felt it was in the best interest of Patient #1 to have a responsible person escort Patient #1 outdoors to an approved smoking area to smoke and then escort Patient #1 back to the 5th floor.

An interview was conducted with Patient #1's Social Worker on 06/21/11 at 11:45 AM. She stated she made DCBS Representative #1 aware of the incident involving Patient #1 leaving the hospital with his/her friend to go home to get more cigarettes and then returning to the hospital. She also informed the DCBS Representative that Registered Nurse (RN) #1 "forgot" to document the incident. She stated DCBS Representative #1 was attempting to get guardianship of Patient #1.

A telephone interview was conducted with RN #1 on 06/21/11 at 11:15 AM. She stated she "forgot" to chart the 05/15/11 incident involving Patient #1 leaving the hospital with a friend to go home and get more cigarettes and then returning to the hospital. She revealed Patient #1's friend took the patient outside to smoke and then apparently drove the patient home to get more cigarettes and then returned to the hospital. RN #1 stated Patient #1 was gone from the 5th floor for approximately 20-25 minutes with his/her friend to smoke. She revealed while Patient #1 was outside with his/her friend, she received a phone call from one of the patient's neighbors asking about the patient and informing her that Patient #1 was briefly seen at home. RN #1 stated as she walked outside to check on Patient #1, the patient and his/her friend pulled up in a car. She revealed she talked to both the patient and the patient's friend about not leaving hospital grounds. She stated she made her supervisor and Physician #1 aware of the above incident. She revealed nursing staff routinely checked on Patient #1 about every 30 minutes, but the checks were not documented.

An interview was conducted with Certified Nursing Assistant (CNA) #1 on 06/23/11 at 9:00 AM. She revealed she and all the other nursing staff were very familiar with Patient #1 since he'd been at the hospital so long. She stated we were all aware to keep a close eye on Patient #1. She checked on Patient #1 at least every 30 minutes or more often since the patient had a history of wandering. She stated staff tried to keep Patient #1 busy by talking to him/her, walking with him/her, and just tried to entertain Patient #1. She stated Patient #1 only slept about 3 hours a night and napped a couple of hours after lunch.

An interview was conducted with the 5th floor's Clinical Manager on 06/21/11 at 11:15 AM. She revealed Patient #1 had been on the 5th floor since his/her hospital admission on 05/09/11 due to "Dilantin Toxicity." She stated Patient #1 was alert and orientated to person and usually to place. She confirmed Patient #1 had three "wandering" incidents inside the hospital as well as one "wandering" incident outdoors. She stated Patient #1 became confused at times and did not remember where he/she was, and/or why he/she was in the hospital. She stated supervision checks were routinely conducted on all patients at least every two (2) hours. She revealed nursing staff was checking on Patient #1 about every 30 minutes since the patient's first wandering incident on 05/13/11. She revealed patient supervision checks were not routinely documented in the patient's record. She confirmed although increased nursing supervision checks were initiated by nursing on Patient #1 on 05/13/11, there was no documented evidence of the changes by nursing in the patient's record. She stated the "Patient's plan of Care-Med/Surg Treatment Plan" dated 05/09/11, should have been updated by nursing staff to include the increased nursing supervision checks due to the patient's wandering.

Based on observations, interviews, clinical record reviews, and review of the hospital's "Patient Assessment : Admission and Ongoing" policy and procedure, it was determined the hospital failed to ensure nursing staff kept an updated and current "Patient's plan of Care- Med/Surg Treatment Plan" to meet the individualized nursing care needs for one patient (#1) in the selected sample of three.

Findings include:

Review of the hospital's "Patient Assessment : Admission and Ongoing" policy and procedure dated 12/08, revealed a "patient reassessment is conducted as an on-going process and is based on the specific care needs of the patient." The policy further revealed the purpose of the assessments was to "formulate and prioritize patient care needs and establish an appropriate plan of care" which meets the patient's care needs.

Review of Patient #1's "Patient's plan of Care-Med/Surg Treatment Plan" dated 05/09/11, revealed no changes were documented as being initiated on the patient's plan of care since the patient's admission on 05/09/11. Review of the patient's record revealed Patient #1 had four (4) documented incidents of wandering. However, there was no documented evidence in the patient's record and/or on the patient's plan of care of the increased nursing supervision due to the patient's wandering. Record reviews revealed nursing care needs were not continually assessed and changes were not promptly documented and/or initiated on Patient #1's plan of care dated 05/09/11, which reflected the necessary nursing care needs and interventions to be put in place in order to protect Patient #1 from wandering.
( Refer to A 395 for the wandering incidents. )

Interviews conducted with the Clinical Manager and RN #1 on 06/21/11 at 11:15 AM, and an interview conducted with the CNO on 06/22/11 at 3:40 PM, revealed Patient #1's "Patient's plan of Care-Med/Surg Treatment Plan" should have been updated by a Registered Nurse (RN) to reflect the patient's increased nursing supervision needs and any other measures which were utilized by nursing staff to decrease Patient #1's wandering. The hospital's nursing services failed to ensure Patient #1's nursing care needs were continually assessed and that needed changes to his/her plan of care were promptly documented and implemented in order to ensure Patient #1's nursing care needs were met.