HospitalInspections.org

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Based on interview and document review, the hospital failed to ensure that patients were provided care in a safe environment, free from abuse or neglect.

Failure to protect patients from neglect places patients at risk for serious physical and/or psychological harm and death.

Findings included:

The hospital failed to implement interventions to prevent patient elopement.

Due to the severity of deficiency under 42 CFR 482.13, the Condition of Participation for Patient Rights was NOT MET.

Cross reference: Tag A-145
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Based on observation, interview, and record review, the hospital failed to develop and implement an effective system to prevent patient elopement for 1 of 1 patients reviewed (Patient #1).

Failure to protect patients and to ensure care in a safe environment by preventing patient elopement risks violation of patient rights, serious injury, or death.

Findings included:

1. Document review of the hospital's policy titled, "Patient Rights and Responsibilities," PolicyStat ID 8769890, last revised 01/21, showed that patients are made aware of their rights and responsibilities prior to receiving hospital care or services.

2. Document review of the hospital's patient handout titled, "Patient Rights and Responsibilities," last revised 11/22, showed the following:

a. Patients will be treated with dignity, and be free from neglect, exploitation, abuse, harassment, racism, or discrimination.

b. Patients have the right to receive care in a safe setting.

3. Document review of the hospital's policy titled, "Inpatient Elopement - Adult," PolicyStat ID 8569682, last revised 05/22, showed the following:

a. Elopement is defined as a patient leaving the facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge.

b. Patient assessment for elopement risk includes a patient history of elopement, wandering, or becoming disoriented; cognitive changes or symptoms of anxiety, depression, or agitation that may lead to erratic behavior.

c. Preventative measures for patients determined to be at elopement risk include but are not limited to bed alarm or egress alarm use, placing the patient in a view room, placing the patient as a close observation assignment, placing the patient in clothing that identifies them as an elopement risk, documenting elopement risk in the medical record, and communicating elopement risk at daily bed huddles.

4. Medical record review showed the following:

a. On 4/25/23 at 3:10 PM, Patient #1 was admitted for bilateral forearm abscesses (skin infections), substance use disorder, and schizophrenia after being detained in the field by the Designated Crisis Responder (DCR). On 04/26/23, Patient #1 underwent an incision and drainage procedure to treat her bilateral forearm wounds.

b. On 04/28/23 at 5:06 PM, provider documentation showed a plan for DCR consultation if Patient #1 attempted to leave the facility against medical advice.

c. On 04/29/23 at 4:45 PM, security documentation showed that Patient #1 eloped from the facility without receiving a DCR consultation.

d. On 04/30/23 at 8:59 PM, Patient #1 was detained for grave disability by the DCR at her residence. Patient #1 was transported to St. Peter Hospital and readmitted.

e. On 05/06/23 at 5:07 PM, Patient #1 eloped from the facility again. Patient #1 was on an involuntary hold for grave disability at the time of the elopement.

f. On 05/07/23 at 11:45 AM, Patient #1 returned to St. Peter Hospital by ambulance for treatment of her bilateral forearm wounds and DCR evaluation for involuntary detainment. An Unavailable Detention Facilities Report showed that Patient #1 was unable to be transferred to a psychiatric care facility due to two large abscesses requiring IV antibiotics until 05/10/23.

g. On 05/08/23 at 8:48 PM, the DCR evaluated Patient #1. The evaluation showed that Patient #1 was in imminent danger because of being gravely disabled and was in danger of serious physical harm resulting from a failure to provide for health and safety. Patient #1 had admitted to injecting heroin into her wound sites after her elopement on 05/06/23. As a result, Patient #1 was involuntarily detained.

h. On 05/15/23, Patient #1 remained gravely disabled and was placed on a court-ordered a 14-day involuntary hold.

i. On 05/16/23, Patient #1 underwent surgical debridement, skin grafting, and wound vacuum placement for wounds on both forearms.

j. On 05/21/23, Patient #1 was being watched by in-person and virtual (by camera) staff members due to her high risk for elopement. Another staff member requested that the in-person staff watching Patient #1 assist with patient care in another room. During the caregiver's absence, Patient #1 eloped from the facility. At 3:01 PM, staff reported the elopement to security, but they were unable to locate the patient on hospital property.

5. On 02/28/24, investigators received a copy of the coroner's report that showed that 2 community case workers found Patient #1 deceased in her residence on 05/30/23. The report showed that the patient died from an accidental drug overdose.

6. On 02/27/24 at 3:24 PM, Investigator #1 and Investigator #2 interviewed Staff #1. Staff #1 stated that in-person or virtual (camera) sitters could be used to keep detained patients from eloping. Staff #1 stated that staff assigned as 1:1 patient sitters for reasons other than suicidal ideation might be asked to step away to provide temporary assistance with other patients depending on the 1:1 patient's recent behavior.

7. On 02/27/23 at 3:40 PM, Investigator #1 and Investigator #2 interviewed Staff #2. Staff #2 stated that if they were assigned as a 1:1 for a patient for a reason other than suicidal ideation and were asked to provide care for a patient in another room, they would go help the other patient "if the 1:1 had been behaving."
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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that adverse events were recognized and reported for 2 of 2 events reviewed (Patient #1).

Failure to ensure patient safety and adverse events are recognized and reported limits the hospital's ability to enact measures that prevent or mitigate patient harm.

References:

National Quality Forum. List of Serious Reportable Events - Patient Protection Events - Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person.

Findings included:

1. Document review of the hospital's policy titled, "Sentinel / Adverse Events," PolicyStat ID 10525436, last revised 10/21, showed the following:

a. Events identified as actual or potential sentinel or adverse events as defined in the policy's attachment should be immediately reported to the Director or Manager for Quality Services, the Administrator on Call, or their designee.

b. The attachment titled, "PSPH Attachment Definitions of Adverse and Sentinel Events Adverse Events (Washington State Department of Health (DOH): October 2012," last revised 10/21, showed that discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person was listed as a reportable event.

c. The Director of Quality Services, or designee, has the ultimate responsibility to determine if an event is a sentimental or adverse event that requires reporting.

d. The facility is required to submit a report to the Department of Health within 45 days of confirmation of the adverse event, including a root cause analysis and corrective action plan if one is determined to be necessary.

2. Medical record review showed the following:

a. On 4/25/23 at 3:10 PM, Patient #1 was admitted for bilateral forearm abscesses (skin infections), substance use disorder, and schizophrenia after being detained in the field by the Designated Crisis Responder (DCR).

b. On 04/28/23 at 5:06 PM, provider documentation showed a plan for DCR consultation if Patient #1 attempted to leave the facility against medical advice.

c. On 04/29/23 at 4:45 PM, security documentation shows that Patient #1 eloped from the facility without receiving a DCR consultation.

d. On 04/30/23 at 8:59 PM, Patient #1 was detained for grave disability by the DCR at her residence. Patient #1 was transported to St. Peter Hospital and readmitted.

e. On 05/06/23 at 5:07 PM, Patient #1 eloped from the facility again. Patient #1 was on an involuntary hold for grave disability at the time of the elopement.

f. On 05/07/23 at 11:45 AM, Patient #1 returned to St. Peter Hospital by ambulance for treatment of her bilateral forearm wounds and DCR evaluation for involuntary detainment.

g. On 05/08/23 at 8:48 PM, the DCR evaluated Patient #1 and involuntarily detained Patient #1 for grave disability.

h. On 05/15/23, Patient #1 remained gravely disabled and was placed on a court-ordered a 14-day involuntary hold.

i. On 05/21/23, Patient #1 eloped from the facility. At 3:01 PM, staff reported the elopement to security, but they were unable to locate the patient on hospital property.

3. On 02/29/24 at 3:01 PM, Investigator #1 interviewed the Director of Quality and Risk (Staff #3), who confirmed that Patient #1's elopement events were not reported to the Washington Department of Health because the hospital did not know that Patient #1 had expired after eloping. Staff #3 confirmed that involuntary detainment for grave disability would indicate that a patient was unable to make decisions, making the event reportable regardless of whether the event caused a patient harm.
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