HospitalInspections.org

Based on record review and staff interview, it has been determined that the facility failed to provide care in a safe setting relative to patient constant observation in the Emergency Department (ED) for 1 of 1 patient (Patient ID # 1).

Findings are as follows:

The Hospital's policy for Observation Levels, last revised on 9/19, states in part;

"I. Purpose: To define the different levels and types of observation and to specify requirements associated with each level and type of observation.

II. Definitions: ...
Constant Observation (CO): highest level of observation. CO is used when a patient is high risk for intentional self-harm, high risk for suicide or harm to others. This requires a 1:1 staff to patient ratio..."

Record review for Patient ID #1 revealed s/he presented to the hospital Emergency Department (ED) on January 4, 2020 at approximately 3:00 PM reporting having suicidal ideation and ingestion of medication. The nursing assessment tool "Columbia-Suicide Severity Rating Scale (used to identify whether a patient is at danger to him/herself or others)" indicated the patient required constant observation for suicide and self-injury precautions.

Further review of the medical record revealed the patient was placed on constant observation at 3:19 PM and security was notified. At 3:42 PM it was determined that based on the patient's clinical assessment, s/he required medical clearance prior to transfer to behavioral health services. Nurses notes from 5:38 PM revealed the patient eloped after last being seen by an ED Patient Care Technician, who moved the patient to a different area in the same vicinity, at approximately 4:17 PM.

According to a surveyor interview with Risk Management on 1/10/2020 at 8:45 AM,when the patient was identified as missing on January 4, 2020, police were notified of the elopement at 6:57 PM and the patient was found (by police) at his/her residence. The patient voluntarily presented to another hospital and was discharged early the following morning with behavioral health follow-up.

During a surveyor interview with the ED Clinical Manager and the ED Nursing Quality and Safety Manager on 1/10/2019 at 9:28 AM, they both stated an investigation was conducted and there was an obvious staff communication issue between the nurse, security officer, and patient care technician which lead to the patient's elopement. Neither the Clinical Manager nor the Nursing Quality and Safety Manager could provide evidence that the patient was under constant observation while hospitalized, which resulted in elopement.