HospitalInspections.org

Based on surveyor observation, policy review, record review, and staff interview, it has been determined that the hospital failed to follow its own policy relative to the observation checks procedure for 1 of 1 patient reviewed who was on "safety watch" checks and eloped from the emergency department (Patient ID #1).

Findings are as follows:

The hospital's policy titled "Observation Levels" last revised 2/2023 states:

II. DEFINITIONS

Safety Watch: used when a patient, based on nursing assessment requires continual observations to prevent unintentional or intentional self-harm, including observation for suicide risk when other alternatives such as remote monitoring are not adequate. Continual is defined as happening again and again within short periods of time. This observation type will be a staff physically present at the patient location ...

Patient Observer: Specially trained staff designated to provide observation of a patient at risk for safety. Staff member has completed required education to function as a patient observer which includes, but is not limited to, Nursing Assistant (NA), Patient Care Technician (PCT), Patient Care Assistant (PCA), Medical Assistant (MA), Mental Health Worker (MHW), Registered Nurse (RN), Security staff. General responsibilities include: ...

-Being alert and aware of all patient activity and avoiding distraction ...

III. POLICY

This policy applies to emergency departments and an inpatient unit of Rhode Island, The Miriam, and Newport Hospitals ...

IV. PROCEDURE

Safety Watch

Safety Watch is used for patients requiring continual observations to prevent unintentional or intentional self-harm. It is most often used for confused patients at risk for falls or wandering; but may also be used for behavior that may negatively impact clinical care as well as potential use for patients with moderate suicide risk ...

The mode of observation is in person, 1:1, 1:2, 1:3, or 1:4 staff to patient ratio depending on patient condition.

1. Patient ID #1 was brought to the emergency department on 4/4/2023 by EMS after drinking alcohol all day, intoxicated and making threats to harm self. The patient was placed on alcohol withdrawal protocol, and safety watch observation status. The patient was reported by the hospital to have eloped from the Emergency Department while under safety watch protocol being observed by Employee D, Security Officer (SO).

During a record review for Patient ID #1 on 4/7/2023 at approximately 11:00 AM, review of the orders revealed a nursing order dated 4/4/2023 in 6:06 PM placing Patient ID#1 on safety watch due to safety concerns, at 7:15 PM there was a second order placed by the Physician Assistant for continued safety watch.

During an observation of the hospital video from 8:38 PM through 8:44 PM, (with no audio) of the elopement which occurred on 4/4/2023 reveals the SO outside of the "U" shaped area containing rooms 12, 13, 14, and 15. Patient ID #1 was observed outside of his/her doorway of room 12 at approximately 8:43 PM. The SO is noted speaking with Patient ID #1 (no audio), and he is noted to abruptly turn to the right and quickly enter room 15 at 8:44 PM. He is not observed for approximately 29 seconds before he exits room 15, quickly looking around, glances in room 12, Patient ID #1's room, then is observed to use his portable radio.

During a surveyor interview with Employee D, Security Officer, he stated he was observing 4 patients in the A core unit. He reported Patient ID #1 came out of room 12, asked him to use the restroom, he informed Patient ID #1 he would request a nurse assistant to assist, and asked Patient ID #1 to wait in his/her room. He stated at this moment, he thought the patient had turned as if he/she was returning to room 12. The nurse who was assisting a new patient in room 15 called out for assistance. He stated he could see the patient in room 15 becoming agitated through the window area of the room. He states he reacted and quickly responded to room 15 to assist the nurse who was alone with the patient. He reported he came out seconds later and Patient ID #1 was gone, so he immediately called for help.

During a surveyor interview with Employee C, the Security Manager, he stated the SO was responding to what he felt was an emergency. When asked the protocol for an emergency situation which may interfere with observations, the Security Manager stated all observers should call for assistance prior to leaving the area.